Archive for the ‘High Reliability Orgs’ Category

Reduce obesity and improve Patient Safety?

In Behavior change, design, Force function, High Reliability Orgs, Human Factors on March 15, 2015 at 2:01 pm

I have read much material lately about addressing the obesity epidemic and there are many commonalities in the latest theories.
1. Motivation- focusing on motivation as a strategy is not the best approach. Willpower has been dismissed by many as a poor approach to weight management
2. Behavior change- changing behaviors is not easy. Much of a person’s day consists of habitual activities resulting from cues from tv, peers, childhood… example wanting to eat popcorn while watching a movie, reaching for the salt before tasting food…
3. Environment changes-For obesity this holds the most promise. Its seen in weight watchers programs and Wansink’s book Slimdown by design. Change architecture and nudging can help make behavior change easier and lasting. This includes things like using smaller colorfull plates, moving healthy foods to a prominent kitchen spot and unhealthy foods to hidden cabinets. In some estimates people who follow certain environmental patterns are 18% thinner than those who do not.

What’s the correlation with patient safety?
1. Motivation- focusing on motivation as a strategy is not the best approach. Motivating staff to be more vigilant? Teaching them? Telling them to Follow rules and policies? These have not been shown to increase safety measurably. In fact sometimes recognizing when to deviate from rules can add resilience
2. Behavior change- changing behaviors is not easy. Other articles on this cite describe many nursing behaviors as being based on tradition and automatic behavior. Often under stress people revert back to old knowledge. How many times has an initiative been rolled out only to see it vanished from practice within a year?
3. Environment changes- just as in obesity management here we might find the most bang for our buck so to speak. Make it easy for staff to do the right thing. Make it hard for staff to do the wrong thing. Create systems that nudge staff toward safe behaviors. Use change architecture to produce reliability

A healthier world depends on reducing obesity and unsafe patient care. Maybe the solutions to both are the same.

See Reference Page for some articles related to this page

WE could use these labels in healthcare

In High Reliability Orgs, Human Factors, Neuroscience on May 4, 2014 at 5:04 pm

If only medical supplies had labels like this instead of the crazy font, placement and design of current hospital supply products. There is no standard place for expiration date or wonder regulators often find expired items throughout a hospital.


Go check out SAFECHART

Hosptials are nothing to croak about

In High Reliability Orgs on October 31, 2013 at 2:29 pm

Latest Leapfrog results

Of the 2,539 general hospitals issued a Hospital Safety Score, 813 earned an “A,” 661 earned a “B,” 893 earned a “C,” 150 earned a “D” and 22 earned an “F.”
Read the report

Chocolates and patient safety

In High Reliability Orgs, Normal Accident Theory, Patient Safety, Resiliency on September 22, 2013 at 3:17 pm

From Rosemary Gibson:

How Overtreatment and High Volume Health Care is Making Patient Safety a More Distant Reality by Rosemary Gibson

“This past week at the National Health Care Quality Colloquium I showed the classic “I Love Lucy” chocolate factory video during a presentation. The laughter was audible and the point was made: when the pace of work speeds up, work-arounds and cutting corners are inevitable. Employees tell the boss everything is fine –when its not.

In a health care system riddled with defects where doctors and nurses are required by health care executives to work at a faster pace, the number of adverse events — and patients harmed — will increase. High volume health care and productivity targets are a toxic mix. … Read and’s funny but not…
The Chocolate scene on you tube

Infographic on the GE ANA survey of Nurses and Patient Safety

In High Reliability Orgs, Safety climate on August 7, 2013 at 7:54 am

I made this infographic from the data from GE + ANA global survey of nurses

Read press release

Fake Fixes

In High Reliability Orgs, Patient Safety, Safety climate on February 5, 2013 at 12:07 pm



Read this op-ed piece from the Times by the author of “Bad Pharma…”

(Ben has an interesting website:

How should we handle omission of information?

Is dont ask dont tell dangerous for healthcare?

some hightlights from op-ed:

“Trials with positive or flattering results, unsurprisingly, are about twice as likely to be published — and this is true for both academic research and industry studies”

“These problems would be bad enough on their own, but they are compounded by a generation of “fake fixes” that have delivered false reassurance, and so prevent realistic public discussion.”

“All of these problems are perhaps best illustrated by the case of Tamiflu, which governments have spent billions of dollars stockpiling, in the belief that the drug will reduce the rate of complications from influenza. But roughly half the trial results have never been published, and researchers trying to obtain the full Clinical Study Reports have been stonewalled by the manufacturer, Roche.”

“This cannot be acceptable. Withholding data not only misleads doctors and patients; it’s an insult to the patients who have participated in clinical trials, believing that they were helping to improve medical knowledge.”


Physician-Patient Alliance for Health & Safety

In alarm fatigue, Force function, High Reliability Orgs, hospital, Patient Safety on April 15, 2012 at 6:56 am

What can be better than a caregiver-patient alliance for safety?

Check out this website from PPAHS

Improving health and safety involves many facets:

  • Innovative technology to provide for necessary monitoring of patient vital signs. For example, as the Wall Street Journal proclaimed in its story about Howard Snitzer “A little known device is shaking conventional wisdom for reviving people who suffer sudden cardiac arrest: People may be able to go much longer without a pulse than the 20 minutes previously believed.”
  • Health Care Providers who must make critical live-saving decisions, such as anesthesiologists who, as the American Society of Anesthesiologists says, “are responsible for administering anesthesia to relieve pain and for managing vital life functions, including breathing, heart rhythm and blood pressure, during surgery. After surgery, they maintain the patient in a comfortable state during the recovery and are involved in the provision of critical care medicine in the intensive care unit.”
  • Information on what works and how it enhances patient health and safety.”

Much of their site is dedicated to respiratory events and technology.

Here is an interesting post about children and sedation.  Is monitoring RR and o2 via pulse oximeter giving us a false sense of security?


New from the Just Culture Community…Patient safety applied to Life!

In High Reliability Orgs on February 4, 2012 at 9:14 am


Back to the Future…

In Behavior change, High Reliability Orgs, Resiliency, Root cause analysis on January 28, 2012 at 8:08 am

ISMP newsletter, 1998

“Currently, there is no consistent process among healthcare organizations for detecting and reporting errors. Since many medication errors cause no harm to patients, they remain undetected or unreported. Still, organizations frequently depend on spontaneous voluntary error reports alone to determine a medication error rate. The inherent variability of determining an error rate in this way invalidates the measurement, or benchmark. A high error rate may suggest either unsafe medication practices or an organizational culture that promotes error reporting. Conversely, a low error rate may suggest either successful error prevention strategies or a punitive culture that inhibits error reporting. Also, the definition of a medication error may not be consistent among organizations or even between individual practitioners in the same organization. Thus, spontaneous error reporting is a poor method of gathering “benchmarks;”it is not designed to measure medication error rates.” Read the full newletter here

Hey McFly, why have we made so little progress?

Caps don’t belong INSIDE patients

In Force function, High Reliability Orgs, usability on January 1, 2012 at 8:15 am

Let me begin 2012 by recommending that everyone subscribe to ISMPs safety newsletters: let that be your first New Year’s resolution in committing to make your practice safer. There is an acute care edition, ambulatory edition, nursing edition and consumer edition.  Subscribe here.

The december nursing edition (Nurse-ERR) describes a case where an ADULT patient (not a pedi patient!) was found to have swallowed one of the small white caps that covers the end of a syringe. This was discovered after the patient developed a cough after discharge. After a particularly intense coughing episode, the cap came out!   This patient had no recollection of swallowing this cap.  The newsletter recounts historical dangers associated with small parts left at the bedside of patients and their subsequent inhalation.  Of course this has always been a concern for pediatric patients but now we see the SAME RISK in adults.

Nurse ERR wisely recommends all staff scan patients’ rooms for potentially dangerous items left at the bedside and that this be added to rounding procedures by all disciplines: housekeeping, Nursing, MDs and even family and visitors. The more eyes the better.

In the spirit of this blog and its focus on human factors, I would also like to implore manufacturers of hospital products (especially IV related products with small caps and pull caps) to help eliminate these hazards alltogether by making caps that are NOT detachable.   Make all removable small pieces removable but stay attached.

It can be done for usb ports…why not do it for something that can save a life?

I always lost these caps...

This design Prevents loss of the cap!

Even better! This design prevents loss of cap and actually encourages one to recap.

Update: I emailed the ISMP asking for their advocacy in getting manufacturers to develop products that force safety in their IV supply products..then I emailed Baxter requesting they develop a product. I got a call back and they were concerned about infection and recapping but responded that they would pass this onto their engineers to see if something could be done that would attach the cap yet protect the patient from potential infection by preventing recapping. Here’s hoping they can come up something so our only safety barrier isn’t front line staff vigilance. Thanks to both these agencies for being responsive.

Remember: SPEAK UP! your ideas might just save a life!

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