In 2013, a 52-year-old man went to an emergency department complaining of dizziness. Physicians evaluated him, decided that it was a benign condition — as it usually is — and sent him home. Days later, it became apparent that this was no harmless event. He suffered a significant stroke, with permanent disability as the result. […]

Reinventing the Physical Exam
Posted by Peter Pronovost | Designing Safer Systems, Patient-Centered CareIn the technology-thick landscape of modern health care, the physical exam remains in a backwoods. Sure, there have been advances — blood-pressure cuffs, for example, now inflate themselves — but on the whole the exam has barely changed in the past century. Patients still open up and say "ah," take deep breaths and gaze at […]
Oct 6, 2016 3 comments

Thinking Outside the Hospital: A Call to Action for Outpatient Safety
Posted by Nisa Maruthur and Melinda Sawyer | Patient-Centered Care, Preventing Patient HarmHealth care has been thinking about medical errors for nearly 20 years, starting with the Institute of Medicine’s 1999 report “To Err is Human.” This and other work across the country have correctly shed light upon such medical errors as amputation of the wrong limb, inpatient adverse drug events and hospital-acquired infections, and we have […]
Sep 20, 2016 7 comments

How Teamwork Can Reduce Missed Diagnoses
Posted by David Newman-Toker | 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. […]
Jul 6, 2016 6 comments

How the Flint Water Crisis Is a Cautionary Tale for Health Care
Posted by Lori Paine | 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 […]
Jun 23, 2016 6 comments

What Teenage Patients — and Their Parents — Want from Their Care Team
Posted by Peter Pronovost | Patient-Centered CareFor anyone with a serious medical condition, frequent hospitalizations and clinic visits can have a profoundly disruptive impact. Yet adolescent and teenage patients have a uniquely challenging experience. A boy who would otherwise be playing on a soccer team or performing in a play may be undergoing chemotherapy. A girl who had expected to be […]
Jun 16, 2016 10 comments

Improving the Odds for a Chance at Life
Posted by Melania Bembea | Preventing Patient HarmTens of thousands of people owe their lives to extracorporeal life support (ECLS) — a treatment that uses mechanical devices to perform the work of the heart and lungs for days, weeks or even months when those organs cannot function on their own. With ECLS, we can give newborns with major congenital defects a fighting […]
Jun 9, 2016 No comments

The Risks of the 15-Minute Doctor’s Appointment
Posted by Peter Pronovost | Patient-Centered CareHow would you react if you sent your sputtering car to the auto mechanic, and they stopped trying to diagnose the problem after 15 minutes? You would probably revolt if they told you that your time was up and gave back the keys. Yet in medicine, it's common for practices to schedule patient visits in […]
Apr 21, 2016 10 comments

It’s Not All About the Checklist: The Power of Believing and Belonging
Posted by Peter Pronovost | 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 […]
Apr 8, 2016 4 comments

5 Lessons for Creating Health Care Performance Dashboards
Posted by Matt Austin | Measurement of Safety and QualityIn recent years, Johns Hopkins Medicine has grown increasingly sophisticated in its use of patient safety and quality dashboards, not just to spur internal improvement efforts but also to increase transparency with the public about our performance. In 2013, we launched an internal dashboard for our health system’s 41,000 employees, sharing our performance data on […]
Mar 10, 2016 No comments