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.

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NPSF Awards Research Grants for Patient Safety Projects

The National Patient Safety Foundation (NPSF) announced on May 9 that it has awarded a total of $200,000 in grants for two innovative patient safety research projects. The grants are awarded through the NPSF Research Grants Program, which promotes studies leading to the prevention of human errors, system errors, patient injuries, and their consequences.

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Psych Patients Need Patience in the ER, Average Wait 11 Hours

Patients having psychiatric emergencies wait 11.5 hours in the emergency department, and those who are older, uninsured or intoxicated wait even longer, according to a study published online recently in Annals of Emergency Medicine (“Patient and Practice-Related Determinants of Emergency Department Length of Stay for Patients with Psychiatric Illness”).

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ANA and AONE Release Joint Principles of Collaboration

Communication and collaboration are critical elements of success for effective work environments, particularly in health care. When these elements break down, the result can be a cascade of negative events. Yet when collaboration is strong, it reaps positive benefits on the workplace culture and patient outcomes.

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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.

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