Pulse
Pulse
Call for Letters of Intent to Conduct Research and Development in Patient Safety
Applications invited for grant projects to begin in 2012.
The National Patient Safety Foundation’s (NPSF’s) Research Grants Program seeks to stimulate new, innovative projects directed toward enhancing patient safety in the United States. The Program’s objective is to promote studies leading to the prevention of human errors, system errors, patient injuries and the consequences of such adverse events in the healthcare setting.
It’s Just Common Sense
Editor’s Notebook
It’s Just Common Sense
I recently moderated a webinar about a problem in healthcare that hadn’t occurred to me—nor to many others, it appears—but seems quite obvious now that it’s been brought to my attention. In the webinar, Dennis Tribble, chief pharmacy officer at Baxa Corporation, joined Stuart Levine of ISMP and Denise LaStoria, owner of Training Advantages, LLC, to discuss problems inherent in train-the-trainer programs used for technology training, especially in the pharmacy.
Say No to Paper
Health IT & Quality
Say No to Paper
Paper came one pill away from killing my 91-year-old mom. Only through luck did we dodge a medical error that could have extinguished a life that survived the Great Depression, World War II, polio epidemics, the birth of two children, the Cold War, the loss of her husband, and more than 60 years of employment. Up until her admission on May 7th, she had never experienced being an ill patient in a hospital.
“Can’t Rather than Don’t” Saves Lives
Human Factors
“Can’t Rather than Don’t” Saves Lives
A recent article in The New York Times, “U.S. Inaction Lets Look-Alike Tubes Kill Patients,” (Harris, 2010) shows that American hospitals are 80 or more years behind manufacturing industries in basic safety. This inexcusable situation deserves zero tolerance from patients, insurers, healthcare professionals, and other healthcare stakeholders.
Applying the IHI Global Trigger Tool to Pediatric and Special Needs Populations
Applying the IHI Global Trigger Tool to Pediatric and Special Needs Populations
Gillette Children’s Specialty Healthcare (Gillette) provides specialized healthcare services to individuals with disabilities, with a primary focus on children. Serving a wide geographic region, Gillette’s programs focus on the needs of patients with cerebral palsy, spina bifida, neuromuscular diseases, brain and spinal cord injuries, and complex neurological, craniofacial, and orthopedic conditions.
Heed This Warning! Don’t Miss Important Computer Alerts
ISMP
Heed This Warning! Don’t Miss Important Computer Alerts
Although pharmacists typically enter prescriptions and orders into the pharmacy computer, in some settings, specially trained pharmacy technicians or pharmacy interns perform this function. In these circumstances, a pharmacist later verifies that the order has been entered as prescribed at the same time he or she is assuring the appropriateness of the medication and verifying that the proper drug and dose has been prepared.
Barcode Technology for Positive Patient Identification Prior to Transfusion
Barcode Technology for Positive Patient Identification Prior to Transfusion
Renewed initiative engages nurses and achieves 100% compliance.
In today’s increasingly complex, highly demanding clinical environment, introducing a new technology is challenging under the best of circumstances. What if, right when roll-out is going well, an unrelated connectivity interruption leads nurses to conclude “this doesn’t work”? You need to get your initiative back on track—especially when it relates to improving the safety of a critically important patient-care process.
Forever Changed: Shared Learning in Patient Safety
In an effort to promote patient safety, Baptist Health South Florida (Baptist Health) has instituted the Shared Learning process, the purpose of which is to educate and communicate with all stakeholders—our clinical staff, the Quality and Patient Safety Steering Council, and board members—in a proactive way.
Design for Reliability: Barcoded Medication Administration
Design for Reliability: Barcoded Medication Administration
There is now widespread agreement that hospital patients can be harmed by medication errors. Providing patients with medications in the acute care setting is a complex process that requires coordination in the flow of information when individuals order, transcribe, verify, dispense, and administer a medication. Early studies quantified the extent to which errors occur at each of these stages; one of the most troubling steps in the process is the administration phase, when 26 to 38% of the errors occur (Bates et al., 1995; Leape et al., 1995).
Editor’s Note: Training Options
Effective training is crucial for safety improvement, and there is a wide range of programs and approaches available for healthcare. I’ve had the opportunity recently to reflect on three in particular: train-the-trainer, TeamSTEPPS, and Virtual Experience Immersive Learning Simulation (VEILS®).