Editor’s Notebook

Conferences and Silos

By Susan Carr

While attending a number of conferences in October, I was struck by the
siloed nature of most of the educational sessions I attend. As a member
of the media, I go to a lot of conferences. Though I often work on
articles that identify “silos” — the provincial cultures of specialized
communities in healthcare — as counter-productive for safety, I had not
previously recognized the silos in conference-based education.

AHRQ

Comparative Effectiveness Research: Keeping the Patient at the Center

By Carolyn M. Clancy, MD

With this issue, Patient Safety & Quality Healthcare (PSQH)
reaches its fifth anniversary, which prompts me to take a moment and
think about how much the world has changed and stayed the same in the
past five years. When we published the first issue, in July 2004, the
patient safety community was discussing how much progress—if any—had
been made since the IOM published To Err Is Human five years earlier, and now we are assessing progress made over the past 10 years.

Health IT & Quality

Making Meaningful Use “Meaningful”

By Barry P. Chaiken, MD, FHIMSS

A short three years ago, the Office of the
National Coordinator for Health Information Technology was funded
at a level of less than $150 million. Today, thanks to the Health
Information Technology for Economic and Clinical Health Act of 2009 — part of the American Recovery and Reinvestment Act —
the ONC received a budget of over $2 billion. In addition, no less than
an additional $19 billion is set aside to facilitate the adoption of
electronic medical records over the next decade.

How a Captive Insurer Uses Data and Incentives to
Advance Patient Safety

By Diane W. Shannon, MD, MPH

The Institute of Medicine report (2000), To Err Is Human,
unveiled a truth about the U.S. healthcare system that was previously
either obscure or unrecognized: we have a “non-system” of care with a
relatively high frequency of errors. The high defect rate leads to the
death of thousands of people each year from preventable errors — more
individuals than die from motor vehicle accidents, breast cancer, or
AIDS (Kohn, 2000).

Never Events

Rhode Island Hospital Uses Integrated Approach to Prevent Falls

By Steve Elder

Falls have been a patient safety concern for years. Yet there has been
an increased focus on this issue in recent times, as its scope and
resulting costs have come into clearer focus. Pressure has come from
many directions. In July 2000, the Joint Commission issued Sentinel Event Alert 14,
“Fatal Falls: Lessons for the Future,“ and in 2005 made reducing the
risk of patient harm from falls one of its National Patient Safety
Goals.

Rapid Response Teams and Continuous Quality Improvement

By Mary Sue Dailey, APN-CNS; Sue Durkin, APN-CNS; Barbara Gulczynski, APN-CNP, APN-CNS; Marge Kearney, APN-CNS; Barbara Loeb, MD; Joanne Pouliot, RN, MS

When the Institute for Healthcare Improvement initiated the
100,000 Lives Campaign in late 2004, Advocate Good Samaritan Hospital
joined the endeavor to promote patient safety by instituting the six
components of the initiative, including development and deployment of a
Rapid Response Team.

MedWise: Preventing Medication Waste While Promoting Safe Administration

By Jeffrey Conzelmann, PharmD; Karyl King, PMP; Sharon Sarnicola, RN; and Brenda Wierenga, RN, BSN

Hospitals face a frustrating medication dilemma: should inpatients be
allowed to take their multi-dose medications (e.g., inhalers, topical
creams, eye drops, insulin) home upon discharge? The natural
inclination is for patients to ask, “These are paid for; why can’t I
take them home? What’s the big problem?”

Measuring and Improving Surgical Quality

By Clifford Y. Ko,MD, MS, MSHS, FACS

Over the past decade, the number of quality measurement programs — both
mandatory and voluntary — has grown exponentially as hospitals respond
to public and government demands for greater transparency and
accountability and improved patient care. Many on the front lines of
hospital quality improvement efforts may find it difficult to tell
which measurement programs are having the greatest impact on patient
care. At the end of the day, we all want to know: Is our quality of
care improving?

Advancing the Practice of Evidence-Based Medicine with Standardized Order Sets

By Linda R. Peitzman, MD

A growing body of literature makes it clear that providing clinicians
with access to a greater breadth of automated clinical decision support
tools can improve the quality of care and patient safety. By
integrating clinical guidelines, alerts and reminders, order entry, and
drug information into electronic health records and computerized
physician order entry for point-of-care access to evidence-based
best practices, hospitals also benefit from reduced costs due to fewer
medication errors and other adverse events and enhanced productivity
and workflow.

Quality Improvement

Improve Screening for Osteoporosis with a Simple Intervention

By Alicia Appel, MD; Thomas Mackenzie, MD, MSPH, FAC

Osteoporosis is a common disease characterized by low bone mass with
microarchitectural disruption and skeletal fragility, resulting in an
increased risk of fracture. In the United States today, an estimated 10
million individuals have the disease, and almost 34 million more have
low bone mass, placing them at increased risk for osteoporosis. In
2005, osteoporosis-related fractures were responsible for an estimated
$17 billion in costs By 2040, experts predict that these costs may
double or triple due to the aging population (NOF, 2008).