AHRQ: CUSP – Scaling Up a Safety Framework
AHRQ
CUSP: Scaling Up a Safety Framework
In the 13 years since the Institute of Medicine (IOM) issued its clarion call exposing major deficiencies in U.S. healthcare (2000), improving patient safety has been a foremost goal within our system. Providers, purchasers, consumers, payers, regulators, and other stakeholders have worked tirelessly together to formulate strategies to reduce needless harms (including needless deaths) resulting from care.
Diagnostic Error: Safe and Effective Communication to Prevent Diagnostic Errors
Diagnostic errors (i.e., diagnoses that are delayed, wrong, or missed) are increasingly recognized as a patient safety concern in ambulatory care (Singh & Graber, 2010). A recent report from the American Medical Association (AMA) Center for Patient Safety (Lorincz et al., 2011) highlighted the importance of diagnostic error and the critical need for future research on this topic.
ISMP: Drawn Curtains, Muted Alarms, and Diverted Attention: Tragedy in the PACU
ISMP
Drawn Curtains, Muted Alarms, and Diverted Attention: Tragedy in the PACU
Last April, a 17-year-old girl died following an uncomplicated tonsillectomy performed in an outpatient ambulatory surgery center after receiving a dose of IV fentaNYL in the postanesthesia care unit (PACU). The case made headline news again recently when a civil lawsuit filed by the teen’s parents was resolved. While it is too late to reverse the tragic outcome of this case, we call upon all hospitals and outpatient surgery centers to learn from the event and take action to prevent a similar tragedy in their facilities.
The Transformation of Healthcare
Our approach to health is undergoing a transformation, with profound implications for the role of the patient, the practice and business of medicine, and for many of the efforts we’ve come to think of as patient safety projects. The impulses feeding this transformation come largely from the public—consumers, politicians, government agencies, nonprofit organizations—not so much from providers and traditional medical institutions. This transformation is consistent with a broad-based consumerism movement, driven in part by access to information and technology.
Editor’s Notebook: Personal Accountability
Editor’s Notebook
Personal Accountability
I’m struck by the number and variety of patient safety initiatives that individuals, organizations, and government entities have underway. We’re engaged in so many different activities in the name of safety and quality, it’s hard to tell if we’re headed collectively toward a coherent goal. Despite success stories and pockets of excellence, many still wonder if we’re better off than we were a decade ago. In patient safety, how can we be sure that we’re cultivating a forest and not just a vast collection of specimen trees?
Video Monitoring System Measures Hand-washing Compliance
The North Shore-LIJ Health System is expanding a first-of-its-kind video monitoring system used to measure hand-washing compliance at North Shore University Hospital in Manhasset, NY, by introducing cameras in operating rooms at Forest Hills (NY) Hospital.
More Denominators
In the last issue of PSQH, I wrote about different takes on the concept of numerators and denominators. Kerry O’Connell leaves the comfortable world of uneventful patients (denominators) when he experiences preventable harm and joins the numerators. National Coordinator for Health IT Farzad Mostashari, on the other hand, thinks of denominators as patients whose individual characteristics—including chronic and underlying conditions in need of treatment—may be invisible until brought to light through electronic records and analytics.
GOJO Announces Launch of SMARTLINK™ Hand Hygiene Solutions
GOJO Industries, a leader in hand hygiene and skin health and inventors of PURELL® Hand Sanitizer, is assisting Texas Scottish Rite Hospital for Children (TSRHC) in measuring and improving hand hygiene compliance through its SMARTLINK Activity Monitoring System.
Philips Healthcare Launches Healthcare Transformation Services Business
Royal Philips Electronics has launched its Healthcare Transformation Services Business, which in collaboration with healthcare service providers, will offer consulting services to improve the operational and financial performance of hospitals and health systems, and improve patient outcomes across the continuum of care from diagnosis to treatment and after care at home.
New IOM Report Explores Inter-professional Education for Healthcare Workforce
The latest report from the Institute of Medicine summarizes the work of the Global Forum on Innovation in Health Professional Education. The Forum held two workshops in 2012 focused on the connection between inter-professional education and collaborative practice. The report summarizes the results of the workshops.