Editor’s Notebook

Denominators Count, Too

By Susan Carr

In patient safety, it’s usually better to a denominator than a numerator, to be among the average folks than among the exceptions that prove the rule, to be among those who represent the baseline than among the few who deviate from the norm, to be among those in whom risk slumbers, not among those in whom risk is revealed.

News

ISMP

Red Flags that Represent Credible Threats to Patient Safety

By The Institute for Safe Medication Practices

Disruptive behaviors, intimidation in the workplace, and a culture of disrespect among healthcare professionals have repeatedly surfaced as significant barriers to patient safety. The hierarchical nature of patient care and the autonomy with which healthcare professionals have been taught to practice set the stage for a culture that does not respond well to even the slightest queries about possible problems with patient care, particularly from subordinates. It’s clear that such a culture needs to be repaired, and many healthcare organizations are working to address disrespectful behavior, staff reluctance to speak up about risks and errors, and blatant disregard of expressed concerns.

Health IT & Quality

The Eyes Have It

By Barry P. Chaiken, MD, FHIMSS

As we continue down the path toward digitized medical records, the challenges we face become incrementally harder. Moving from the HIMSS Analytics Stage 0 to Stage 1 where three ancillaries—lab, radiology, pharmacy—are all driven by healthcare information technology systems, is not a difficult jump.

Human Factors

Design Principles for Manual Safety Systems

By William A. Hyman, PhD

Safety systems can be added to a wide variety of medical devices ranging from relatively simple sharps protection for scalpels and syringes to the most complex systems, such as multi-parameter monitors and ventilators. In general, added safety takes one of two forms. The first is when the technology is made inherently safer as a result of eliminating or mitigating hazards at the most fundamental level. The second is when technological safety elements are added to the design in order to prevent a variety of use errors.

Medical Simulation:
A Holistic Approach to Highly Reliable Healthcare

By Ruth M. Fanning, Mb, MRCPI, FFARCSI

In the next three decades, significant demands will be placed on healthcare systems worldwide. Economic progress in rapidly developing countries and federal mandates closer to home will envelope greater numbers of patients in the healthcare net. In addition, in most parts of the western world, an aging population and rising levels of obesity will further challenge the status quo.

Intravenous Infusion Medication Safety:
The Vision Becomes Reality

By Tim Vanderveen, PharmD, MS

In 2000 the Institute of Medicine (IOM) published To Err Is Human, the first in its groundbreaking series of reports that brought the issue of medication safety to national awareness. The Institute for Safe Medication Practices (ISMP) February 2002 Medication Safety Alert! suggested that “with computerized prescriber order entry (CPOE), barcode medication administration (BCMA), and now smart infusion pumps, we may finally have a solid defense against the most serious medication errors” (ISMP, 2002). While these three technologies have played a major role in improving medication safety, there are still opportunities for errors.

Patients and Families:
Key Partners in Improving Patient Experience

By Jason A. Wolf, PhD

Perhaps it is time for those of us in healthcare to realize that patients and families are no longer simply “receivers” of care offered by “providers.” In fact, the trend of engaged patients has taken on increasing significance in the larger healthcare dialogue.