AHRQ Offers Free Quality Indicators (TM) Toolkit

The Agency for Healthcare Research and Quality (AHRQ) offers a free toolkit to help hospitals understand and make effective use of the agency’s Quality Indicators (QIs) and Patient Safety Indicators (PSIs). In addition to its focus on these indicators, the toolkit is a general guide to using improvement methods.

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Health 2.0 and ONC Announce Reporting Patient Safety Events Challenge

Health 2.0 and the Office of the National Coordinator for Health Information Technology (ONC) today launched the Reporting Patient Safety Events Challenge, designed to spur development of platform-agnostic health information technology (HIT) tools to facilitate the reporting of medical errors in hospital and outpatient settings. The deadline to submit applications is August 31, 2012.

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Noah’s Story: Please Listen

Noah’s Story: Please Listen

 

Communication in healthcare—provider to patient, patient to provider, and provider to provider—is at the heart of improving quality and patient safety. This is the story of my son Noah, whose experience with the healthcare system 13 years ago inspired me to work toward making positive changes in hospital care. His story is interspersed below with my present-day commentary about what I now understand about how poor communication contributed to his death. I hope Noah’s story inspires patients, families, and providers to communicate as effectively as possible and helps other patients and families avoid harm.

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We Can All Define Patient Safety… or Can We?

We Can All Define Patient Safety… or Can We?

Patient safety is a term used frequently in healthcare… perhaps too frequently, and sometimes without appropriate context. An exploratory survey was conducted at the Estes Park Institute conferences in the 2009–2010 season to probe the definition of patient safety among hospital executives, board members, and physician leaders. Participants were given 3 to 4 minutes to define patient safety with up to 10 single words.

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ISMP: Building Patient Safety Skills: Common Pitfalls in Root Cause Analysis

ISMP

Building Patient Safety Skills: Common Pitfalls in Root Cause Analysis

Most hospitals are acquainted with the root cause analysis (RCA) process and have conducted numerous RCAs in the past 15 years since The Joint Commission first required its use to investigate sentinel events. RCA is the most basic type of event investigation; an analytical approach to problem solving that seeks to identify why adverse events happen and how to prevent them.

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Smart Pump Workarounds: What’s the Legal Risk?

What’s the Legal Risk?

Smart Pump Workarounds: What’s the Legal Risk?

 

In the past few years the need to improve intravenous (IV) medication safety has been heightened by several highly publicized reports of medication errors. At Methodist Hospital in Indianapolis, heparin administration errors led to the deaths of three premature infants. The actor Dennis Quaid’s newborn twins almost died of heparin overdoses. In Wisconsin, a teenage mother in labor died because bupivacaine was administered intravenously instead of epidurally.

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