Supporting Safer Healthcare

“Your child was harmed while under my care, by a mistake that I made, and I am so sorry.”  How would it feel to hear those words?  How would it feel to say those words?  How would you help coach a healthcare professional who was about to face that conversation? I had the opportunity to explore all of those [...]

 What happens when an object is unexpectedly left inside a patient after surgery?  In some cases patients suffer no adverse effects, in others life-threatening complications can develop.  In a effort to avoid this problem and enhance patient safety, various items used during surgery are counted before and after a procedure.  While it seems that process should solve the problem, statistics [...]

Healthcare consumers now have another key data element to review when comparing hospitals. The Health and Human Services Hospital Compare web site now displays death rates from pneumonia, as well as death rates from heart attack and heart failure for individual hospitals across the country. These numbers can be compared with the national mortality rate for heart attack (16.1 percent), [...]

For most healthcare organizations the concept of transparency is big and scary.  It isn’t what we’ve done.  Legal privilege, confidentiality, peer-review; that’s what we’re used to invoking when care goes wrong. And with good reason.   Healthcare leaders don’t want events and near-events swept under a rug of secrecy. Process problems can’t be fixed if no one with authority to [...]

CMS has added three additional hospital acquired conditions (HAC’s) to it’s list of events that qualify for reduced reimbursement as of October 1, 2008. In last year’s final rule, CMS listed eight preventable conditions for which it would not make additional payments.  In this year’s proposed rule, CMS identified nine potential categories of conditions, but [...]

Retail companies have long understood that customer complaints need to be addressed. The customer is not always right. (Whoever came up with that slogan never worked behind a sales counter!)  But if a company wants to be successful in business, someone needs to listen and whenever possible, act on behalf of the customer. Healthcare however, is just beginning [...]

 Buckeye Surgeon speaks personally about the benefits of being able to say ‘I’m sorry.’ “As soon as the word “sorry” left my lips, I could almost detect a physical change sweeping over her. Her shoulders relaxed. She smiled warmly. The lines in her face smoothed out. She had heard what she needed to hear. It’s OK, [...]

The 2008 Estes Park Healthcare Leadership conference is all about discontinuous change.  Continuous change, as it has been explained over the past few days here in Orlando, can be predicted and projected.  Discontinuous change occurs when future direction does not follow historical patterns.  In other words, the future of healthcare cannot be predicted with any [...]

The doctor (physician assistant, nurse, etc.) who makes the mistake needs help too. From the British Medical Journal: http://www.bmj.com/cgi/content/full/320/7237/726 ============ When I was a house officer another resident failed to identify the electrocardiographic signs of the pericardial tamponade that would rush the patient to the operating room late that night. The news spread rapidly, the [...]