The most recent edition of AHRQ’s Morbidity & Morality spotlight cases are now available. This edition includes cases covering Emergency Error, Discharge Instructions in the PACU – Who Remembers, and Anesthesia: A Weighty Issue…
SorryWorks! has been promoting transparency and disclosure since 2005 and has outstanding tools to support that effort. But often we struggle with setting patient expectations and opening up communication from the patient’s side. SorryWorks! has developed a letter that physicians and other providers can use as a temple for their own handout to open a dialog about how to communicate. The template is available here.
Posted in AHRQ, Medical Error, TeamSTEPPS Posted March 7, 2013
The Agency for Healthcare Research & Quality (AHRQ) has released its three latest M&M cases from which lessons can be learned to improve patient safety.
#1 – Incorrect documentation of a toddler’s weight as 25 kg instead of 25 lbs, leading to an error in calculating the appropriate antibiotic dosage. Information focuses on the risks of weight-based dosing, data entry errors and automation complacency with free CME, CEU or trainee certification for taking the quiz.
#2 – how to avoid errors related to the use of unfamiliar devices, highlighting a nurse’s failure to clamp the post-lung transplant patient’s large-bore central line after drawing labs, allowing air to enter the catheter.
#3 – Inaccurate pathology report which changed diagnosis from an unusual lymphoproliferative disease to adult-onset celiac disease.
Also learn from physicians at Stanford and the Mayo Clinic about the introduction of the modern full-body patient simulator and the use of crew resource management (TeamSTEPPS) training used to improve the delivery of care.
Posted in Medical Error, Patient Safety Posted October 2, 2012
The Center was pleased to host two 2nd Victim Workshops in September. They were inspiring and helpful to remind us how important it is to support health professionals that are impacted by unexpected clinical events and errors, in addition to patients and families! For more about the University of Missouri Health System’s 2nd Victims Program go to http://www.muhealth.org/body_foryouteam2ndvic.cfm?id=6833.
Posted in Medical Error, Medical Error Lawsuits Posted January 23, 2012
Medical malpractice is a constant concern for doctors, says Dr. Kevin Pho, known for his blog KevinMD.com. Depending on the type of medicine practiced, most or all doctors will face a lawsuit during their careers. Probably the greatest point in Dr. Pho’s January 23 USA Today article, How doctors can reduce medical errors, lawsuits, is what we all know – but need to be reminded of often. No one wants medical mistakes! The point which is a close second for its wisdom is that saying “I’m sorry” works.