SafetyDog

Archive for April, 2011|Monthly archive page

Spring Issue of Horizons

In Patient Safety on April 28, 2011 at 8:14 pm

Horizons provides articles on specific topics of broad interest to the medical technology community, such as information technology, home healthcare, and human factors engineering.

from their site:

TOPIC SPRING 2011: Alarm Systems

“Medical alarm systems warn of danger by alerting caregivers to critical medical information. They also frequently malfunction or are turned off, ignored, or unheard, earning a top spot on lists of the most frequent and serious problems seen with devices. How can the safety and effectiveness of alarms be improved?”

These are the planned topics:

2011 Alarm Systems Horizons – Editorial Content

The following articles are under development for the Spring 2011 issue of Alarm Systems Horizons:

  • Why Clinical Alarms Are a ‘Top Ten’ Hazard: How You Can Help Reduce the Risk
  • IEC 60601-1-8 Alarm Standard and Risk Management Considerations
  • Alarm Systems in Critical Care: Highlights of the New International Standard for Critical Care Ventilators
  • Understanding the Relationship between Cardiopulmonary Monitors and Clinically Significant Events in Critically Ill Children
  • Physiologic Alarm Load on Med/Surg Floors of a Community Hospital
  • Taking Alarm Standardization to the Floors: Demonstrating the Use of Telemetry In-Situ with a Training System
  • The Patient Monitoring Conundrum: “Managing Alarms” Versus Managing Patients
  • Pulse Oximetry Advanced Alarm Threshold
  • An Evidence-Based Strategy to Reduce SPO2 Nuisance Alarms
  • Visual and Auditory Perception Research: Implications for the Design, Selection, Use, and Maintenance of Alarms
  • A Decentralized Hierarchical Network Model for Alarms
  • Designing Effective Alarm Sounds
  • Complementing Alarms with Useful Troubleshooting Guidance
  • Clinical Alarm Hazards: Overview and Recommendations
  • Using Modern Internet Techniques to Distribute Alarms
  • Use of Mobile Devices to Improve Alarm Systems
  • Functional Basics of Third-Party Alerting Alarming Systems
  • Advancing the Functionality of Medical Alarms

Fogg on Behavior Change

In Patient Safety on April 23, 2011 at 7:50 am

I recently heard BJ Fogg speak at a design conference. He has facsinating material on persuasion.

He also has developed a great model of behavior change which I feel could help redesign heathcare worker’s behavior in terms of safety practices.

Here is a link to his model  http://www.behaviormodel.org/

Here is a link to his behavior grid http://www.behaviorgrid.org/

Here is a link to his interactive behvavior change wizard  http://www.behaviorwizard.org/wp/

Book on Mobile persuasion http://mobilepersuasion.com/

Fortune named him a guru!  http://money.cnn.com/galleries/2008/fortune/0811/gallery.10_new_gurus.fortune/

Partnership for Patients

In Patient Safety on April 21, 2011 at 10:33 am

Government initiatve to eliminate harm…(site excerpts:)

The two goals of this new partnership are to:

  • Keep patients from getting injured or sicker. By the end of 2013, preventable hospital-acquired conditions would decrease by 40% compared to 2010. Achieving this goal would mean approximately 1.8 million fewer injuries to patients with more than 60,000 lives saved over three years.
  • Help patients heal without complication. By the end of 2013, preventable complications during a transition from one care setting to another would be decreased so that all hospital readmissions would be reduced by 20% compared to 2010. Achieving this goal would mean more than 1.6 million patients would recover from illness without suffering a preventable complication requiring re-hospitalization within 30 days of discharge”

“Improving patient safety is not easy. Health care providers are committed to providing high-quality care – that’s why they entered the field. They work hard, so finding time to learn new science, reorganize teams, and change routines can be challenging. Hospital leadership and staff can do a lot to prepare their organizations for a successful journey to improved care and safer patients. Here are some tools and guidance to help you begin

More trust. Less fear.

In Safety climate on April 7, 2011 at 9:58 am

Mark Graban has a great post about culture and LEAN. http://leanblog.org/2011/04/more-trust-less-fear/

More trust. Less fear. All his points can easily be applied to safety efforts!  If staff are afraid of making a mistake or losing their jobs, their attention will be directed as self-preservation rather than organizational goals for safety or anything else.

Safetydog magazine?

In Patient Safety on April 7, 2011 at 8:41 am

For readers who use the IPAD:

This blog and our sister blog Evidence Based Nursing Management will appear in magazine format courtesy of the new Onswipe feature in WordPress.  Great new feature!

Hollnagel Quote

In Patient Safety on April 3, 2011 at 4:35 pm

A guiding principle for safety research and programs:

“Safety is the sum of the accidents that DO NOT occur.
While accident research has focused on why accidents have occurred, safety research should focus on why accidents have not occurred.”

This reminds me of the study of wellness. Do you gain more by studying those with disease or those who are healthy?

in her 90s!

My grandmother had a high cholesterol count since the first time they checked it when she was in her 70s..yet she died at 95 with no heart disease. Should we be studying those who have high cholesterol and heart disease or studying someone like her who had high cholesterol but obviously some mediating factors that prevented heart disease? the latter is what will build resiliency in heathcare because it is those mitigating factors that we want to strengthen. Just as we never eradicate all disease we will never eradicate all risk in hospital care. But we stand a chance to live as providers safely into old age if we can enhance those mitigating factors..

How do we know things are safe?

In Patient Safety on April 1, 2011 at 4:26 pm


Researchers at The Johns Hopkins University School of Medicine have determined that electronic faucets are more likely to become contaminated with unacceptably high levels of bacteria, including Legionella spp., compared with traditional manually operated faucets. The study will be presented on Saturday at the annual meeting of the Society for Healthcare Epidemiology of America (SHEA).

Click :Automatic sinks are unsafe

Team up for smart ideas~

In Patient Safety on April 1, 2011 at 10:42 am

The concept of Team Intelligence is very important in the fight for patient safety.

Here is a link to Suzanne Gordon’s information on this topic.
Team Intelligence

excerpt: “Building Team Intelligence (TI) — the capacity of people to learn, think,reflect, and act together — has been a major focus of my research for several years now. In fact, I am writing a book with an airline pilot and medical educator on the aviation safety movement and how it changed aviation culture. The book – Come Fly With Me — considers what those working on quality and safety in health care can learn from the aviation safety movement.”

I also recommend reading information from Southwest Airlines about relational coordination. The folks at Southwest even blog as a team Nuts about Southwest

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