Preventing Wrong-Site Surgery in Minnesota: A 5-Year Journey
While rare, surgeries and invasive procedures on the wrong body part (wrong-site procedures) are proving to be one of the most intractable patient safety issues. Despite years of effort at the state, national, and individual facility levels, these preventable events continue to occur.
Better Care for Patients with Atrial Fibrillation: A Three-Part Approach
Some 2.6 million Americans have atrial fibrillation, a leading cause of hospitalization in the United States. Each year, 300,000 new cases of this form of cardiac arrhythmia are diagnosed, often due to the chest pain, palpitations, syncope, and exacerbation of heart failure associated with the condition. It is a condition that requires careful management: atrial fibrillation causes 20% of all strokes, and these are more likely to be the most severe, life-altering strokes.
Quality in Healthcare: A Five-Dimensional View
Readers may be familiar with John Godfrey Saxe’s poetic version of the Asian Indian legend concerning the six blind men who each tries to describe an elephant by reaching out and touching the part closest to where he is standing. One touches the trunk, another a leg, one the tusk, and so on; and each describes the pachyderm by what his sense of touch has revealed, and of course none of them accurately describes the elephant.
Rapid Change with Clinical Performance Groups: Define, Design, Implement
An analysis of current practice indicated few of our facilities had policies regarding elective deliveries at less than 39 weeks, and those that did were not following them consistently. It became clear to the CPG this was an area that could be positively impacted in a short period of time.
The Leadership Value Equation: Quality Care at Reasonable Cost
Effective quality programs require leadership engagement. External pressures such as healthcare reform, pay-for-performance reimbursement, value-based government purchasing, public reporting of outcomes, Sarbanes-Oxley Act corporate responsibility requirements, state laws regarding corporate oversight, the Joint Commission leadership standards, the Institute for Healthcare Improvement’s campaign for “Getting Boards on Board,” and the American Hospital Association’s governance principles have brought the value equation between the quality and financial aspects of healthcare into sharp focus.
The ‘Big Universe’ of Diagnostic Error
Patient safety advocates look forward to the day when principles they currently pursue as part of a directed agenda infuse the practice of medicine extensively, resulting in less need for advocacy, remedial training, and re-engineering because patient safety is baked into the culture of medicine.
Drug Shortages and Emergency Care: Your Action Is Needed
An unprecedented, unexpected, and unplanned shortage of emergency medications has resulted in a quickly expanding set of problems for emergency departments (EDs) and emergency medical services (EMS) systems. The causes of this shortage are poorly understood, but the manufacturers and federal agencies that oversee drug supply and manufacturing practices—Federal Drug Administration (FDA) and Drug Enforcement Administration (DEA)—have been at odds for the past few years over safe manufacturing and quality processes. In certain circumstances, problems in the supply chain for raw materials for drugs cause shortages; for example, some raw materials come from overseas sources and may be subject to factors such as wars, weather, and problems with supply. Medication shortages are affecting many specialties, including oncology and anesthesia, but the emergency care system is particularly at risk for patient safety issues.
Key Characteristics of Successful Leaders
Replacing senior leaders in an organization is never easy. With a board of directors and other top executives having invested a lot of time and money in supporting the former leader, now they face the difficult task of replacing that knowledge and experience with a leader who will help advance the organization into the future. Finding effective leaders is different today than it might have been in the past, but there are certain, proven criteria organizations should consider using to find the right people.
The American Society of Medication Safety Officers
A Conversation with Christian Hartman, Founder and President
PSQH Editor Susan Carr talked with Chris Hartman in June 2012 about the American Society of Medication Safety Officers (ASMSO), an organization he started in 2006.
Sterile Compounding Tragedy: Symptom of a Broken System
In the wake of the current multistate meningitis outbreak (www.cdc.gov/HAI/outbreaks/meningitis.html), ISMP wishes to express its deepest sympathy to all affected by the contamination of compounded products from a New England compounding pharmacy. This is certainly a tragedy of monumental proportions.
Meningitis Outbreak Prompts State and Federal Action to Improve Safety
According to the Institute for Safe Medication Practices (ISMP), the fungal meningitis outbreak caused by contaminated products from a Massachusetts compounding pharmacy may be the most serious medication safety incident in recorded history.
Peer Review: Why Current Models Undermine Safety Culture
The field of radiology is known for its rapid innovations in technology. We continually offer up exciting new ways to image the body, but when it comes to improving the accuracy of professional interpretations, little meaningful progress has been made in the last 50 years. This is true in part because current radiology peer review models are insufficient, and in some circumstances, even harmful to quality improvement efforts.
Health IT & Quality
‘Show Me the Money’ Revisited
In the immortal words of Ronald Reagan, “There you go again.” Something that can be explained simply is twisted to look infinitely complicated with plots and subplots that would make J.K Rowling proud. The recent controversy over the use of electronic medical records (EMRs) to increase reimbursements to providers suggests intrigue, fraud, and bad intent. In contrast, if you learn how the money flows, you will better understand the true reasons for the outcomes seen in organizations using EMRs.