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,(...)
Organizational and Cultural Change
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.(...)
How the Flint Water Crisis Is a Cautionary Tale for Health Care
Posted by | Designing Safer Systems, Organizational and Cultural Change, Preventing Patient HarmThere 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(...)
It’s Not All About the Checklist: The Power of Believing and Belonging
Posted by | Organizational and Cultural Change, Preventing Patient HarmTrine 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(...)
Patient Care: What’s Love Got to Do with It?
Posted by | Organizational and Cultural Change, Patient-Centered CareTalking to health care professionals about the importance of loving your patients and colleagues — as I often do — might raise eyebrows. How can we be expected to love our patients during a 15-minute clinic visit? How can love form among hospital teams coming together for a surgical procedure but then moving on to other work?(...)