Check out the last issue of ASHRM’s Forum newsletter for 2011. The Q4 issue profiles ASHRM President-Elect Mary Anne Hilliard and her goal to “get to zero” serious safety events. Part two of the electronics medical records (EMRs) article (continued from Q3) looks at the advantages and pitfalls of EMRs. The patient safety article shines a light on the most overlooked victims of adverse events—healthcare workers. As always, the Forum details ASHRM’s latest accomplishments and lists the newest CPHRMs.
Patient Safety
The Q4 Issue of the Forum Newsletter is Now Online
Posted in Culture of Safety, Patient Safety, Preventable Errors Posted January 3, 2012 | No Comments
Joint Commission Releases New Sentinel Event Alert on Long Work Hours
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.
Hospitals face fines for overdose, leaving sponge in patient
Posted in Culture of Safety, Just Culture, Medical Error, Patient Safety Posted December 16, 2011 | No Comments
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.
Latest Issue of AHRQ WebM&M
Posted in AHRQ, Falls, Falls Reduction, Medical Error, Patient Safety Posted December 12, 2011 | No Comments
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.
Latest AHRQ Newsletter Notes Improved Patient Safety with Medical Team Training
Posted in AHRQ, Culture of Safety, Patient Safety, Prevention Posted November 10, 2011 | No Comments
The November AHRQ newsletter has two examples about the positive influence of team training on medical workers and its effect on patient safety. Dr. Robert Wachter, Editor of AHRQ WebM&M, spoke with Dr. Eduardo Salas, a professor of Psychology at the University of Central Florida who served in the Navy for 15 years, about applying lessons learned from military team work training to medical teams. “Those who know about teamwork do better.” Read the interview and listen to a perspective piece online.
MRI Safety Week, Getting to the Root Cause and Prevention
MRI Safety Week (this past June) was founded to celebrate and promote excellence in MRI safety. Much of the week long event was inspired by the 2001 tragic MRI-related death of Michael Columbini, age 6, resulting from a portable steel oxygen cylinder being brought into the MRI room during his exam.
Even though this MRI safety week information came to us this summer, activity surrounding the related resources continues on LinkedIn. It’s great info showing how analysis at the root cause level is needed and what can be gained.
OIG Report Calls For Improved Tracking Of Serious Adverse Events In Hospitals
Posted in Department of Health and Human Services, DHHS, Media, Medical Error, Medicare Medicaid, OIG, Patient Safety Posted November 7, 2011 | No Comments
MHA Staff Contact: Sharon Burnett
A report from the U.S. Department of Health and Human Services’ Office of Inspector General finds state survey agencies need to improve their tracking of serious hospital errors, including suicide and other adverse events. OIG recommends that the Centers for Medicare & Medicaid Services require all immediate jeopardy complaint surveys to evaluate compliance with the quality assessment and performance improvement Conditions of Participation. OIG also suggests that CMS ensure state agencies monitor hospitals’ corrective actions for sustained improvements, amend guidance on disclosure to explain the nature of complaints to hospitals and improve communication with accreditors.
Streamline Your Patient Safety Culture Survey!
Posted in AHRQ, Center Info, Media, Patient Safety, Patient Safety Survey Posted October 31, 2011 | No Comments
Do you Want to Streamline your Patient Safety Culture Survey?
Using AHRQ’s standardized test questions and format, the Missouri Center for Patient Safety has developed a convenient, online environment for your staff to anonymously take the survey on a computer at work, at home, or in the local coffee shop – anywhere they feel comfortable providing honest feedback about your safety culture.
