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.
Medical Errors
The Q4 Issue of the Forum Newsletter is Now Online
Posted in Culture of Safety, Patient Safety, Preventable Errors Posted January 3, 2012 | Comments Off
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.
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 | Comments Off
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 | Comments Off
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 | Comments Off
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.
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 | Comments Off
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.
Chicagoland Patient Safety Summit: Focus on Transparency
Kimberly O’Brien shares a recent experience: The 2011 Chicagoland Patient Safety Summit kicked off on September 15th with a heartbreaking story from an Indiana family who recently lost Michelle – their beloved daughter, sister, wife and mother – to a medical error at a Chicago-based hospital. There wasn’t a dry eye in the room of over 150 providers and other patient safety advocates as Michelle’s family recounted the painful details of the days and hours leading up to Michelle’s premature and preventable death.
