Sleepy or Sad? You’re more likely to make a mistake.

Last week while leaving a message for a client I discovered that where my own phone number should have been, there was only a disconcerting empty spot in my memory.  Most embarrassing.  My only excuse was that I'd gotten up at 3:30 a.m. to head for the airport to catch an early flight.  An obvious example that sleep deprivation isn't good for brain function. 


Mayo Clinic agrees.

In a recently released study of major medical mistakes, findings indicated a direct connection between errors and fatigue.  "For every point increase in the fatigue score, doctors were 14 percent more likely to make a major medical error.

The error rate doesn't just increase for residents, but also for more experienced practicing physicians as well.  And not just fatigue, but distress, depression, and burnout contribute to increased medical error.  The study found that there is often no good system in place to help physicians address those issues.

From my own observation it's worth noting that once a serious error has occurred, there is often no good system in place to help physicians and other caregivers deal with the emotional repercussions that inevitably follow. Based on the Mayo study, that in itself may be an indicator that those providers are then more likely to make additional errors.

The Mayo study results are published in the Sept. 23/30 Journal of the American Medical Association.

Related Article:
Tired, Stressed Docs Make More Mistakes, Study Finds

Can The Joint Commission Transform Healthcare?

JC Center for Transforming HealthcareThe newly established Joint Commission Center for Transforming Healthcare aims to solve healthcare’s most critical safety and quality problems. The Center’s participants – the nation’s leading hospitals and health systems – analyze specific breakdowns in care and discover their underlying causes in order to develop targeted solutions.

There are currently 18 hospitals working on patient safety projects with the JC Center for Transforming Healthcare; if your organization is interested, the “Transforming” web site lists the requirements.  The web site also states that Lean and Six Sigma methodologies will be used, and the solutions will be shared with the more than 16,000 healthcare organizations that JC accredits.

First up:  Hand hygiene and and Hand-off communication.

AHRQ Releases Common Formats 1.0 for Patient Safety Organizations

The Agency for Healthcare Research and Quality (AHRQ) announced the release of Common Formats Version 1.0 for collecting and reporting patient safety information, including adverse events, near misses, and unsafe conditions.  Example Common Format – Falls

The Common Formats were authorized by the Patient Safety and Quality Improvement Act of 2005, and they facilitate Patient Safety Organizations’ (PSOs) collection of patient safety work product from health care providers in a standardized manner. The formats are being used by health care providers and PSOs to report a comprehensive range of patient safety concerns, capturing both structured and narrative information.

 Download Common Formats 1.0


My friend Kerry recently traveled to Austria and took these lovely photos.  I post them here as a reminder that ours is a breathtakingly beautiful and unique planet sculpted by a Grand Designer. Let’s take care of it.  (Click for larger images.) 







Credentialers Beware – Not All Board Certifications Created Equal

Seal The American Geriatrics Society has issued a Notice regarding the American Board of Geriatrics

The American Geriatrics Society (AGS) would like to alert members to the activities of an organization calling itself "American Board of Geriatrics" (ABG) and a related organization called "The American College of Geriatrics."Certification from this Board is not recognized by the American Board of Medical Specialties (ABMS), or its approved member specialty boards, nor does the AGS recognize this as evidence of Board certification in geriatrics or in its consideration for advancement to a Fellow of the Society. The ABG claims to be a tax-exempt 501(c)(3) public charity. The Internal Revenue Service has advised that the ABG does not have such tax-exempt status.

American Medical News also issued an alert regarding this certification, and others that appear to be bogus.