Medical Error

PSOs and Others Chime in on ACA Delayed Rule for PSO Participation

    Posted in ACA, Medical Error, Medicare Medicaid, Patient Safety, PSO    |    Comments Off

The Center for Patient Safety and others discuss concerns and benefits of the delay in the PSO participation rule requirement of the Affordable Care Act. While the delay allows additional consideration on how to implement the rule, are current Medicare requirements sufficient to move patient safety improvement forward? Will the delay stifle the expanded sharing, learning and prevention of medical errors possible through PSOs?  Read full February 4 Modern Healthcare article.

Seven components of a friendly medical error reporting environment

    Posted in Medical Error, Patient Safety    |    Comments Off

Henry Ford Health System shares seven components of a friendly medical error reporting environment:  leadership support, appropriate infrastructure, anonymous reporting, error disclosure to patients and families, communication, just culture, and continual improvement of its patient safety culture.  Their successes were recognized in 2011 when they received the Malcolm Baldrige National Quality Award and the John M. Eisenberg Patient Safety and Quality Award.  Read more.

Are you at risk for wrong site surgery?

    Posted in Medical Error, Patient Safety, Safe Surgery    |    Comments Off

Think a wrong site surgery can’t happen at your hospital or surgicenter?  Every surgery or invasive procedure is at risk!  The Joint Commission recently shared 5 tips to reduce the chances:

1.  Evaluate your entire operative process to identify areas of risk

2.  Standardize your scheduling process; do not allow the use of abbreviations

3.  Assign specific active roles for the time out; everyone must be consciously involved

4.  Reference the marked site during the time out; allow only permanent markers so the marking is visible

5.  Don’t rush the time out

Learn more:

AHRQ July/August WebM&M Available

    Posted in AHRQ, Medical Error, Patient Safety, Preventable Errors    |    Comments Off

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…

Read More

Sorry Works! Template to Improve Patient/Provider Dialog

    Posted in Medical Error, Patient Safety Culture    |    Comments Off

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.

AHRQ Releases Latest M&M Cases

    Posted in AHRQ, Medical Error, TeamSTEPPS    |    Comments Off

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.

2nd Victim Workshops Train 25 in Missouri!

    Posted in Medical Error, Patient Safety    |    Comments Off

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

Latest issue of Web M&M released

    Posted in AHRQ, Healthcare Safety Practices, Medical Error, Patient Safety    |    Comments Off

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.


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