In late October, I attended three conferences: Health 2.0, the Center for Connected Health symposium, and the annual congress of the Center for the Integration of Medicine and Innovative Technologies. Although these organizations have somewhat different audiences (Health 2.0 is more a community than organization), their conferences share a focus on technology, especially applications and devices that give patients new ways to manage their health and medical care.

While not spread evenly, our national investment into improving the quality of care has begun to pay dividends. So far, the payback has been modest: Quality inched upward by 2.3% between 1994 and 2005, according to a 2007 national report from the Agency for Healthcare Research and Quality (AHRQ).

One early morning in September 1982, a 12-year-old girl awoke in her home in the outskirts of Chicago with moderate cold symptoms. Her loving parents prepared a tall glass of water and one Extra Strength Tylenol® capsule for her to take before sending her back to bed. A few hours later, Mr. and Mrs. Kellerman awoke to find their daughter Mary critically ill on the bathroom floor. Her parents rushed her to the hospital, and she died a short time later.

Making drugs is messy. Take heparin. You raise pigs and then slaughter them. You isolate the pig intestines and cook them. Then you scrape the intestinal insides, dry them, and get them to a factory to undergo more processing (Harris, 2008).

Patient Safety. It’s one of the highest priorities in healthcare today. The Institute of Medicine reported in 1999 that approximately 1 in 10 patients in the United States is injured and nearly 100,000 die every year from preventable medical errors. While most of the news seems discouraging, many hospitals are making progress in bringing about improvements in their patient safety practices. To help recognize these healthcare organizations, Precision Dynamics Corporation (PDC) and Patient Safety & Quality Healthcare (PSQH) cosponsored a nationwide Partner in Patient Safety Success Story contest.

I, like many of you, read in July about another heparin-IV versus heparin-flush incident. As reported by CNN.com, as many as 17 infants in Corpus Christi, Texas, received the all-too-common 1000x overdose believed in this case to have been caused by a mixing error. As of this writing, two of the children have died, though causes of death were still uncertain. Several industry leaders said that barcoding is an obvious solution, but if the error occurred when the drug was being prepared or mixed in the pharmacy department, many found it difficult to understand how a few black lines in a barcode would have made a difference.

Disruptive clinician behavior continues to make headlines in news media, as first reported by the lead author in 2006 (Porto & Lauve). In July of this year, The Joint Commission, recognizing that disruptive clinician behavior continues to present challenges to healthcare organizations and impacts the quality and safety of patient care, released a Sentinel Event Alert on this topic to provide guidance on how to deal with it (Joint Commission, 2008, July 9). Despite this, hospitals and healthcare organizations continue to struggle with this issue…

Philadelphia-area hospitals have charted a unique strategy in patient safety: Facilities that are normally competing for patients are collectively identifying effective measures to prevent patient falls. Harnessing their strength as a regional collaborative, the hospitals have shared stories of how to implement effective interventions for falls prevention and have participated in brainstorming workshops to identify a long list of additional strategies. The facilities can then choose from the list those interventions that zero in on their unique challenges.

When sentinel events and near misses occur, the risk manager investigating the event often hears these types of statements from the people involved: “I didn’t mean to…,” “I thought you were…,” or often, “If only I could do it all over again…”

Surgical procedures account for a major share of a typical hospital’s overall financial performance. It is estimated that surgical services and associated care often generate around 60% of a hospital’s total revenues and some 30% to 40% of a hospital’s total expenses. Yet even as clinical information systems evolve forward rapidly in many areas of hospital operations, the vast majority of hospital organizations still have not yet fully automated their surgery processes.