Archive for June, 2011|Monthly archive page

How transparent is transparency?

In Patient Safety on June 26, 2011 at 6:21 pm

The Reno Gazette Journal runs quite a few stories on patient safety in the Nevada heathcare system. An article posted online on June 19, reviews the mandatory state reporting situation of local hospitals. While the hospitals are posting many areas with zero defects, other pieces of evidence show a different story. They interview two women whose medical complications did not fall under the current reporting system. The journal also compared rates of error reported to billing info submitted to the state and found quite a discrepancy. Read the full story.
What do you think? Does mandatory reporting work? Does healthcare need more of an FAA-type body akin to aviation where incidents are investigated by outside sources if safety is really to be a priority? Can we really expect hospitals to engage in full disclose related to errors when their survival may depend on this data?? This article made me wonder if mandatory reporting may do more harm than good.. It’s like applying old theories of clinician error to entire systems ..publicly shame and sanction the system..hospitals will start looking for ways NOT to report or ways to reclassify their errors…

Evidence of Team Science

In Patient Safety on June 23, 2011 at 1:47 pm

There are few projects that can be completed in today’s complex healthcare delivery environments without the use of teams. But how many of these teams actually accomplish their goals? IS it the goal that is wrong or the team functioning?

A field of study the Science of Team Science is poised to develop theories, research and evidence based practice guidelines on team function. The National Cancer Institute has developed a free team science toolkit.  The site includes training, tools, reference article links, and guidelines to help your safety teams improve their outputs. This site promises to be robust and interactive as it includes a blog and ways to connect with colleagues.

Check it out at Team Science Toolkit

The blog link is on the right side of the page.

For a site that just went live a couple of months ago there are already over 331 resources!

One interesting article link is entitled “Team science of nursing, engineering, statistics and practitioner in the development of a robotic reflexology device” (Wyatt, Sikorskii, Bush & Mukherjee, 2010).

Sleep, Shower or Slip up

In High Reliability Orgs, human error on June 2, 2011 at 10:09 am

Sad news coming out of Japan: workers at the nuclear power plants are stressed, sleep deprived and showerless (Hongo, 2011).  In addition to having lost their own homes to the Tsunami, the workers at the nuclear plants have gone up to 10 days with rest or showers in trying to keep the stricken reactors cool. The nuclear industry is already a high risk industry and these workers are really being expected to perform in a superhuman manner; dealing with occupational catastrophe as well as personal tragedy. While most of the articles are being written about the nuclear risk, there is worker risk at a much higher dimension than usual.  This is truly a tragic situation.

%d bloggers like this: