Integrated Solution Helps Improve Pediatric Patient Safety, Streamline IV Medication Management

By Bobbie Carroll, RN, MHA

Among the most common and dangerous types of medication error are errors made in administering medications intravenously—especially when the patient is a child.

Mentoring Programs: Essential for Sustaining a Culture of Safety

By Mary A. Seisser, MSN, RN, CPHRM, CPHQ, FASHRM; and Rosalie S. Brown, BA, MHA, RN, CPHRM

An effective mentoring program can strengthen a healthcare enterprise’s performance in many areas, including quality improvement, risk management, personnel recruitment and retention, staff education, and leadership. By enhancing staff knowledge and team integration, mentoring programs help support an enterprise-wide culture of safety, which, in turn, helps minimize adverse patient occurrences and related financial losses. This article examines the theory and practice of mentoring, focusing on how adult learning strategies and ongoing managerial support can improve mentor-mentee rapport and produce better outcomes for participating individuals and the organization.

A Team Approach to Fall Prevention

By Catherine Edmonds, MSN, RN, CNL

Falls are a growing health concern, especially within the acute care arena. A fall is defined as “an event which results in a person coming to rest inadvertently on the ground or floor or other lower level” (Johnson et al., 2011). More than 30% of adults age 65 and older fall each year (Centers for Disease Control and Prevention, 2011), and up to 50% of adults age 85 and older fall each year (Bohl et al., 2010). With the aging population, the incidence of falls is only expected to increase.

Enhancing Clinical Education and Training, Improving Care

By Manon Maitland Schladen, MSE, PMP, EdS; and Cynthia G. Pineda, MD, FAAPM&RI

More than a decade ago the Institute of Medicine published its landmark study, To Err is Human (2000), documenting an unacceptably high rate of medical errors, many of them resulting from poor clinical decision-making. In fact, surgeons in the United States make medical errors more than 4,000 times a year, which can result in permanent injury or death. These types of preventable errors include wrong-site surgery, retained surgical items, wrong-patient surgery, and wrong-procedure surgery, causing nearly half of the affected patients to suffer temporary injury (Landro, 2012).

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Fall Prevention: No, Falls Are Not Inevitable

By Tom Inglesby

Patients fall. It’s a fact of hospital life. Weakened by illness or surgery, confused by medication or aging, patients try to do more than they can and the result is often a fall. It might be a fall from bed, a fall while trying to walk unsupported, a fall when trying to get up from a chair. These things happen all too regularly. As caregivers, your job is to prevent those falls from happening.

Editor’s Notebook

Denominators Count, Too

By Susan Carr

In patient safety, it’s usually better to a denominator than a numerator, to be among the average folks than among the exceptions that prove the rule, to be among those who represent the baseline than among the few who deviate from the norm, to be among those in whom risk slumbers, not among those in whom risk is revealed.

News

ISMP

Red Flags that Represent Credible Threats to Patient Safety

By The Institute for Safe Medication Practices

Disruptive behaviors, intimidation in the workplace, and a culture of disrespect among healthcare professionals have repeatedly surfaced as significant barriers to patient safety. The hierarchical nature of patient care and the autonomy with which healthcare professionals have been taught to practice set the stage for a culture that does not respond well to even the slightest queries about possible problems with patient care, particularly from subordinates. It’s clear that such a culture needs to be repaired, and many healthcare organizations are working to address disrespectful behavior, staff reluctance to speak up about risks and errors, and blatant disregard of expressed concerns.

Health IT & Quality

The Eyes Have It

By Barry P. Chaiken, MD, FHIMSS

As we continue down the path toward digitized medical records, the challenges we face become incrementally harder. Moving from the HIMSS Analytics Stage 0 to Stage 1 where three ancillaries—lab, radiology, pharmacy—are all driven by healthcare information technology systems, is not a difficult jump.