Preventing Patient Harm

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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Weighing the Need for Surgical Volume Thresholds

Weighing the Need for Surgical Volume Thresholds

Posted by  | Preventing Patient Harm

In May, three academic medical systems turned up the heat on a long-simmering debate about the link between surgical volumes and quality of care. Leaders from Dartmouth-Hitchcock Medical Center, the University of Michigan Health System and the Johns Hopkins Health System declared that their surgeons would need to meet annual volume thresholds for 10 high-risk(...)

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The Surgeon Scorecard and the Need for Measurement Standards

The Surgeon Scorecard and the Need for Measurement Standards

Posted by  | Measurement of Safety and Quality, Preventing Patient Harm

Most of us would agree that there aren't enough valid and meaningful health care quality measures to guide patients' choices of hospitals and physicians. While the federal government has steadily expanded the number of publicly available measures on its Hospital Compare website, it still falls short of what many patients, payers and providers would like.(...)

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Blood Clots Show Limits of Quality Care Penalties

Blood Clots Show Limits of Quality Care Penalties

Posted by  | Measurement of Safety and Quality, Preventing Patient Harm

In the world of medicine, blood clots during hospitalization have become synonymous with imperfect care. As many as 600,000 patients per year experience a blood clot, and more than 100,000 die as a result, accounting for between 5 and 10 percent of hospital deaths. Regulatory agencies have taken clots as signals that safety and quality(...)

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