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PSQH Blog

Improving patient safety is one of the most urgent issues facing healthcare today. Patient Safety and Quality Healthcare (PSQH) is written for and by people who are involved directly in improving patient safety and the quality of care.

PSQH welcomes original submissions from all healthcare professionals on topics related to safety and quality. PSQH publishes a variety of articles, to reflect the breadth of work being done in this field: case studies, surveys, research, book or technology reviews, guest editorials, essays, and letters to the editor.

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Our responses to the news that Ebola had been diagnosed in the United States for the first time reveal gaps in our understanding of how to protect others and ourselves from Ebola and other infectious diseases. When we overreact in fear and take comfort from actions that don’t actually make us safer, we may overlook aspects of our systems and institutions that really do put us at risk.

The case of Thomas Duncan, diagnosed in Dallas with Ebola on September 26, 2014, reveals how unreliable our systems can be, especially under stress. The actions of Texas Health Presbyterian Hospital Dallas, where Duncan went for emergency care when he first became ill, reveal broad problems with implications that reach beyond the immediate response to one patient with Ebola.

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First, I must disclose a conflict of interest: I am co-author of one chapter in this edited collection, and the editor, Lorri Zipperer, is a close friend and colleague. I was pre-disposed to like this book, and as I spend more time with the other chapters, my respect for Lorri’s vision and the resulting text continues to grow.

Efforts to improve patient safety should be informed by the best evidence, information, and knowledge (EI&K) available, but often they are not. This is a familiar, if unexamined, problem in this time of “information overload,” but first I should review how the terms EI&K are defined and used in the book. These terms are common but not often used in the safety and quality improvement literature as precisely as they are in Patient Safety:

  • Evidence is the result of research, of tested hypotheses, such as trials and studies published in peer-reviewed publications across all disciplines (not just medicine).
  • Information is data that has been analyzed, organized, and printed/presented for a specific use.
  • Knowledge is what individuals know, either implicitly or explicitly. Knowledge is dynamic, with elements of action or experience.

Many of us are familiar with the challenge posed by the abundance of evidence, information, and knowledge currently available about all things. It is exhilarating that we live in a time of rich and increasingly available resources, but it is rarely self-evident how best to access the EI&K we need or easy to feel confident that we’ve found the best advice on a given subject. How do we know, for example, that what we really need is on page 10 or 25 of our Google search results or will only appear if we use a particular search word. Social media such as Twitter and email discussion groups have made experts more accessible than ever, but knowing who has the answer to your question, having the time to search, and simply knowing where to begin, is not always easy. These challenges exist in patient safety, too, with potentially profound implications for patients and all who are involved in their care.

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New guidance from the Centers for Medicare & Medicaid Services (CMS) recommends monitoring of patients receiving opioids.

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AdverseEvents’ primary customers are health plans, PBMs, health systems, and hospitals. We provide these healthcare decision makers with important insight on drug safety concerns that were not revealed during clinical trials and are not being communicated by the manufacturer.

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I had the radio on as I drove to the market, but I wasn’t really listening until I heard “It's very important to have a culture of safety that says, if you've got a problem, talk about it.” I didn’t recall ever having heard the phrase “culture of safety” outside of safety improvement circles.

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A recent CDC report found that 1 in 25 hospital patients develop healthcare-associated infections (HAIs). According to the report, about 75,000 of these patients die during their hospital stay.

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On May 7, the Dept. of Health and Human Services (HHS) reported on the effects of federal efforts to decrease the rates of hospital-acquired conditions (HACs) and readmissions. These efforts, implemented through a system of Hospital Engagement Networks (HENs), have been supported with funding from the Affordable Care Act (ACA), starting with grants to the HENs in October 2011.

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In 2005, the Pennsylvania Patient Safety Reporting System received a report of a near miss that brought up a new issue in the nursing field. It involved a nurse who worked in two hospital facilities; one facility used yellow wristbands for limb restrictions (do not use this limb) and the other facility used them to indicate DNR (do not resuscitate). This nurse had a patient with arm restrictions. So, well-intentioned, she placed a yellow wristband on the patient’s arm.

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OpenNotes is a program that allows patients to read their clinicians’ notes as they appear in the medical record. The program started less than five years ago and currently includes 2 million patients in health systems across the country, including the Department of Veterans Affairs.

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Patient safety has been a topic of interest at the annual HIMSS conference for the 10 years that I have attended and probably longer. Safety improvement usually appears on the program and in discussion as the result or at least the goal of technology implementations.

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The latest issue of Patient Safety & Quality Healthcare (PSQH) offers articles that focus on the pros and cons of information technology in healthcare, an interdisciplinary approach to managing drug shortages, new efforts to improve workplace safety for healthcare professionals, and more.

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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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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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Still hunting for that perfect holiday gift for the coder on your list? This illustrated guide to weird entries in ICD-10 could be just what the, um… doctor ordered. Struck by Orca includes more than 30 ICD-10 codes for the unfortunate, often surprising things that turn people into patients, including Y92.253 Opera house as the place of occurrence of the external cause, Y93.D1 Activity, knitting and crocheting and V91.07xD Burn due to water-skis on fire, subsequent encounter.

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Diane Shannon, MD, stopped practicing medicine 17 years ago and recently wrote a blog post to describe her feelings about being a doctor, her daily experience as an internist, and her decision to focus instead on medical writing.

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At the opening session of the annual conference of the American Society for Healthcare Risk Management (ASHRM), futurist Ian Morrison described current changes in the U.S. healthcare industry and how they relate to the interests of risk managers. While the Affordable Care Act is important and the obvious driver of change, Morrison is convinced that current trends—consolidation, cost reduction, and realignment of risk—will continue, independent of the federal legislation.

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From its early days in the 1980s and 90s, the patient safety movement has been blessed with high quality, accessible writing. Many of the early contributors—Michael Millenson, Bob Wachter, Atul Gawande, to name only a few—continue to contribute and update their research and reflections. Millenson and Wachter have recently commented on their earlier works and reflected on what if any progress they have seen over the years.

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At this year’s Quality Colloquium, multidisciplinary approaches to safety and quality improvement were discussed in many sessions, with benefits cited in the context of leadership, education, scholarship, as well as care delivery.

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The medical community has debated the value of sleep versus continuity of care since 2003, when the Accreditation Council for Graduate Medical Education limited the number of consecutive hours medical residents may be on duty. (Organizations are required to comply with the duty hour standard to retain ACGME accreditation.) Research, however, has shown that making sure resident physicians get enough rest doesn’t insure safer care for patients, which was the main driver of the standard.

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The operating room is one place in a hospital where things are expected to run like clockwork – it is imperative that surgical procedures start on time.  When delays occur, the impact can be significant:  staff and equipment are underutilized, surgeons become frustrated, patients grow (more) anxious and optimum outcomes may be placed at risk, particularly if the prior administration of medications or antibiotics had been timed to the projected start of a procedure. It is thus alarming that a recent study in JAMA Surgery found that 10 percent of surgical procedures were delayed due to a missing piece of paper – the consent form.

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EMPSF Institute for Safe Medical Practices
           
Medically Induced Trauma Support Services (MITSS) Medication Safety Officers Society NPSF Partnership for Patient Safety Society to Improve Diagnosis in Medicine