Leadership: Ending Nurse-to-Nurse Hostility
Years ago, at a National League of Nursing meeting, Loretta Nowakowski, former director for Health Education for the Public at Georgetown University School of Nursing in Washington, D.C., proposed that disease could be best understood by looking at hurricanes. She noted that, like a serious illness, hurricanes occurred only when many factors were present within relatively narrow parameters and that an appropriate intervention could alter the severity or course of a disease or hurricane. This discovery was encouraging to Nowakowski—it meant that an intervention, made at any point, could alter the final outcome.
ISMP: Key Medication Errors in the Surgical Environment
Medication errors in the perioperative area received widespread media attention with the publication of an article in the journal Anesthesiology (Nanji, Patel, Shaikh, Seger, and Bates, 2016). The perioperative area is one of the most medication-intensive locations in a hospital, often with more medications, particularly high-alert medications, administered per patient than other patient care units. Yet, this area of the hospital often operates with fewer medication safety strategies in place than most other patient care units. For example, the anesthesia provider often selects, prepares, labels, and administers medications without the benefit of electronic clinical decision support, pharmacy review of medication orders prior to administration, barcode scanning of products prior to administration, and other secondary checks by other healthcare providers (Nanji et al., 2016; Brown, 2014). This lack of normal checks and balances, along with the use of multiple medications, time-sensitive tasks, complex and stressful working conditions, distractions, and fatigue all contribute to making the perioperative area particularly error-prone when medications are administered.
Challenge Issued to Promote Precision Medicine for the Underserved
To support President Obama’s Precision Medicine Initiative, the National Health IT Collaborative for the Underserved (NHIT Collaborative) offers a challenge to advance health equity through the development of digital health tools. Proposals are invited for tools that: Address the precision medicine needs of people in underserved and medically underserved communities Facilitate participation of people from … Continued
Opioids: What Do Healthcare Professionals Want and Need to Know?
The availability of, and access to effective and safe treatments for pain remain serious problems in the United States (Institute of Medicine, 2011). Opioid medications are important for addressing short-term and chronic pain management. Given the benefits that they provide, usage of opioids has become widespread over the past decade. However, opioid medications also carry substantial risk, and their increased usage has introduced a host of unintended consequences across the care continuum. Given this, opioids have significant implications for patient safety. The National Patient Safety Foundation (NPSF) conducted a convenience flash poll survey to obtain a snapshot of opioid-related patient safety concerns, learning needs, and familiarity with existing seminal publications among healthcare professionals.
Standing Up to Falls
“Why do we fall? So we can learn to pick ourselves back up.” That inspirational quote is designed to focus on lessons that can be learned in order to move forward effectively and ultimately succeed.
When a fall is approached as an opportunity to learn, new knowledge is gained, informing changes that can lead to improvement. Learning is at the heart of improvement, innovation, and growth. But when a patient fall is treated as a failure, the learning stops.
Despite advancements in technology and methodology, hundreds of thousands of patients continue to fall in hospitals each year, and 30%–35% of them suffer injuries. On average, 358 patients fall each year in a typical 200-bed hospital, resulting in approximately 117 injuries. The implementation of evidence-based best practices has not eliminated patient falls in healthcare settings. In order for patients to stop falling, a change in approach is necessary.
Health IT & Quality: Precision Requires FHIR
On January 20, 2016, President Barack Obama celebrated the one-year anniversary of his announcement of the Precision Medicine Initiative. The initiative, first announced in the president’s 2015 State of the Union address, initially included $215 million in research funding (“Precision Medicine Initiative,” n.d.).
Most medical treatments are designed to treat the average patient. However, this broad approach fails to account for differences in genetics, physiology, environments, and lifestyles, all of which greatly impact the effectiveness of therapies. Precision medicine works to overcome such shortcomings by conducting research into the efficacy of available treatments in different patients while taking into account these and additional factors.
Education: Interdisciplinary Skills Labs for Quality Improvement
In spring 2014, one day after taking the United States Medical Licensure Examination: Step 2 Clinical Knowledge, I finally had time to turn my attention to thoughts about my future and to the email messages that had accumulated over the past month. One announcement stood out: the Emory University Institute for Healthcare Improvement (IHI) Open School Chapter was seeking applications for its leadership team. With plans to begin the master of public health (MPH) in health policy and management program at the end of the summer, between my third and fourth years of medical school, I was searching for extracurricular opportunities that would complement my studies. In that moment, as I read the email solicitation, I took a leap of faith. I had never heard of IHI, yet within a week I had applied, interviewed, and accepted a position as director of education for Emory’s Chapter of IHI Open School. I was compelled to act so spontaneously by what I understood to be the vision, mission, and approach of IHI: to work with health systems and other organizations around the world to improve healthcare quality, safety, and value.
ISMP: Key Medication Errors in the Surgical Environment
Medication errors in the perioperative area received widespread media attention with the publication of an article in the journal Anesthesiology (Nanji, Patel, Shaikh, Seger, and Bates, 2016). The perioperative area is one of the most medication-intensive locations in a hospital, often with more medications, particularly high-alert medications, administered per patient than other patient care units. Yet, this area of the hospital often operates with fewer medication safety strategies in place than most other patient care units. For example, the anesthesia provider often selects, prepares, labels, and administers medications without the benefit of electronic clinical decision support, pharmacy review of medication orders prior to administration, barcode scanning of products prior to administration, and other secondary checks by other healthcare providers (Nanji et al., 2016; Brown, 2014). This lack of normal checks and balances, along with the use of multiple medications, time-sensitive tasks, complex and stressful working conditions, distractions, and fatigue all contribute to making the perioperative area particularly error-prone when medications are administered.