Noah’s Story: Please Listen

By Tanya Lord, MPH, PhD

Communication in healthcare—provider to patient, patient to provider, and provider to provider—is at the heart of improving quality and patient safety. This is the story of my son Noah, whose experience with the healthcare system 13 years ago inspired me to work toward making positive changes in hospital care. His story is interspersed below with my present-day commentary about what I now understand about how poor communication contributed to his death. I hope Noah’s story inspires patients, families, and providers to communicate as effectively as possible and helps other patients and families avoid harm.

We Can All Define Patient Safety… or Can We?

By Della M. Lin, MD, and Sanjaya Kumar, MD

Patient safety is a term used frequently in healthcare… perhaps too frequently, and sometimes without appropriate context. An exploratory survey was conducted at the Estes Park Institute conferences in the 2009–2010 season to probe the definition of patient safety among hospital executives, board members, and physician leaders. Participants were given 3 to 4 minutes to define patient safety with up to 10 single words.

ISMP

Building Patient Safety Skills: Common Pitfalls in Root Cause Analysis

By The Institute for Safe Medication Practices

Most hospitals are acquainted with the root cause analysis (RCA) process and have conducted numerous RCAs in the past 15 years since The Joint Commission first required its use to investigate sentinel events. RCA is the most basic type of event investigation; an analytical approach to problem solving that seeks to identify why adverse events happen and how to prevent them.

What’s the Legal Risk?

Smart Pump Workarounds: What’s the Legal Risk?

By Tim Vanderveen, PharmD, MS

In the past few years the need to improve intravenous (IV) medication safety has been heightened by several highly publicized reports of medication errors. At Methodist Hospital in Indianapolis, heparin administration errors led to the deaths of three premature infants. The actor Dennis Quaid’s newborn twins almost died of heparin overdoses. In Wisconsin, a teenage mother in labor died because bupivacaine was administered intravenously instead of epidurally.

AHRQ

Evidence-Based Methods and Tools Help Reduce Risk of Falls in Hospitals

By Carolyn M. Clancy, MD

Wider acceptance of practices, methods, and tools to prevent the risk of patient falls holds promise in preventing a serious, and often catastrophic, event for older Americans. Evidence-based practices that can lower the incidence of falls are especially important in light of the aging of the U.S. population and the federal government’s inclusion of injuries from falls that occur during a hospital stay as a “never event” whose additional costs are not reimbursed (Centers for Medicare & Medicaid Services, 2008).

Health IT & Quality

Sensory Overload?

By Barry P. Chaiken, MD, FHIMSS

Although the tourist slogan for Las Vegas claims “what happens in Vegas, stays in Vegas,” some of the most exciting consumer technology announcements come out of Las Vegas each year. The annual Consumer Electronics Show (CES) held each January introduces to the world the latest gadgets that manufacturers hope will be hit items for the coming year.

Meaningful Use

The Next Stage for BCMA

By Jamie Kelly

On February 23, 2012, CMS took the next step toward meaningful use of electronic health records (EHRs) by proposing Stage 2 criteria. In 2 years, CMS has provoked dramatic change in the EHR landscape, stimulating nearly 2,000 hospitals and more than 41,000 doctors to invest in IT with $3.1 billion in Stage 1 payments.

Human Factors

Design Principles for Manual Safety Systems

By William A. Hyman, ScD

Safety systems can be added to a wide variety of medical devices ranging from relatively simple sharps protection for scalpels and syringes to the most complex systems such as multi-parameter monitors and ventilators. In general, added safety takes one of two forms.

Applying Lessons Learned to Accelerated Adoption of BCMA

By Robert Bayly, MD, FCCM, FCCP, and Susan Imhoff, RN, MSN

When JFK Medical Center in central New Jersey went live with barcoded medication administration (BCMA) in 2009, it took 12 months to reach and maintain a 97% scanning rate. The organization did not intend to stop after just three patient care units, but priorities changed, and the rollout was suspended.