Let's say that you're a nurse on a hospital unit, and a colleague has recently been involved in a medication error. It was a mistake that anyone might make — a tenfold overdose that occurred when she wrote down an order and accidentally moved a decimal point one space to the right. Luckily, it didn't lead(...)
Supporting ‘Second Victims’ with Emotional First Aid
Posted by | Organizational and Cultural Change, Preventing Patient HarmShe 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(...)
Blood Clots: The Least-Appreciated Complication of Hospital Care?
Posted by | Patient-Centered Care, Preventing Patient HarmIf 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(...)
Patient Safety and Quality Champions Grow into Leaders
Posted by | Organizational and Cultural Change, Preventing Patient HarmFor 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(...)
What’s Your Theory? Bringing Rigor to Local Quality Improvement Projects
Posted by | Measurement of Safety and Quality, Organizational and Cultural ChangeFor a moment, consider that you work at a primary care clinic, and your team needs to improve performance on annual foot exams on patients with diabetes — a critical step to prevent foot ulcers and amputations. At your monthly meeting, staff members enthusiastically suggest solutions, such as using robocalls to urge patients to schedule appointments(...)
Can Hospitals Police Themselves to Avoid Too-Risky Surgeries?
Posted by | Measurement of Safety and Quality, Preventing Patient HarmImagine 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(...)
Hospital Star Ratings Could Use an Asterisk
Posted by | Measurement of Safety and Quality, Patient-Centered CareWhen you stay at a five-star hotel — if you are so lucky — you might expect a bowl of fresh fruit in your room every morning, gourmet restaurants on-site, and staff members who know your name and anticipate your needs. At a one-star hotel, you may just hope for value, cleanliness and decent water pressure. The(...)
Why Health Care Performance Measures Need Their Own Grades
Posted by | Measurement of Safety and QualitySome measures of health care quality and patient safety should be taken with a grain of salt. A few need a spoonful. In April, a team of Johns Hopkins researchers published an article examining how well a state of Maryland pay-for-performance program measure for dangerous blood clots identified cases that were potentially preventable. In reviewing(...)
Mining Patients’ Wisdom for Safer Care
Posted by | Patient-Centered Care, Preventing Patient HarmConsider, 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(...)
Getting Patients’ Loved Ones off the Sidelines: The Family Involvement Menu
Posted by | Patient-Centered Care, Preventing Patient HarmYears ago, I felt firsthand what it was like to be the helpless family member of a hospitalized patient. My mother had undergone surgery in a hospital nearly three hours away, and things had not gone well. She was unconscious when I arrived in the intensive care unit. One of the first things I noticed(...)