RFID SHOWCASE: Fewer Events, Better Reporting
RFID SHOWCASE
Fewer Events, Better Reporting
Patient safety event-reporting systems are found in all hospitals and are a mainstay of efforts to detect potentially critical events and quality problems. Initial reports usually come from the personnel directly involved in an event or the actions leading up to it, such as the nurse or physician caring for a patient when an error occurred, rather than management or patient safety professionals.
Trends
Trends
When Nurses Hurt Nurses
Seventy-three percent of adult women found workplace bullying to be “common” or “very common.” The same women reported that weekly, they are, on average, a bully 1.5 times, a victim of bullying 1.8 times and a bystander to bullying nearly 7 times.
ABQAURP News
In Pursuit of a Patient-Centered VA Prescription Label
In Pursuit of a Patient-Centered VA Prescription Label
The patient-centered prescription label movement has roots in primary research studies by notable health literacy proponents (Davis et al., 2006; Davis et al., 2008; Shrank et al., 2007; Sharnk, Avorn et al., 2007). This foundational work paved the way for setting standards for prescription label formats, content, lexicon, and numeracy interpretation.
Pulse
Pulse
Call for Letters of Intent to Conduct Research and Development in Patient Safety
Applications invited for grant projects to begin in 2012.
The National Patient Safety Foundation’s (NPSF’s) Research Grants Program seeks to stimulate new, innovative projects directed toward enhancing patient safety in the United States. The Program’s objective is to promote studies leading to the prevention of human errors, system errors, patient injuries and the consequences of such adverse events in the healthcare setting.
It’s Just Common Sense
Editor’s Notebook
It’s Just Common Sense
I recently moderated a webinar about a problem in healthcare that hadn’t occurred to me—nor to many others, it appears—but seems quite obvious now that it’s been brought to my attention. In the webinar, Dennis Tribble, chief pharmacy officer at Baxa Corporation, joined Stuart Levine of ISMP and Denise LaStoria, owner of Training Advantages, LLC, to discuss problems inherent in train-the-trainer programs used for technology training, especially in the pharmacy.
Say No to Paper
Health IT & Quality
Say No to Paper
Paper came one pill away from killing my 91-year-old mom. Only through luck did we dodge a medical error that could have extinguished a life that survived the Great Depression, World War II, polio epidemics, the birth of two children, the Cold War, the loss of her husband, and more than 60 years of employment. Up until her admission on May 7th, she had never experienced being an ill patient in a hospital.
“Can’t Rather than Don’t” Saves Lives
Human Factors
“Can’t Rather than Don’t” Saves Lives
A recent article in The New York Times, “U.S. Inaction Lets Look-Alike Tubes Kill Patients,” (Harris, 2010) shows that American hospitals are 80 or more years behind manufacturing industries in basic safety. This inexcusable situation deserves zero tolerance from patients, insurers, healthcare professionals, and other healthcare stakeholders.
Applying the IHI Global Trigger Tool to Pediatric and Special Needs Populations
Applying the IHI Global Trigger Tool to Pediatric and Special Needs Populations
Gillette Children’s Specialty Healthcare (Gillette) provides specialized healthcare services to individuals with disabilities, with a primary focus on children. Serving a wide geographic region, Gillette’s programs focus on the needs of patients with cerebral palsy, spina bifida, neuromuscular diseases, brain and spinal cord injuries, and complex neurological, craniofacial, and orthopedic conditions.
Heed This Warning! Don’t Miss Important Computer Alerts
ISMP
Heed This Warning! Don’t Miss Important Computer Alerts
Although pharmacists typically enter prescriptions and orders into the pharmacy computer, in some settings, specially trained pharmacy technicians or pharmacy interns perform this function. In these circumstances, a pharmacist later verifies that the order has been entered as prescribed at the same time he or she is assuring the appropriateness of the medication and verifying that the proper drug and dose has been prepared.