Editor’s Notebook

Story Power

By Susan Carr

The patient safety community generally understands the value of stories as a way to honor the experience of people who have been harmed by medical error, to humanize efforts to improve safety, and to inspire the will to change. I had an experience in August that demonstrated just how powerful and disarming these stories can be.

AHRQ

Eliminating CLABSI: Progress on a National Patient Safety Imperative

By Carolyn M. Clancy, MD

At any given time, about 1 in every 20 patients has an infection related to his or her hospital care. These infections cost the U.S. healthcare system billions of dollars each year and lead to the loss of tens of thousands of lives.

Medical Interpretation

Working Together for Patients with Limited Proficiency in English

By Armando Ezquerra Hasbun

Effective communication between the patient and the medical provider plays a vital role in the delivery of high-quality medical care. But what if that patient is a non-English speaker? Not only do healthcare facilities have a duty to provide language assistance services to limited-English proficient (LEP) patients to ensure quality medical care, but currently there are requirements for equal language access that recipients of federal funding must adhere to.

Daily Check-In for Safety: From Best Practice to Common Practice

By Carole Stockmeier, MHA, CMQ-OE; and Craig Clapper, PE, CMQ-OE

In the nuclear power industry, knowing the status of plant operations and early identification of potential problems is safety critical. At nuclear generating stations across the country, like the Black Fox plant (a pseudonym), each day begins with a plan-of-the-day meeting of plant leaders.

Automated Pre-op Instructions in a Culture of Continuous Improvement

By James Gottesman, MD

The benefits of providing patients with pre-operative instructions tailored specifically to their unique procedures, health status, and medications are well established. Patient safety perhaps tops this list. Healthcare providers have long recognized that offering clear, easily understandable instructions that cover requirements including fasting, discontinuing anticoagulants or blood pressure regulators, avoiding tobacco and alcohol, and more can enhance patient safety by reducing the chances of potentially life-threatening perioperative complications (Tea, 2010).

The Silent Treatment: Why Safety Tools and Checklists Aren’t Enough

By David Maxfield; Joseph Grenny; Ramón Lavandero, RN, MA, MSN, FAAN; and Linda Groah, RN, MSN, CNOR, CNAA, FAAN

Poor communication is deadly, especially in critical care settings (Wachter, 2010; The Joint Commission, 2010). When communication breaks down in intensive care units (ICU) and operating rooms, the result is catastrophic harm (Alvarez, 2006; Gandhi, 2005) and even death (Consumers Union, 2009; Institute of Medicine, 2000).

Patient Safety Summit in Emergency Care

By Stephen D. Armstrong

Emergency care and patient safety thought-leaders from across North America convened in Las Vegas in May 2011 to spend two days together to address the patient safety challenges and opportunities throughout the continuum of emergency care. The event was hosted by the Emergency Medicine Patient Safety Foundation (EMPSF), a national not-for-profit organization based in California whose mission is to improve patient safety in the practice of emergency medicine through education, research, collaboration, and training.

Remote Monitoring Showcase

Where Are the ‘Dots’?

A network is comprised of nodes, sometimes called dots, that have to be connected for the system to provide benefits.

By Tom Inglesby

When you design a network, you want to connect the nodes or devices—“connect the dots”—to be sure that the units that have to “talk” to one another do so efficiently. If a node drops out, due to loss of power for example, there should be a way to route the data around the blacked-out dot and maintain the network’s throughput. If a node moves out of range, you want to know where it went and why.