Story Power
Editor’s Notebook
Story Power
The patient safety community generally understands the value of stories as a way to honor the experience of people who have been harmed by medical error, to humanize efforts to improve safety, and to inspire the will to change. I had an experience in August that demonstrated just how powerful and disarming these stories can be.
Eliminating CLABSI: Progress on a National Patient Safety Imperative
AHRQ
Eliminating CLABSI: Progress on a National Patient Safety Imperative
At any given time, about 1 in every 20 patients has an infection related to his or her hospital care. These infections cost the U.S. healthcare system billions of dollars each year and lead to the loss of tens of thousands of lives.
Web 3.0 Data-Mining for Comparative Effectiveness and CDS
Health IT & Quality
Web 3.0 Data-Mining for Comparative Effectiveness and CDS
“Turbulent times” accurately describes the state of the American healthcare system. The list of critical challenges is well known—upward spiraling healthcare costs now approaching 17% of GDP, healthcare payment reform, shortage of clinical professionals, aging population, and the economic downturn.
Scanner Beep Only Means the Barcode Has Been Scanned
ISMP
Scanner Beep Only Means the Barcode Has Been Scanned
You might find it hard to believe that wrong patient and wrong drug/dose/time errors can still happen when using a bedside barcode scanning system. One source of error stems from the fact that, regardless of whether the correct product has been scanned or an associated warning has been issued, audible barcode scanners produce the same beeping sound.
Working Together for Patients with Limited Proficiency in English
Medical Interpretation
Working Together for Patients with Limited Proficiency in English
Effective communication between the patient and the medical provider plays a vital role in the delivery of high-quality medical care. But what if that patient is a non-English speaker? Not only do healthcare facilities have a duty to provide language assistance services to limited-English proficient (LEP) patients to ensure quality medical care, but currently there are requirements for equal language access that recipients of federal funding must adhere to.
Medication Reconciliation in Daily Rounds in the NICU
Medication Reconciliation in Daily Rounds in the NICU
There is a major thrust for patient safety nationwide. With an estimated 1.5 million preventable adverse drug events (ADEs) occurring annually in the United States, there is still a need for better error prevention systems (Institute of Medicine, 2007).
State-wide Leadership Creates a Culture of Patient Safety in Rhode Island
State-wide Leadership Creates a Culture of Patient Safety in Rhode Island
To provide a safer environment for patients in Rhode Island, 13 hospitals in the state have initiated a program to improve the way data on adverse medical events is reported, analyzed, shared, and utilized.
Daily Check-In for Safety: From Best Practice to Common Practice
Daily Check-In for Safety: From Best Practice to Common Practice
In the nuclear power industry, knowing the status of plant operations and early identification of potential problems is safety critical. At nuclear generating stations across the country, like the Black Fox plant (a pseudonym), each day begins with a plan-of-the-day meeting of plant leaders.
Automated Pre-op Instructions in a Culture of Continuous Improvement
Automated Pre-op Instructions in a Culture of Continuous Improvement
The benefits of providing patients with pre-operative instructions tailored specifically to their unique procedures, health status, and medications are well established. Patient safety perhaps tops this list. Healthcare providers have long recognized that offering clear, easily understandable instructions that cover requirements including fasting, discontinuing anticoagulants or blood pressure regulators, avoiding tobacco and alcohol, and more can enhance patient safety by reducing the chances of potentially life-threatening perioperative complications (Tea, 2010).
The Silent Treatment: Why Safety Tools and Checklists Aren’t Enough
The Silent Treatment: Why Safety Tools and Checklists Aren’t Enough
Poor communication is deadly, especially in critical care settings (Wachter, 2010; The Joint Commission, 2010). When communication breaks down in intensive care units (ICU) and operating rooms, the result is catastrophic harm (Alvarez, 2006; Gandhi, 2005) and even death (Consumers Union, 2009; Institute of Medicine, 2000).