C. Michael Armstrong has long been more than the namesake of the Armstrong Institute for Patient Safety and Quality. His commitment goes beyond making generous gifts to create the institute and, later, our Center for Diagnostic Excellence, or endowing a professorship in patient safety. Indeed, he's been part of the patient safety movement for years,(...)
Why Public Reporting of Diagnostic Errors Might Come Sooner than You Think
Posted by | Measurement of Safety and Quality, Preventing Patient HarmOne night, a woman is examined in the emergency department complaining of vertigo. Her physician orders a CT scan, and when the tests come back negative, he diagnoses her with a benign inner ear condition and sends her home. He never sees her again. What he never learns is that her dizziness was far from(...)
With New Online Patient Safety Specialization, Class is Always in Session
Posted by | Organizational and Cultural Change, Patient-Centered Care, Preventing Patient HarmFifteen years ago, if you wanted to carve out a career niche in patient safety, you had to be resourceful — and a tad lucky. I was a bedside nurse at Johns Hopkins then, and my manager was helping me find a track for promotion. Noting that I submitted far more adverse-event reports than anyone else,(...)
Seeing It Through: Confronting the Danger of Missed Blood Clot Prophylaxis
Posted by | Patient-Centered Care, Preventing Patient Harm- By Elliott Haut and Brandyn Lau on behalf of the Johns Hopkins Venous Thromboembolism Collaborative You pack a healthy lunch for your child, but the carrot sticks and apple come home untouched. You donate to disaster relief, but the supplies sit unused in a shipping container. You mail a birthday gift to a friend,(...)
A New Focus — and Journal — at the Intersection of Patient Safety, Legal and Risk
Posted by | Preventing Patient HarmIn 2009, Erlanger Health System in Chattanooga, Tenn. upended the classic "deny and defend" approach to fighting malpractice lawsuits and instituted a communication-and-resolution program. In this system, when the hospital determines that it made an error, it apologizes to the patient or family members and commits to changes to reduce the chances of similar events(...)
The Psychology Behind Antibiotic Misuse
Posted by | Organizational and Cultural Change, Preventing Patient HarmNone of us wants to live in a world without access to lifesaving antibiotics. No patient should be subject to an allergic reaction or organ dysfunction from these drugs. No one wants to contract a potentially deadly form of diarrhea, claiming roughly 30,000 lives a year in the U.S., that can take hold after antibiotics wipe out(...)
Blockbuster Data: How Reporting Surgical Volumes Could Save Lives
Posted by | Measurement of Safety and Quality, Preventing Patient HarmIf there was a wonder drug to save the lives of infants with serious heart abnormalities, doctors would be sure to prescribe it. Parents would insist that their children get it. The company that invented it would get rich. But there already is something that can have as dramatic an impact on these young lives(...)
Supporting ‘Second Victims’ Also Helps Hospital Budgets
Posted by | Organizational and Cultural Change, Preventing Patient HarmSaving their hospital nearly $2 million a year wasn't the goal for Albert Wu and Cheryl Connors when they created a program to support traumatized colleagues. Wu, a physician and health services researcher, and Connors, a patient safety specialist from a nursing background, were responding to a human need: Health care professionals too often had to(...)
“War Gaming” for Patient Safety
Posted by | Designing Safer Systems, Organizational and Cultural ChangeOver a decade ago, I consulted on a project for the U.S. Air Force involving very large-scale simulations. These "war games" involved more than 1,500 participants around the world — some in simulators and some using real equipment in training mode. In a warehouse-sized building, a wall of gigantic screens captured the mock battle, as a(...)
A Clear-Eyed Approach to Reducing Costly Health Care Regulations
Posted by | Measurement of Safety and QualityJohns Hopkins ophthalmologist Oliver Schein has found a simple way to save a half a billion dollars a year from our country's health-care bill, with no negative effect on patient health. The only thing standing in the way is a stubborn government requirement. Seventeen years ago, Dr. Schein and colleagues published a study finding that(...)