Lessons from a lifetime thinker and doer At just 7 years old, Story Musgrave faced a crisis that tested his critical thinking. While pretending to drive his father’s red farm tractor, he unlocked the brake, sending himself and the tractor down the hill into the river. He didn’t want to admit he was at fault,(...)
Organizational and Cultural Change
36 hours. Unlimited possibilities to transform health care.
Posted by | Designing Safer Systems, Organizational and Cultural ChangeImagine this. You are locked in Turner Concourse for 36 hours with relative strangers, tasked with creating a project that will revolutionize health care. Now what? If you are one of this year’s MedHacks participants, you are out of the gate running, ready to innovate and transform health care. MedHacks, run by Johns Hopkins University(...)
Radiology’s Quality Improvement Committee: A Formula for Success
Posted by | Designing Safer Systems, Organizational and Cultural Change"That’s how it’s always been done" is a phrase you will not hear uttered in the Department of Radiology and Radiological Science at The Johns Hopkins Hospital or at Johns Hopkins Medical Imaging. Organizations often cite historical precedent for why “option A” is being implemented instead of trying “option B.” The radiology department has seen(...)
After Surviving a Medical Error, Mike Armstrong Vowed ‘Never Again’
Posted by | Organizational and Cultural Change, Preventing Patient HarmC. 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,(...)
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,(...)
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(...)
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(...)
Hospitals Helping Hospitals Improve Patient Safety
Posted by | Organizational and Cultural Change, Preventing Patient HarmThe 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(...)
How Teamwork Can Reduce Missed Diagnoses
Posted by | Organizational and Cultural Change, Preventing Patient HarmEvery American will experience a missed or delayed diagnosis at some point in his or her lifetime. Saying that is not a scare tactic — it's a reality, according to a 2015 National Academy of Medicine report titled "Improving Diagnosis in Health Care." Yet we have not made effective use of a simple solution: teamwork.(...)