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“

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!

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?

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..

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

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

New Patient Safety book due out in May from Sidney Dekker (quoted often on this blog).

Description from the publisher CRC press:
•Presents material written with the medical practitioner audience in mind
•Includes the latest Human Factors/Ergonomics research applicable to patient safety
•Contains examples and cases on Human Factors and patient safety
•Discusses accountability and just culture
•Presents information in easy to use bulleted lists and illustrations where possible

Summary
“With coverage ranging from the influence of professional identity in medicine and problematic nature of “human error”, to the psychological and social features that characterize healthcare work, to the safety-critical aspects of interfaces and automation, this book spans the width of the human factors field and its importance for patient safety today. In addition, the book discusses topics such as accountability, just culture, and secondary victimization in the aftermath of adverse events and takes readers to the leading edge of human factors research today: complexity, systems thinking and resilience.” -CRC Press

I’ve pre-ordered this one!

My friend received a phone message tonight asking for volunteers to do massages at the Walk for Breast Cancer (she’s an LMT). The call back phone number was difficult to hear. She first called xxx-xxx-9762 wrong number. I quickly listened to the number too and I thought it was xxx-xxx-9752. Wrong number again! I stopped, shut the lights off, and closed my eyes and said play it again. I took a deep breath and very clearly heard xxx-xxx-2222. Bingo! Right number and now my friend is helping out that day.

Why tell this story? To point out the need for quiet zones where staff can stop, take a breath and pay attention to important notes and numbers. Any inpatient areas without a quiet zone are putting their patients and staff at risk. Build one today! Look for a future post with more evidence-based information 🙂

All patients deserve safe care but no where is it more pressing than in Peds. Check out this piece on peds safety http://news.nurse.com/article/20110307/PED01/110310001

Here is a preview:
“I realized that it doesn’t matter how intelligent you are,” says Alleyne, who now is the patient safety/quality improvement coordinator for the cardiac center at CHOP. “You can harm a patient if you are in a system that doesn’t support safe patient care. Rather than be a critic of the system, I decided I wanted to be part of the solution. I believe that as long as people agree that there is a problem and are committed to a solution, then they will see change.”

Are you committed?