RMF Strategies Develops First-of-Its-Kind Surgical Malpractice Benchmarking Report
Report provides healthcare organizations with actionable data and insights for enhanced patient safety.
RMF Strategies, leading an innovative national effort to use malpractice data to help healthcare organizations reduce medical errors and enhance patient safety, announced it has developed a first-of-its-kind surgical benchmarking report, “Annual Benchmarking Report: Malpractice Risks in Surgery.”
NPSF Honors National Leaders with Awards at Patient Safety Congress
The National Patient Safety Foundation honored individuals and organizations with awards during the organization’s annual Patient Safety Congress in Orlando, May 18–19.
Using Automated Heparin Protocols and CPOE to Reduce Errors
When the Joint Commission adopted a National Patient Safety Goal requiring hospitals to reduce the likelihood of patient harm from the use of anticoagulants, St. Clair Hospital in Pittsburgh, Pennsylvania, swiftly mobilized and seized the opportunity to improve patient care. In fall 2007, the 329-bed hospital collected and analyzed data on anticoagulant medication occurrences over the preceding 2 years.
Electronic Health Records
A Vendor’s Diary
This is the first in an occasional series chronicling the implementation of an electronic health record in a small community hospital system in rural New Hampshire. Serious discussion about the implementation began in 2009, during a time of seismic change in healthcare and healthcare IT.
Human Factors 101
Affordances and Constraints Improve Reliability
In the first article in this series, we introduced concepts of human factors engineering (HFE) and their application to healthcare. We discussed how healthcare traditionally relies on the “weak aspects of cognition” (short term memory, attention to details, vigilance, multitasking etc.) and how that contributes to many of the errors experienced in healthcare.
Building a Culture of Safety
In the 10-plus years since the inaugural publication of the Institute of Medicine (IOM) study on medical error, To Err Is Human, there has been surprisingly little progress in reducing the rate of medical error, despite the adoption of technologies specifically intended to combat medical errors. A growing number of people attribute this lack of progress to fundamental flaws in the American healthcare culture that prevent success.
Health IT & Quality
Regulate HIT Tools as Medical Devices? Yes and No
The Food and Drug Administration recently announced it is reconsidering its previous decision to exclude health information technology (HIT) tools from regulation as medical devices. When last evaluated in the late 1990s, this decision made common sense. At that time HIT consisted of rudimentary clinical documentation systems, electronic reference materials, and administrative applications.
The unTechnology Conference
Many sports fans are familiar with the quip, “Last night I went to a fight, and a hockey game broke out.” Well, in early May, I went to a technology conference, and a patient safety meeting broke out. I didn’t expect the conference to be run-of-the-mill; the unSummit, by its name, signals that it offers an alternative conference experience and claims to offer high-quality, practical advice.
Safety Huddles for a Culture of Safety
When the Institute of Medicine (IOM) published To Err Is Human: Building a Safer Health System in 2000, the executives and quality and patient safety staff at Gundersen Lutheran immediately started discussions around issues emphasized in the report.
Common Cause Analysis
To improve medication safety, many healthcare systems implement a technology (such as barcode at point of care) or a best practice (such as double-check of high-risk medications). This approach turns performance improvement into experimentation with other people’s solutions for other people’s system problems — the assumption being all providers share the same system problems.