Preventing Patient Harm

Hospitals Helping Hospitals Improve Patient Safety

Hospitals Helping Hospitals Improve Patient Safety

Posted by  | Organizational and Cultural Change, Preventing Patient Harm

The moment that an accreditation team shows up unannounced can spike the pulse of even the most seasoned hospital executive. The next several days will amount to one big exam for the safety and quality of care, as surveyors meet with executives, managers and care teams, and watch first-hand as care is delivered. Make the(...)

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How We Can Engineer a Less Costly Health Care System

How We Can Engineer a Less Costly Health Care System

Posted by  | Designing Safer Systems, Patient-Centered Care, Preventing Patient Harm

If we want to rein in the costs of the U.S. health-care system — now equal to nearly 18 percent of the nation's gross domestic product — we cannot ignore the fragmented technologies used to help heal and save lives. At first glance, the devices, monitors, electronic health records and machines found in today's hospitals(...)

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Common Symptoms, Uncommon Causes: Reducing Misdiagnosis on the Front Lines

Common Symptoms, Uncommon Causes: Reducing Misdiagnosis on the Front Lines

Posted by  | Preventing Patient Harm

In 2013, a 52-year-old man went to an emergency department complaining of dizziness. Physicians evaluated him, decided that it was a benign condition — as it usually is — and sent him home. Days later, it became apparent that this was no harmless event. He suffered a significant stroke, with permanent disability as the result.(...)

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Thinking Outside the Hospital: A Call to Action for Outpatient Safety

Thinking Outside the Hospital: A Call to Action for Outpatient Safety

Posted by  | Patient-Centered Care, Preventing Patient Harm

Health care has been thinking about medical errors for nearly 20 years, starting with the Institute of Medicine’s 1999 report “To Err is Human.” This and other work across the country have correctly shed light upon such medical errors as amputation of the wrong limb, inpatient adverse drug events and hospital-acquired infections, and we have(...)

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How the Flint Water Crisis Is a Cautionary Tale for Health Care

How the Flint Water Crisis Is a Cautionary Tale for Health Care

Posted by  | Designing Safer Systems, Organizational and Cultural Change, Preventing Patient Harm

There has been no shortage of blame for the poisoning of Flint, Michigan's water supply. In March, a governor-appointed task force issued a report that rebuked local, state and federal authorities for their actions — and inactions — that created the public health crisis. Then, in late April, state prosecutors announced the first charges in the(...)

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It’s Not All About the Checklist: The Power of Believing and Belonging

It’s Not All About the Checklist: The Power of Believing and Belonging

Posted by  | Organizational and Cultural Change, Preventing Patient Harm

Trine Engebretsen was clinging to life. It was the early 1980s, and the girl had a genetic liver disorder that would kill her if she did not get a transplant. Yet, as she waited for a matching liver, some providers called her parents and urged them not to allow the surgery. They cautioned them that(...)

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Patient Safety at 15: How Much Have We Grown?

Patient Safety at 15: How Much Have We Grown?

Posted by  | Designing Safer Systems, Measurement of Safety and Quality, Organizational and Cultural Change, Preventing Patient Harm

Fifteen-year anniversaries often come and go without fuss, overlooked in favor of those we can mark in full decades. Yet recently, at Johns Hopkins and nationally, we've crossed that mark for a couple of events in patient safety that merit both celebration and reflection. In January 2001, a series of lapses at Johns Hopkins led(...)

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