Disclosure, Apology, and Resolution—No Turning Back Now

Rick Boothman has been thinking about when he knew that the University of Michigan Health System, where he is executive director of clinical safety, had reached the “point of no return” about openly discussing preventable harm with patients. In his keynote to the MITSS Annual Dinner in November, Boothman explained that he had been struck by something he heard during a meeting in Washington, which led him to reflect on Michigan’s commitment to this approach.

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Innovative System Ensures Reliable Care for Patients at Risk of Pressure Ulcers

Despite known and effective methods for identifying risk and preventing hospital-acquired pressure ulcers, pressure ulcers remain the most prevalent preventable hospital-acquired condition. Turning patients at certain intervals is a proven approach to preventing HAPUs, but this routine task is often delayed or skipped when nurses are drawn unexpectedly into demanding or emergent situations.

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Press Ganey Acquires Technology Firm to Enable Real-Time, Point-of-Care Patient Feedback

Press Ganey, the leading patient experience improvement firm, has acquired On The Spot Systems®, a point-of-care survey technology firm that enables organizations to capture real-time patient feedback. The acquisition advances Press Ganey’s Patient Voice™ portfolio for health care organizations by adding Point of Care to existing modes of mail, phone, and eSurvey.

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Infection Prevention

Recent features, columns and news articles on infection prevention from Patient Safety and Quality Healthcare: Industry News and Products 3M Makes Call to Action to Reduce Surgical Site Infections JCI, SHEA Release “Best Practices in Infection Prevention and Control: An International Perspective, Second Edition” Pharmacy OneSource Releases New Features for Sentri7 Patient Safety & Quality … Continued

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System Monitors Patient Movement, Improves Reliability of Routine Patient Care Tasks, and Reduces Incidence of Pressure Ulcers

 

Quality healthcare delivery has never been more achievable. Our knowledge of human physiology and diagnosing and treating disease is comprehensive. The armamentarium of diagnostic tools, therapeutic modalities and patient monitoring capabilities is considerable. So why do adverse and sentinel events continue to plague healthcare delivery?

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New York Metro-North Train Crash Offers an Opportunity

The deadly train derailment that occurred on Dec. 1, 2013, north of New York City apparently offers another example of an industry—or at least one heavily traveled commuter line—that is ripe to learn the lessons of safety science. With Dr. Lucian Leape’s discovery 25 years ago of the science of human error, healthcare began to assimilate knowledge from other disciplines and to improve safety by addressing the underlying, latent causes of error and harm. It appears that railroads would benefit from the same.

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