Engaging Patients and Families in Root Cause Analysis of Sentinel Healthcare Events: The Story of Justin Micalizzi
Working with two patient advocates, the Reliability Center has released a webcast that analyzes the sudden, unexpected death in January 2001 of 11-year-old Justin Micalizzi immediately following surgery for an infected ankle. For 10 years, the Micalizzi family—especially his mother, Dale, now a well known patient safety advocate—sought unsuccessfully and without the cooperation of the hospital to discover what caused Justin’s death or at least to elicit a clear and honest pledge that the hospital would commit sincerely to understanding what had happened.
Ekahau Launches Next Generation Wi-Fi RTLS Staff Badge and Pager
Northeast Georgia Physicians Group Chooses Phytel to Enhance Its Patient-Centered Medical Home Model
UC Irvine Medical Center Selects iSirona for Medical Device Integration
iSirona, a provider of simplified solutions for medical device integration, announced on May 8 that UC Irvine Medical Center will be implementing iSirona’s device connectivity solution throughout its campus.
HMS Fellowship in Patient Safety and Quality
NPSF Awards Research Grants for Patient Safety Projects
I-PASS: Standardizing Patient “Handoffs” to Reduce Medical Errors
Psych Patients Need Patience in the ER, Average Wait 11 Hours
ANA and AONE Release Joint Principles of Collaboration
The Risk of Workarounds
In April, Patient Safety and Quality Healthcare published an article summarizing a recent webinar presented through ourCenter for Safety and Clinical Excellence. The article is titled “Smart Pump Workarounds – What’s the Legal Risk?”, and it focuses on personal accountability on the part of caregivers in safely operating Smart IV pumps.
Caregiver accountability has been a hot topic in recent months. As it relates to IV medication safety, it’s a critical issue and worth paying attention to. It’s been shown that clinicians often implement process workarounds, including not utilizing the drug library, overriding soft dose and concentration alerts, reprogramming infusions as rate in ml/hr following hard limits, and occasionally removing IV tubing from pumps and delivering medication boluses by gravity to avoid a high dose alert.