Please visit Mark Graban’s Lean blog for his thoughts on this program first aired back in June.
Archive for the ‘Patient Safety’ Category
CNN is re-airing its 25 Shocking Medical Mistakes programming
In Patient Safety on January 5, 2013 at 8:10 pmCan we honesty say we are doing enough to keep our children safe from harm?
In Patient Safety on December 16, 2012 at 10:41 pmPresident Obama uttered these words in his speech to the citizens of Newtown after the tragedy at Sandy Hook elementary.
Those of us in healthcare should ask the same question: Can we honesty say we are doing enough to keep our children safe from harm?
Facts:
School systems continue to layoff professional nurses and untrained school personel are managing medications http://www.philly.com/philly/blogs/healthcare/Denursifying_of_Phila_public_schools_puts_children_at_added_risk_of_medication_errors.html
Studies show children are at risk for safety events in hospitals
“PSI (patient safety indicators) events occurred more frequently in the very young and those on Medicaid insurance, some of the most vulnerable hospitalized children. Regression analysis found that almost all PSIs are associated with significant and substantial increases in length of stay, charges, and in-hospital death. Using the estimates derived here and the actual number of cases identified in the 2000 data, we estimate that patient safety events incurred >$1 billion in excess charges for children alone in 2000.”
Miller, Elixhauser, and Zhan (2003) conducted a review of potential pediatric safety issues by using the previously defined adult indicators. They found that hospitalized children who experienced a patient safety incident, compared with those who did not, had
Length of stay 2- to 6-fold longer
Hospital mortality 2- to 18-fold greater
Hospital charges 2- to 20-fold higher
Slonim and colleagues (2003) found almost 2-3 medical errors per 100 discharges of hospitalized children
Why are children more vulnerable (Excerpt Beal, 2004)?
Development: As children mature both cognitively and physically, their needs as consumers of health care goods and services change. Therefore, planning a unified approach to pediatric safety and quality is affected by the fluid nature of childhood development.
Dependency: Hospitalized children, especially those who are very young and/or nonverbal, are dependent on caregivers, parents, or other surrogates to convey key information associated with patient encounters. Even when children can accurately express their needs, they are unlikely to receive the same acknowledgment accorded adult patients. In addition, because children are dependent on their caregivers, their care must be approved by parents or surrogates during all encounters.
Different epidemiology: Most hospitalized children require acute episodic care, not care for chronic conditions as with adult patients. Planning safety and quality initiatives within a framework of “wellness, interrupted by acute conditions or exacerbations,” presents distinct challenges and requires a new way of thinking.
Demographics: Children are more likely than other groups to live in poverty and experience racial and ethnic disparities in health care. Children are more dependent on public insurance, such as State Children’s Health Insurance Program (SCHIP) and Medicaid.
There are regional pediatric safety collaboratives trying to protect our nation’s children from harm but we need a national coordinated effort. When it comes to children’s safety, there should be no competition only collaboration. Richard Brilli, chief medical officer at Nationwide Children’s Hospital in Columbus, Ohio, said there’s just one acceptable course of action: Commit to eliminating medical errors and harmful practices altogether:”I couldn’t look a family in the eye and say we aspire to be 50 percent better.” (Sternberg, US News, 2010)
Safety Signs, instruction and designs
In Patient Safety on November 30, 2012 at 7:46 amBrowse this website collection of perplexing safety signs.
http://juliasmexicocity.typepad.com/safetygraphics/
Whoa!
Bad designs:
http://www.baddesigns.com/examples.html
one of my favorites http://www.baddesigns.com/USB.html (which way does the usb go in? I always seem to have to flip it)
Think about these when we are designing signs or safety programs in healthcare.
Simple test: have someone who has no knowledge of your project interpret your sign or try to follow your process without any instruction. You will identify many problems with usability this way. It is also enlightening to see what in your design contradicts human tendencies
CPPS
In Patient Safety on November 1, 2012 at 9:09 pmCongratulations to me! Today I passed the Certification Board for Professionals in Patient Safety’s exam. It is a computerized 100 question exam related to the role patient safety professionals play.
This professional certification program
- Establishes core standards for the field of patient safety, benchmarks requirements necessary for health care professionals, and sets an expected proficiency level.
- Gives those working in patient safety a means to demonstrate their proficiency and skill in the discipline.
- Provides a way for employers to validate a potential candidate’s patient safety knowledge and skill base, critical competencies for today’s health care environment.
The Certified Professional in Patient Safety (CPPS) credential is maintained on a three-year cycle of re-examination.
Read more about the program here http://cbpps.org/
and Get Certified!!!
Recommended by the NPSF
Despite bacteria in labs, clean pharmacy report
In Behavior change, hospital, Patient Safety on October 31, 2012 at 9:15 amWhenever 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 http://www.mc.vanderbilt.edu/documents/mysite/files/AccredNewsletter.pdf)
Even the Joint comission tells you what to do http://www.jointcommission.org/assets/1/18/2012_Organization_SAG.pdf
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..
Calling all Dummies and Smarties!
In Patient Safety on September 22, 2012 at 3:12 pmreposted:
PRESS RELEASE: Outcomes Measurement for Dummies…And Smarties Webinar
- Outcomes Measurement for Dummies…And Smarties
- October 5, 2012
- 11:30 a.m. EDT
- www.ihpm.org/webinar-registration.php
PRESS RELEASE Contact: IHPM Phone: (480) 305-2100 Email: deborah@ihpm.org
WASHINGTON DC USA — PATIENT SAFETY UPDATE NEWS SERVICE — SEPTEMBER 22, 2012: In conjunction with the Institute for Health and Productivity Management (www.ihpm.org), one of the most popular speakers at our past Disease Management Colloquia, Al Lewis, is presenting a webinar “Outcomes Measurement for Dummies…and Smarties” October 5. Registration is at www.ihpm.org/webinar-registration.php.
Non-compliance: have we transferred complexity to the patient?
In Patient Safety on August 7, 2012 at 10:28 amIs non-compliance a patient safety issue? Of course it is. And patients have been “fired” from their doctor’s practice for messing up their quality metrics. Does this add to patient safety?
Victor Montori has offered a solution called Minimally disruptive medicine. Dr Montori describes the complexity for patients in following all the evidence based guidelines we heap on them in order to meet safety quality metrics. According to Dr Montori, a patient with diabetes alone would have to spend more than 2 hours a day managing their disease if they followed all the guidelines from the ADA. And what if patients have more than one diagnosis? Dr Montori proposes that we are transferring healthcare complexity onto the patient and this is the root of what we term non-compliance.
Watch Dr Montori explain Minially Discruptive Medicine http://www.evidencelive.org/community/victor-montori-fit-and-the-translation-of-evidence-into-clinical-care/1132359
Where are we safe? Stay home and watch this movie.
In Patient Safety, Safety climate on July 26, 2012 at 3:16 pm
TED talks: Medical Mistakes
In human error, Patient Safety on July 12, 2012 at 10:42 amDr Brian Goldman talks about error stats in an easy to understand analogy to baseball
http://www.ted.com/talks/brian_goldman_doctors_make_mistakes_can_we_talk_about_that.html
I’ve spent precious time struggling to understand how my diagnosis was missed
In adverse events, Patient Safety on May 12, 2012 at 11:59 amI have not been to this site for awhile but when I went there today it touched me as usual. I thought it deserved a post
http://www.patientadvocare.blogspot.com/
These are some heartbreaking patient stories that help us see how much the transformation of heathcare is needed.
Some quotes:
“I’ve spent precious time struggling to understand how my diagnosis was missed. I’ve struggled with the knowledge that the delay in diagnosis resulted in a delay in treatment, which could have alleviated so many years of intense suffering, and potentially added many more years to my life (especially had I known to stop taking HRT).”
“At some point, Paul’s psychiatrist explained that his diabetes probably resulted from taking Seroquel. Paul wondered why doctors would prescribe him a drug that caused another illness, but he figured at first that they knew what they were doing.”
Safety Dog's Blog 