Organizational and Cultural Change

Radiology’s Quality Improvement Committee: A Formula for Success

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(...)

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After Surviving a Medical Error, Mike Armstrong Vowed ‘Never Again’

After Surviving a Medical Error, Mike Armstrong Vowed ‘Never Again’

Posted by  | Organizational and Cultural Change, Preventing Patient Harm

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,(...)

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With New Online Patient Safety Specialization, Class is Always in Session

Posted by  | Organizational and Cultural Change, Patient-Centered Care, Preventing Patient Harm

Fifteen 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,(...)

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The Psychology Behind Antibiotic Misuse

The Psychology Behind Antibiotic Misuse

Posted by  | Organizational and Cultural Change, Preventing Patient Harm

None 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(...)

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Supporting ‘Second Victims’ Also Helps Hospital Budgets

Supporting ‘Second Victims’ Also Helps Hospital Budgets

Posted by  | Organizational and Cultural Change, Preventing Patient Harm

Saving 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(...)

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“War Gaming” for Patient Safety

“War Gaming” for Patient Safety

Posted by  | Designing Safer Systems, Organizational and Cultural Change

Over 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(...)

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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 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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