Supporting Safer Healthcare

Readers Digest provides a first-hand account of the stress and anxiety medical professionals can feel after a medical error in Doctors Confess Their Fatal Mistakes.  Former Cleveland, Ohio pharmacist Eric Cropp talks about, not just his regret over his error and the subsequent death of a child, but also the enormous impact the event had on his life.  Patient [...]

Our days. or in some cases our nights, are spent with co-workers.  The desire to collaborate with compassionate, intelligent people led me to a career in healthcare, and over the past 25+ years, I’ve had the pleasure of working with some phenomenal individuals. Some have been physicians; both those who have cared for family and for me, as well as those with whom [...]

Prior to the establishment of the new National Hemovigilance Program in February, 2010, the U.S. was the only developed country without an established method to nationally track and aggregate adverse events associated with blood transfusions. The program is part of the National Healthcare Safety Network of the Centers for Disease Control (CDC), and allows all U.S. hospitals that transfuse [...]

You may know the story of Taylee Blischke, a newborn who nearly died in April 2009 at Mission Hospital in Mission Viejo, California. Morphine was mistakenly given to Taylee, instead of her mother who was holding the infant. California investigators say mother and baby had IVs that were mixed up.  To add insult to injury, the hospital [...]

“I care for you, I care about you, and I know you in ways no one else does; I am your doctor. ” The physician patient relationship is unique, sensitive, and vitally important.  Imagine for a moment, that you are the physician who made the opening statement, and that the patient to whom you spoke those words has suddenly, [...]

Prior to providing care, treatment, and services, the hospital obtains or renews orders (verbal or written) from a licensed independent practitioner. Sounds like a no-brainer right?  How difficult can it be for hospitals to comply with such a simple standard? Turns out, pretty difficult.  Nearly every hospital struggles to comply with at least one aspect of that simple-sounding [...]

After resigning her position, a female physician in North Carolina brought a claim of sexual harassment against her former employer, the physician-owner of a medical clinic.  Initially the court ruled against her claim, stating that it was “not uncommon in a medical setting to use off-color jokes to “ease the tension.” The 4th U.S. Circuit Court of Appeals [...]

One woman’s courageous response to a devastating sentinel event: My mother was critically burned during surgery in December 2002 when a topical solution was not allowed to dry before the doctor used a cauterizing tool. The entire experience was awful, but the worst realization for me was that nobody would listen. No one apologized, no one showed much [...]

The Joint Commission has released partial pre-publication standards updates for 2011, which will remain available on their web site until October 1, 2010.    The currently available pre-pubs include:   Hospital and Critical Access Hospital Standards – Language for the long-awaited MS.01.01.01 regarding Bylaws requirements - Effective March 31, 2011  Hospital Standards – Patient Centered Communication, which sets requirements for [...]

When jumbo jets collided in the Canary Islands on March 27, 1977, 583 passengers and crew died in the ensuing inferno; the worst aviation accident in history.  Investigation revealed mis-communication between the tower and cockpit, and the fact that the first-officer was apparently too intimidated by the more experienced captain to question his actions. The aviation industry responded by developing Crew Resource Management training, which focuses [...]