Joint Commission National Patient Safety Goals
are Intrinsic to Our Mission

All Systems Go?
Why So Little Progress?

Barbara Youngberg, BSN, MSW, JD, FASHRM
University HealthSystem Consortium
Patient Safety and Quality Healthcare, January/February 2005
www.psqh.com

Excerpted from the article:

"I will start with a quote from Albert Einstein that sums up my feelings about the current challenge associated with patient safety: "We can't solve problems by using the same kind of thinking we used when we created them." Let me provide you with a few examples of where I think we continue to struggle in patient safety because we have retained outmoded and illogical ways of thinking."

AHRQ Patient Safety E-Newsletter

Issued periodically to disseminate patient safety news and information; features research findings, new product announcements, and updates on initiatives in the safety and quality field.

UCLA Emergency Codes - Overhead Pages

Poster provided by Mikki A. Wills and Victor Kennedy, UCLA Medical Center Safety/Security.  Thank you!

JCAHO Patient Safety Goals

UCLA Healthcare's Patient Identification Campaign

UCLA Participation in the MedSun Project

MedSun -- the Medical Product Surveillance Network. Under the direction of the U.S. Food and Drug Administration's Center for Devices and Radiological Health (CDRH), MedSun collects data on problems with medical devices from a sample of healthcare institutions. The project is designed to create a two-way channel of communication between CDRH and the clinical community.

Hospitals, nursing homes and certain other kinds of healthcare facilities are currently required to report certain medical device problems to CDRH, using the MedWatch 3500A Form. MedSun has an Internet-based data entry system that mirrors the MedWatch form along with some additional optional items. CDRH's contractor, CODA, receives incoming MedSun reports, clarifies them as needed with facility MedSun Representatives, and releases them to CDRH analysts for review. The information collected is used to improve the safe and effective design and use of medical devices.

MedSun Participants' Website

Reporting

Relevant Resources

Are We Suffering From Change Fatigue?
Quality & Safety in Health Care - April 2004

The chairman of the neurosurgery department at a large academic medical center recently offered the following recommendations on "how to" facilitate cultural change and improve patient safety:

1. Research how other similar organizations achieve change

2. Identify effective strategies

3. Implement

Wise counsel.

In that spirit, the April 2004 issue of "Quality & Safety in Health Care" is highly germane to our quest for effective strategies. According to P. Garside's trenchant article, "Are We Suffering From Change Fatigue?":

"Quality improvements require change. Performance improvements require change. When a health system aspires to both over a sustained period there is a serious risk of "change fatigue"- key players getting tired of new initiatives and the way they are implemented-invariably the key players needed to make the changes work and bring in the improvements.

"Clinicians want to change things for the better for their patients and for working practices. They perceive an endless stream of initiatives, see many of them "fail" and reappear with a new name, see conflicting directions of change, and a plethora of initiatives so great that they fail to see the final purpose or connecting logic....

"The answers should be in the field of organisational development. Ironically, this is not a body of knowledge and practice generally accepted by clinicians.5 What does motivate people is a shared vision "hooking" into personal desires to improve practice, evidence that the process behind the programme might work, and resources to help them do it. Trust in the leader and in the process taking change forward is also essential. Leadership is critical as people cannot simply be ordered to change. There must be a sense that the prize at the end of the change process is greater than the sacrifices they are making."

Ms. Garside correctly observes that "people cannot simply be ordered to change." Leadership IS critical.  

NOTE:  Above message posted by Louise Underdahl on University HealthSystem Consortium "Communities" and National Patient Safety Foundation Discussion Forum, April 17, 2004.

Learning from Malpractice Claims
Quality & Safety in Health Care - April 2004

The April 2004 issue of "Quality & Safety in Health Care" includes a number of highly relevant articles on risk management and patient safety.

"Learning from Malpractice Claims about Negligent, Adverse Events in Primary Care in the United States" concludes: "Our analyses also suggest that even "trivial," frequent, error related occurrences contribute to severe outcomes. Patients are affected frequently by "problems with records" and failed "communication between providers," but these are not typically thought of as important threats to patient safety. Consistent with recent events, we found that these and other system failures have tragic effects when they align with other errors. More complete characterization in malpractice claims data of system failures that contribute to negligent adverse events may be one of the richest opportunities for future research and efforts to help good doctors prevent lapses in care."

This research confirms the importance of documentation and communication, both to risk management and patient safety

NOTE:  Above message posted by Louise Underdahl on University HealthSystem Consortium "Communities," April 17, 2004.

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RN+ Systems, a provider of learning material and  wireless products for Fall Prevention.