Imagine you are sitting in first class on a plane, waiting for the plane to push off from the gate, when you see two people in uniform, the pilot and co-pilot, dash from the Jetway into the cockpit. A few seconds later, a voice comes over the intercom, saying, “This is Captain Jones, please be sure your seat belts are fastened. We’re ready for takeoff.” What crucial event could not have occurred in this scenario? The pilot and co-pilot did not go through their checklist of safety measures. Fuel tanks full? Check! Flaps up? Check! Checklists, along with scrupulous reporting of all accidents and near misses, have helped transform aviation from one of the most dangerous modes of transportation into one of the safest. Last year, there wasn’t a single fatal airplane crash in the lower 48 states.
From aviation to skyscraper construction to steel manufacturing, checklists and reporting of accidents have become an integral part of safety improvement in practically every complex and potentially dangerous human endeavor you can name. Every endeavor, that is, except for health care, which lags far behind other industries in terms of safety improvement.
When a provider makes a tragic mistake that harms a patient, most healthcare organization executives and their staffs are told to hide. If they say anything, they will be more likely to be sued, they think.
Instead of promptly reaching out to empathize and console with food, housing, money, and social support for those whose lives are irreversibly altered, hospital executives and staff often take a “willful blindness” posture.
Stanford University’s hospitals and clinics have saved $3.2 million in annual premiums since establishing a program to disclose and investigate adverse events and offer an apology and compensation to patients when the bad outcome has been deemed preventable.
The results come on the heels of other successful experiments with a more transparent method of dealing with adverse events. The University of Michigan Health System, for example, says it has cut litigation costs by $2 million a year and seen new claims fall by 40% with a similar disclosure, apology and compensation initiative.
GE hosted a fourth safety webcast in an ongoing series, this time focused on “The Second Victim”. Moderated by GE’s Jeff Terry, the webcast features two guest speakers, Dr. Albert Wu, professor at Johns Hopkins and Jim Conway, adjunct faculty at Harvard School of Public Health who discuss the concept of the second victim. Topics include:
What is a successful second victim support program and what are the measures for success?
How can leaders create a culture that supports second victims?
How should institutions proactively plan to respond to patients, caregivers, media, and board members when an adverse event occurs?
Pascal Metrics is hosting a gathering for thought leaders interested in trigger driven adverse event detection and management. Senior clinical leaders will be meeting in Washington, DC to exchange ideas and develop approaches to using triggers in clinical improvement programs.
Among other thought leaders, Dr. Don Kennerly of Baylor Health Care System and Dr. David Classen of the University of Utah will be sharing their perspectives. Dozens of leading health care systems are being represented as well.
This guide is meant to be used by researchers, quality managers, clinicians and other professionals with an interest in understanding and tackling patient safety concerns in hospitals, without needing to rely on good medical records. The guide comes with a set of supporting materials, such as PowerPoint presentations to train health professionals who will be implementing the protocols and presentations to be used to inform different stakeholders about the different studies. During this session explanations of how to use this guide, the guide contents and practical advice for conducting the different methods will be given.
*Featuring a question and answer session at the close of the webinar.*
Please register here for this webinar before 10 October 2011:
Five patients in Taiwan finally received the organ transplants they had long hoped for this past week, only to find that their new heart, liver, lungs and kidneys belong to a donor who had HIV.
The organ transplants were performed on five different recipients in Taipei and Tainan on Aug. 24, one day after the 37-year-old donor fell into a coma after a serious fall.
The donor’s mother, without knowing that her son was an HIV carrier, agreed to have his major organs donated.
It is more dangerous to go to hospital than to fly on a plane, according to the World Health Organization (WHO), which estimates that millions of patients die annually around the world from medical errors and infections associated with health care.
Liam Donaldson, who has just been appointed envoy for patient safety for WHO said: “If you were admitted to hospital tomorrow in any country, your chances of being subjected to an error in your care would be something like 1 in 10. Your chances of dying due to an error in health care would be 1 in 300.”
Health Serv Res. 2011 Apr;46(2):596-616. doi: 10.1111/j.1475-6773.2010.01204.x. Epub 2010 Nov 24.
Objective: To define the relationship between hospital patient safety climate (a measure of hospitals’ organizational culture as related to patient safety) and hospitals’ rates of rehospitalization within 30 days of discharge.
Data Sources: A safety climate survey administered to a random sample of hospital employees (n=36,375) in 2006-2007 and risk-standardized hospital readmission rates from 2008.
Study Design. Cross-sectional study of 67 hospitals.
Data Collection: Robust multiple regressions used 30-day risk-standardized readmission rates as dependent variables in separate disease-specific models (acute myocardial infarction [AMI], heart failure [HF], pneumonia), and measures of safety climate as independent variables. We estimated separate models for all hospital staff as well as physicians, nurses, hospital senior managers, and frontline staff.
Principal Findings: There was a significant positive association between lower safety climate and higher readmission rates for AMI and HF (p≤.05 for both models). Frontline staff perceptions of safety climate were associated with readmission rates (p≤.01), but senior management perceptions were not. Physician and nurse perceptions related to AMI and HF readmissions, respectively.
Conclusions: Our findings indicate that hospital patient safety climate is associated with readmission outcomes for AMI and HF and those associations were management level and discipline specific.
INFORMATION overload is a headache for individuals and a huge challenge for businesses. Companies are swimming, if not drowning, in wave after wave of data — from increasingly sophisticated computer tracking of shipments, sales, suppliers and customers, as well as e-mail, Web traffic and social-network comments. These Internet-era technologies, by one estimate, are doubling the quantity of business data every 1.2 years.
Yet the data explosion is also an enormous opportunity. In a modern economy, information should be the prime asset — the raw material of new products and services, smarter decisions, competitive advantage for companies, and greater growth and productivity.
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