Safety incident detection and analysis are key components of a framework for patient safety improvement—both allow for understanding the nature of adverse events and can inform healthcare process enhancements to prevent error recurrence (Pronovost, et al., 2009). As the culture of error reporting has grown, the accumulation of data has outpaced our ability to effectively and efficiently analyze it for safety and quality interventions. (Johnson, 2003; Boxwala, et al., 2004).
Forging a New Era of Accountable Care
The country’s current healthcare system is fiscally unsustainable. The United States spends more of its gross domestic product (GDP) on healthcare than any other country, yet ranks only 37 in performance, according to the World Health Organization. Furthermore, healthcare spending is expected to increase from $2.6 trillion to $4.6 trillion by the end of the decade. As a result, new approaches to healthcare with the goal to achieve the Triple Aim—enhance quality, reduce cost, and improve outcomes—have started to emerge.
Safety in Numbers? Try Connectivity
How medical device integration increases patient safety.
Oh, to be a CIO at a U.S. hospital today. No doubt your job is challenging. But your skill set is in very high demand. Plus, you have an opportunity to flex your informatics muscles and escort your hospital towards meaningful use. But first you need board-approved funding for medical device integration, or device connectivity.
Perioperative Technology Improves SCIP Measurements in a Community Hospital
One of the most highly regarded quality initiatives in the hospital operating room (OR) sphere is the Surgical Care Improvement Project (SCIP), an ongoing program whose work was initiated in 2003 by the Centers for Medicare and Medicaid Services (CMS) and Centers for Disease Control and Prevention (CDC) and is coordinated through a steering committee of 10 national organizations committed to improving surgical care quality and patient safety.
Wander-Risk Patients: Best Practices for Hospitals and Assisted-Living Facilities
Older adults and senior citizens with Alzheimer’s disease and other forms of dementia are at elevated risk of wandering away from their medical care facility, which poses unique challenges for the hospitals and specialized care facilities that house these patients. Wandering puts them in harm’s way; they could fall, get into an accident, become a crime victim, or suffer from exposure to the elements.
Emergency Ultrasound at the Bedside: Not Just FAST
A Cost-Effective Technology to Reduce Medical Errors and Improve Safety
For critically injured trauma patients, “there is a golden hour between life and death,” observed R. Adams Cowley, MD, who pioneered the United States’ first statewide Emergency Medicine Service, in Maryland, in 1973. Also the founder of the nation’s first shock trauma center, Cowley is widely credited with being the first physician to recognize the supreme importance of combining skill, speed, and use of state-of-the-art medical technology to diagnose and initiate treatment of trauma patients during the first 60 minutes after an injury. His “golden hour” paradigm has revolutionized emergency care worldwide by highlighting the ideal strategy to optimize trauma patients’ survival (University of Maryland).
Technology and Culture
Each year, the January/February issue of PSQH is distributed at the HIMSS conference and exhibition, the largest annual event focused on health information technology, which takes place this year Feb. 20 to 24 in Las Vegas. Accordingly, this issue has a higher than average percentage of articles about technology and information systems, including electronic medical records, device integration, “big data,” business intelligence software, and adverse event reporting systems.
Health & IT Quality
Big Data Drives Big Change
Every MBTA bus in Boston carries a networked sensor that broadcasts the location of the bus along its route. This allows smartphone users to know exactly when the next bus will arrive at their corner stop, and MBTA supervisors to monitor the performance of drivers.
Every new General Motors automobile includes an event data recorder (EDR) that captures information about the car’s performance during an accident. Law enforcement and insurance companies use this information to help determine the cause of accidents, while car manufactures utilize the information to assist them in designing safer cars.
EMR Adoption and the Roles of the CMIO and CNO
U.S. hospitals have been focused on achieving criteria outlined in meaningful use since the passage of the American Recovery and Reinvestment Act (ARRA). According to the 22nd Annual HIMSS Leadership Survey, half of respondents identified meeting meaningful use criteria as their organization’s top IT priority, and two-thirds of respondents reported that their organization has already made additional IT investments to position themselves to qualify for the incentives associated with achieving meaningful use.
A Closer Look at FDA’s Adverse Event Reporting System
The U.S. Food and Drug Administration (FDA) is responsible for safeguarding patients and protecting public health by assuring the safety, efficacy, and security of medications. In order to accomplish this, the FDA’s primary monitoring process in preventing adverse drug events that occur with marketed drugs is the Adverse Event Reporting System (AERS), a computerized information database.
Taking CDS to the Next Level for Medication Management
Consider the following scenario. A patient in a hospital acquires pneumonia. When the attending physician enters an order for the antibiotic ceftriaxone, an alert pops up indicating that the patient is allergic to the medication. Based on the information provided, the physician chooses another appropriate medication. In this case, clinical decision support (CDS) did its job.
Multiple Latent Failures Align to Allow a Serious Drug Interaction to Harm a Patient
Whenever ISMP assists hospitals with a root cause analysis or conducts its own investigation of an adverse event, we inevitably uncover numerous precipitating latent failures (see definition in box at the end of the article) that led to the actual event. Similar to dominos that require perfect alignment in order to collapse in a series, latent failures also must align perfectly for an event to occur and go unnoticed.