Culture’s Reciprocal Rewards
Spring is a busy season for conferences. In May, I attended a few and missed a few because there weren’t enough hours and days in the month. At the ones I did attend, the effect of an institution’s culture on patient safety was a common theme.
OIG Report Critical of CMS Handling of Serious Adverse Events
In late 2011, the Office of Inspector General (OIG) released a report that examined CMS’s response to serious adverse events in hospitals. The report, Adverse Events in Hospitals: Medicare’s Responses to Alleged Serious Events (Levinson, 2011), concludes that “Medicare’s system of hospital oversight missed opportunities to address patient safety in its response to alleged serious adverse events.”
Health IT & Quality
Print Me a Pill
During the first Star Trek series released in the mid 1960s, the creators introduced viewers to several magical devices—the Communicator, the Padd, the Replicator, and the Transporter. Although building the latter device requires the repeal of several laws of physics, the other three commonly exist today for the public to use. Smart phones are the Communicator of today allowing us to speak, text, or email to anyone around the world who might have a similar device.
Short of Everything Except Errors: Harm Associated with Drug Shortages
In the November 3, 2011, ISMP newsletter, we asked hospital pharmacy staff to let us know if the drug shortage problem in the United States has continued to result in harmful outcomes for hospitalized patients. At that time, an Associated Press article had just reported 15 deaths in the prior 15 months that were linked directly to drug shortages (Johnson, 2011). (Thirteen of these deaths had also been reported to ISMP.) In response to our request for information, nearly 100 practitioners took our short survey and strengthened our belief that the ongoing drug shortage crisis is extracting a significant toll on patient safety.
American College of Surgeons
Four Critical Elements of an Effective Quality Improvement Process
More than a decade since the Institute of Medicine’s (IOM) landmark To Err Is Human report put a spotlight on quality improvement and patient safety, there has been little reduction in the rate of adverse events, according to The New England Journal of Medicine (2010).
Stories of Success!
Case Studies Show Health IT Improves Safety and Quality
The Stories of Success! Project is focused on two goals: the first, to solicit case studies demonstrating how healthcare information technology (IT) is leveraged in support of the National Quality Strategy, the development of which was required by the Accountable Care Act (ACA), the Partnership for Patients Goals (PfP), the National Priorities Partnership (NPP) recommendations for national focus and The Joint Commission National Patient Safety Goals (NPSG) and the second, the use of the Standards for Quality Improvement Reporting Excellence (SQUIRE) to submit case study reports.
Preventing Falls: The A-B-C Approach
Little kids play at falling down. When people are a bit older, falling is avoided—unless they are into tumbling or martial arts! And once they reach the level of senior citizen, falling becomes potentially fatal. According to a literature review by Clyburn and Heydemann (2011), statistics show that falls are the leading cause of fatal and nonfatal injuries to older people in the United States. Each year, more than 11 million people 65 and older suffer falls.
Virtual Patient Platforms
Clinical decision-making skills are among the most valuable assets healthcare professionals possess, but they are also one of the hardest aspects of medicine to teach, learn, and hone. For most caregivers, gaining the skills and experience they need comes from interaction with actual patients, and this approach requires healthcare professionals to strike a delicate balance—one where educational needs are carefully weighed against potential safety issues, and time spent in real-world settings is preceded by countless hours of classroom preparation and instruction.