Posted in Uncategorized Posted April 21, 2015
Thursday, September 24, 2015,
730am – 3pm
Mid-America Transplant Services
1110 Highlands Plaza Drive East
St. Louis, MO 63110
Registration fee $399, second from same organization $350. Space is limited, so register early. Please note cancellations will not be accepted after August 1, although replacement for registered attendees is allowed by contacting the Center.
Posted in Patient Safety Posted April 20, 2015
On March 20, 2015, the American Hospital Association and Federation of American Hospitals filed a friend-of-the-court brief urging the Supreme Court to review a Kentucky Supreme Court decision that could compromise Congress’ intent that the Patient Safety and Quality Improvement Act of 2005 protect health care providers’ reports to patient safety organizations from discovery in litigation. The brief explains that patient safety organizations “can aggregate data from members; provide evidence-based analysis of the root causes of medical errors and near-misses; and propose systems-focused solutions to prevent future mistakes.” Recognizing that these objectives can be achieved only through broad-based participation by providers who can honestly assess their mistakes without fear of repercussions, Congress established federal confidentiality for reports to a PSO. The brief indicates the Act’s privilege is “a critical tool for improving patient safety,” and said the Kentucky decision “is particularly unwarranted” because medical records and traditional tools of discovery are available to plaintiffs to find out the facts underlying an incident.
Posted in EMS, Patient Safety, Preventable Errors Posted April 14, 2015
Nobody wants a medication error but often we don’t have a new strategy or method for prevention. Experts suggest that most errors are linked to a flaw in a system design or an unfortunate behavioral choice. Regardless, working towards prevention requires better processes as well as improving our safety behaviors. To learn more, check out this article by Kim D. McKenna MEd, RN, EMT-P, recently posted at emsreference.com.
Posted in AHRQ, Patient Safety Posted April 6, 2015
The Agency for Healthcare Research and Quality has released the April WebM&M, morbidity & mortality rounds on the web. Spotlighted case is “Dissecting the Presentation“, with additional cases: “Transition to Nowhere” and “Fire in the Hole! – An OR Fire“.
Surgical checklists are also addressed this month with an interview with Lucian Leape,MD, Adjunct Professor of Health Policy at the Harvard School of Public Health, and an interview with David Urbach, MD, MSc, Professor of Surgery and Health Policy, Management and Evaluation at the University of Toronto.
Posted in Alerts, PSO Posted April 6, 2015
The Center for Patient Safety is issuing a Safety Alert based on industry data and recent findings from event data being submitted to the PSO. The following areas of concern have been reported to the PSO:
- A pediatric patient receives a higher than standard dose of Propofol and requires resuscitation.
- A battery fails on an insulin IV pump and goes unnoticed.
- Approximately one in every five reported PSO medication events involves a high alert medication such as anticoagulants (warfarin, heparin, Lovenox), Propofol, insulin, hypoglycemic agents, opioids and so forth. Events relate to prescribing, dispensing, administering and monitoring errors.
Posted in Patient Safety, PSO Posted April 6, 2015
The Center for Patient Safety is issuing a Safety Watch based on industry data and recent findings from event data being submitted to the PSO. The following areas of concern have been reported to the PSO:
- Tube dislodgement during patient movement
- Patient aspiration
- Rapid Sequence Intubation