Preventing Patient Harm

Supporting ‘Second Victims’ with Emotional First Aid

Supporting ‘Second Victims’ with Emotional First Aid

Posted by  | Organizational and Cultural Change, Preventing Patient Harm

She was a newly minted Johns Hopkins Hospital pediatric nurse — let's call her Mary — but she was already unsure if she had chosen the right career path. She had inserted an intravenous line into a young patient's arm, and there had been an infiltrate, a pooling of IV fluid under the child's skin that indicated(...)

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Blood Clots: The Least-Appreciated Complication of Hospital Care?

Blood Clots: The Least-Appreciated Complication of Hospital Care?

Posted by  | Patient-Centered Care, Preventing Patient Harm

If you were undergoing a surgical procedure, would you ever think to refuse the antibiotics your physician had ordered to prevent an infection? For most hospitalized patients, that would be unfathomable. And yet, when it comes to another common complication with a far greater death toll than surgical-site infections, both patients and health care professionals(...)

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Patient Safety and Quality Champions Grow into Leaders

Patient Safety and Quality Champions Grow into Leaders

Posted by  | Organizational and Cultural Change, Preventing Patient Harm

For years, physician assistant Stephanie Figueroa has worked with our Emergency Department and the sickle cell care team to improve the treatment of patients with this disease who arrive with acute pain crisis. When beds were unavailable in the busy adult ED, these patients might spend hours in excruciating pain before our staff were able(...)

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Can Hospitals Police Themselves to Avoid Too-Risky Surgeries?

Can Hospitals Police Themselves to Avoid Too-Risky Surgeries?

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

Imagine you were seeking major surgery, and the hospital's consent form contained this surprise statement, which you were asked to initial: "I understand that this surgeon and hospital have not performed this procedure in the last 12 months. As such, I accept the greater risk of complications and even death." It's hard to believe that(...)

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Mining Patients’ Wisdom for Safer Care

Mining Patients’ Wisdom for Safer Care

Posted by  | Patient-Centered Care, Preventing Patient Harm

Consider, for a moment, that you are a new physician. A patient, who is a lifelong smoker, comes to your clinic complaining of shortness of breath, and after conducting several tests you diagnose him with chronic obstructive pulmonary disease (COPD). Relying on your training, you prescribe medications, arrange for follow-up visits and describe activities that can(...)

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New Bloggers, New Name, Same Mission

New Bloggers, New Name, Same Mission

Posted by  | Preventing Patient Harm

More than a decade ago, a team of Johns Hopkins safety and quality scholars began meeting in a small office building along the Baltimore waterfront to discuss their research ideas. Physicians, nurses, a psychologist, economists, public health researchers and others would describe their goals, and then see how they could help one another to achieve(...)

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Health Care Shouldn’t Judge Itself by Flawed Tests

Health Care Shouldn’t Judge Itself by Flawed Tests

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

As standardized exam scores increasingly define success for students, teachers and schools, parents worry about the dangers of “teaching to the test”—and of their children being judged by tests with low or unknown validity. We want our children to perform well on tests, of course, yet only if they measure something that students, patients and(...)

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