Archive for December, 2010|Monthly archive page

The right timing of safety protocols…

In Patient Safety on December 26, 2010 at 5:48 pm

Boston hospital made 3 spine operation errors

On Friday December 24, 2010, 10:12 am EST
BOSTON (AP) — A major Boston teaching hospital has been cited by federal and state health inspectors after doctors operated on the wrong location on three spine surgery patients.
All three unconnected errors happened since September.
Dr. Kenneth Sands is the senior vice president of health care quality at Beth Israel Deaconess Medical Center. He tells The Boston Globe the surgeons apparently miscounted the patients’ vertebrae and operated directly above or below where they were supposed to.
Two operations were conducted by the same surgeon. The hospital did not release names. The hospital has procedures in place to avoid errors, and those procedures have been improved.
Sands says none of the patients suffered harmful effects as a result of the mistaken surgery. But a lawyer for one says the woman has experienced problems. Information from: The Boston Globe,

Safetydog Comment: When two different surgeons and their teams (and one twice) make an error it is imperative to look at the team process. I think we have to look at the timing of checklists. It seems time out at the onset of an OR procedure is not enough. A time out needs to be repeated before every irreversible cut.
Human Factors can be used to determine when in a process some kind of alert has to occur when that should be a human alert or a technology produced alert. Rather than just copy best practices, hospitals need to review their current practices, reduce unnecessary steps and then identify areas in the process where a reminder or alert should take place. Timing is key. There are always points in a process after which there is no resiliency.

What Patients are talking about in safety…

In Patient Safety on December 26, 2010 at 10:38 am

from the Las Vegas Sun:
“Reform is slow in coming because hospitals and doctors are not directly accountable — financially — to patients and provide little transparency, said Haskell, who was named one of the “100 Most Powerful People in Healthcare” in 2009 by Modern Healthcare magazine.
“The customer doesn’t pay directly, and they (hospitals and doctors) keep everything to do with price and quality secret,” she said.
John James, a Houston toxicologist, lost his son in 2002 when Read the rest of this entry »

More Drug safety: who to believe?

In Patient Safety on December 26, 2010 at 9:42 am

I recently received an email asking to highlight another website on my blog. This site DrugWatch is an A-Z listing of medications, side effects, latest news and uses. There is also a section on lawsuits against particular drugs. This section is particularly appropriate since this site is run by a lawfirm that specializes in personal injury protection (Peterson Firm, LLC). This is clearly delineated on their website banner. The major pharmaceutical companies have their websites and commercials informing the public about “diseases” and drugs that can treat them and the lawyers have their websites about all the side effects of these treatments. Here are the current drugs people are searching for on the lawyers’ website: Read the rest of this entry »

Drug safety?

In Patient Safety on December 24, 2010 at 8:18 am

A thought provoking power point from Vera Sharav who is the founder of the Alliance for Human Research Protection. This brings up the fundamental question in today’s society: in terms of safety, who or what do we believe?
Is there such a thing as an unbiased person or agency?
Given human factors issues of bias, is research really unbiased? How do we know experts are really experts? How do we know safety practices are really supported and followed in hospitals, airlines, oil drilling and other high risk industries? Have regulatory inspections shown to truly increase safety or do they encourage organizations to hide their dirty laundry?
How can we use the concept of transparency to improve the accuracy of the data that is presented in site visits, publications and quality metric reporting?

Scientific fraud article from the same group

10 Million patients later:The case of Darvocet. How long was this drug on the market before being seriously reviewed 😦

ECRI another interesting blog

In Patient Safety on December 22, 2010 at 5:27 pm

Are you looking for information about:
Risk and Quality Resources
Medical Technology
Patient Safety Organization
Hazard & Recall Management

The ECRI is a non-profit evidence based practice center that uses scientific inquiry to look at medical procedures, devices and drugs.
Some of their topics this year included the Baxter pump recall and alarm fatigue.

Learning vs Punishment & Accountability & alittle EBMgt

In hospital, Patient Safety, Resiliency on December 18, 2010 at 9:14 am

I cringe whenever I start hearing the words “employee accountability” for traditionally this refers to a way to blame individuals rather than have a management team or organization take responsibly for the conditions under which an employee has to do their job. Employees must have autonomy to have accountability..strict adherence to scripting or hospital polices is not the definition of accountability. In fact, when a union wants to slow down production in an organization, one tactic is to advise workers to “follow policy to the letter.”
I am constantly searching for blogs who say this in different ways to make the case for this concept as far reaching as possible. These are words from a blog by Jeffrey Pfeffer who an Evidenced Based Management Proponent. He makes… Read the rest of this entry »

Human Factors: information processing

In Human Factors on December 17, 2010 at 6:11 pm

In the Talk Aloud Method of usability, the observer can begin to understand how the user is processing information gained from interacting with the computer software and hardware
designed to improve safety. Situation awareness. Situation awareness refers to the individual’s ability to assess the environment, determine meaning from the perceptions and patterns present and predict events
based on this information (St Pierre, Hofinger & Buerschaper, 2008). Endsley’s three-level model for situation awareness describes it as an aspect of information processing that “follows perception and leads to decision making and action execution” (Salmon, Stanton, Walker, Baber,Jenkins, McMaster, & Young, 2008, p. 300). The layout of a workplace as well as the way in which information is presented can enhance situation awareness (St. Pierre, et al., 2008). This includes the timing of alerts and alarms Read the rest of this entry »

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