Archive for the ‘hospital’ Category

Propublica series on Patient Safety

In hospital, human error on January 5, 2013 at 7:22 pm

From their website:
Too many patients suffer harm instead of healing in U.S. medicine. That’s why ProPublica’s reporters have investigated everything from deadly dialysis centers and dangerous hospitals to the failure of state boards to discipline incompetent nurses.

This page allows patients, providers and readers to join the patient safety conversation. Our goal is to find out why so many patients are suffering harm and highlight the best ways to solve the problem. Here you’ll find regular updates, and places to share your stories, views or expertise.

Read all of our posts on patient safety, and find out how to get involved.

Despite bacteria in labs, clean pharmacy report

In Behavior change, hospital, Patient Safety on October 31, 2012 at 9:15 am

Whenever a story comes out like this one regarding contaminated steriods causing meningitis and DEATHS, I cannot help but wonder whether our accreditation processes are majorly flawed. This is not intended to disprepect the amazing work of say the Joint Commission (their patient safety and quality journal is one of the best and their sentinel alerts have no doubt saved countless lives) however any kind of process such as theirs is going to encourage the hiding of deficits. Compare this with visits by a PSO such as ISMP and you get a totally different level of transparency.

I liken this to a court of law. On the witness stand the advice is to be evasive, answer only the question: don’t comment, add more info or compromise the case in any way.

This is sort of the same prep front line staff often get to be Joint commission ready. I am sure every institution has their own “survey tips” (example

Even the Joint comission tells you what to do

From an organizational psychology standpoint, it seems to me there is just no way that organizational problems will not be hidden in this type of survey. Staff will avoid surveyors, fearful that they will be “the one” who disgraces the organization. There is shame and blame inherent in this type of process. Staff do not usually speak with surveyors without a manager present.

Contrast this with a survey by a Patient Safety Organization where staff are encouraged to speak up and be truthful. They are allowed to speak to surveyors alone. Staff line up for opportunities like this: to share their concerns and frustrations. It seems PSOs are really the future of patient safety and not accreditation programs. Hospitals should be judged by their patient safety culture scores and their employee satisfaction scores. This would be much more enlightening as to whether or not an organization is safe for patients. Happy employees working in a safe culture are likely producing great outcomes.

Transparency and speaking up are two of the basic tennants of any safety program. I am sure many employees knew of the conditions in the compounding pharmacy. If only someone had asked them….in an open and non-threatening manner..

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?


Human Factor response to Boston globe article

In alarm fatigue, hospital, Patient Safety on February 16, 2011 at 4:06 pm

The Boston globe recently published sort of a lay person’s view of the issue of monitor fatigue. Some of the comments that follow by readers illustrate the classic mistake in approaching human error: to blame the human. There are a small number of posts that host some derogatory comments about nurses and their capability and commitment to patients. Over at the Human Factors Blog they have published a response to this article using, obviously a human factors lens.
Check it out here..False alarms in the hospital

To check out the Globe article click here: Part one Part two

Safetydog’s previous post on this topic with more references: 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 »

Dead by Mistake

In High Reliability Orgs, hospital, Patient Safety, safety, Safety climate on October 29, 2010 at 8:03 pm

Healthcare providers know that the public is invested in the reporting of and the prevention of medical errors. The website Dead by Mistake is run by Hearst newspapers and is a consumer oriented site with scary stories of medical mishaps that would make even the bravest among us afraid to receive hospital care.


Read the rest of this entry »

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