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.
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.
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.
The latest AHRQ Web M&M (May 2012) spotlights the challenges with cross coverage hospital teams, the potential for medication duplication following department transfers, and a central line, overlooked at discharge.
Also, don’t miss a great article “The Emergence of the Trigger Tool as the Premier Measurement Strategy for Patient Safety” which highlights the pro’s and con’s of multiple approaches to adverse event reporting.
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.
The Joint Commission is warning hospitals about the potential dangers of extended hours and excessive workloads in a new Sentinel Event Alert. The alert contains documented links between healthcare worker fatigue and adverse events, as well as lower productivity. Sleep deprivation or lack of quality sleep over an extended amount of time can lead to confusion, irritability, memory lapses, loss of empathy, and compromised problem-solving, among other things, according to the Alert. The Joint Commission suggests organizations assess their fatigue-related risks, including off-shift hours and consecutive shift work; examine the hand-off process; invite staff to offer input in their own work schedules; implement a fatigue management plan; and educate staff about the effects of fatigue on patient safety.
L.A. NOW – Southern California
The California Department of Public Health issued $850,000 in fines against 14 hospitals for medical errors that caused — or were likely to cause — serious injury or death to patients, officials announced Thursday.
Three of the hospitals — Henry Mayo Newhall Memorial Hospital, Los Angeles County-USC Medical Center and Torrance Memorial Medical Center — were in Los Angeles County.
This month, the Perspectives on Safety section covers fall prevention with Ann L. Hendrich, RN, PhD, of Ascension Health. A leading expert on health care–associated falls, who developed one of the most widely used risk assessment tools. Listen to an excerpt online or download a podcast interview.
In the Spotlight Case, “Order Interrupted by Text: Multitasking Mishap,” while entering an order via smartphone to discontinue anticoagulation on a patient, a resident received a text message from a friend and forgot to complete the order.