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An IC Check-Up

patient safety webinarPlease register for Strategies to Manage Hospital Acquired Conditions Reporting in an ACA World - An IC Check-Up on Sept 9th, 2014 1:00 PM CDT at: https://attendee.gotowebinar.com/register/5973501898406116610

With the August 1 Final Rule announcement by CMS, it’s time we had an Infection Control check-up from our IC expert, Brian Foy.

Brian will explain recent changes to Federal rules and its impacts on everyday IC preventionists. Then, the team will outline some of the experienced and expected challenges faced by industry partners and their solutions.

More information on Strategies to Manage Hospital Acquired Conditions Reporting in an ACA World - An IC Check-Up...

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Is the Answer to Enhanced Patient Safety Hiding in Plain Sight?
The Transformation of “Incident Reporting"

Is the Answer to Enhanced Patient Safety Hiding in Plain Sight? The Transformation of “Incident ReportingWe all have these systems, whether paper or electronic, that are supposed to capture incidents that can lead to and/or have resulted in patient harm. Most of these systems can do this, but many will agree that there is something missing – something important – when it comes to whether or not these systems actually enhance patient safety.

We cannot just track incidents anymore; we need to make this an organization-wide process where we build awareness, which leads to intervention, and results in changes that can be seen and monitored. In this white paper, we discuss the transformation of traditional “incident reporting” into an integrated patient safety management system and offer a path to achieve this transformation.


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By William A. Hyman

It has been popular to compare aviation’s safety record and procedures to similar processes in healthcare, usually with the notion that healthcare lags aviation in adopting a firm safety-oriented methodology (Carr, 2006; Pronovost et al., 2009; AHA, 2011). There can be considerable challenges when making such cross-discipline comparisons including staffing, training, mission scope, and perhaps personal risk.

It has been popular to compare aviation’s safety record and procedures to similar processes in healthcare, usually with the notion that healthcare lags aviation in adopting a firm safety-oriented methodology (Carr, 2006; Pronovost et al., 2009; AHA, 2011). There can be considerable challenges when making such cross-discipline comparisons including staffing, training, mission scope, and perhaps personal risk. If these challenges are not adequately met, the lessons supposedly learned may not actually be transferable from one profession to another. Or worse, thinking that they are readily transferable may lead to a false sense of accomplishment when one or more safety “fixes” are implemented.

One aspect of the aviation-versus-healthcare comparison that has not received sufficient attention is a direct comparison of the task structures and responsibilities of pilots versus nurses. As shown in the table below, there are very substantial differences between the work and work environment of each. Further, these differences appear to be put nursing at a considerable disadvantage with respect to being able to consistently accomplish their work without identified adverse incidents. Thus the relative deficit in healthcare safety compared to aviation is likely a result of major staffing, system and work design issues that is not likely to be adequately addressed without significant effort and change. However this is not an excuse not to do it, rather it is a call for an level of effort that is commensurate with the risk.


Aviation

Nursing

Work is primarily stationery – at the controls


Work is mobile

Primarily a single task – although that task has multiple components


Multiple often relatively unrelated tasks

Dedicated assistant – the co-pilot

Informal assistance when called upon


Standardizes staffing levels – no exceptions


Variable staffing levels, including working even below local standards


Equipment in use configured and certified by a central integrator



Associated substantial system feedback to operator


Independent equipment from multiple vendors



Limited and non-integrated feedback

Tasks highly standardized

Variable tasks depending on patients and other duties


Highly trained and certified on specific equipment



Mandatory refresher and emergency training


Variable training – often on multiple versions of the same devices


Limited refresher and adverse event training

Mandatory near miss (close call) reporting


Extensive

Haphazard reporting


Activity is partly under direct and continuous observation by third party (FAA)


No supervisor/third party observation

Pilot shares physical risk with passengers

Physical risk not shared


Clear outcome expectations – including by public


Possibly variable expected outcomes depending on patients, making it hard to identify untoward outcomes


Extensive external accident investigations

Primarily internal accident investigations – if at all



William Hyman is professor emeritus of biomedical engineering at Texas A&M University. He now lives in New York where he is adjunct professor of biomedical engineering at The Cooper Union. Hyman may be contacted at This email address is being protected from spambots. You need JavaScript enabled to view it. .

References

AHA Resource Center. (2011, April 11). Aviation and patient safety, American Hospital Association. Available at http://aharesourcecenter.wordpress.com/2011/04/11/aviation-and-patient-safety/

Carr, S. (2006). The joy of cross-fertilization. Patient Safety & Quality Healthcare, 3(2). Available at www.psqh.com/marapr06/editorial.html

Pronovost, P. J., Goeschel, C. A., Olsen, K. L., et al. (2009). Reducing health care hazards: Lessons from the commercial aviation safety team. Health Affairs, 28, 479-489.



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