Some things just don't make sense.
You can read more about Eric Cropp and the circumstances behind the tragic death of a toddler here.
"I had one surgeon tell me that checklists are for the lame and weak"If the chair of your local hospital's board (or one of her close family members) hasn't been the beneficiary of physicians, nurses, and pharmacists who hold similar opinions, you may indeed be somewhere very good. But it's a very different place from where the average American gives, receives, and oversees care.
Too late now but the #NWA188 pilots implausible story is worse for their careers than the likely truth (Zzzzz)
Insanity is doing the same thing over and over again and expecting different results.Results from a multi-center nursing "time and motion" study show that nurses in acute care settings spend about 35% of their time documenting care, 17% on responsibilities related to medication administration and monitoring, and 21% coordinating care. I've heard Marilyn Chow, one of this study's lead authors present these data before, and she included them in a presentation given last week in an IOM webinar on the Future of Nursing.
- Albert Einstein
Ilene Corina, a patient safety advocate, recounts what she found impressive at the National Patient Safety Institute's second annual Lucian Leape Institute gala. The changes in medical education previewed in one roundtable Ilene attended suggest that "reward what you value" is beginning to inform medical students' experiences. Changes which would enhance medical students' exposure to patient safety are in draft.
The recommendations put forth in forums such as this one serve as a "pulse check" for major patient safety initiatives. Ilene noted, with some dismay, how slowly patient safety-sensitive changes take hold in high stakes venues, like academia. She's right when she says the public assumes we are much further along, as my experience this weekend revealed.
My brother-in-law, an engineer, nearly choked on his steak Saturday night when I told him there were 4,000 wrong-site surgeries reported in the U.S. last year. (His number-crunching mind grasped the defect quotient this number represented before the meat bolus had cleared his trachea.) So a take-way corollary--learned not in a seminar but in a Houston steakhouse--is this: In the interest of patient safety, don't share disturbing facts when a healthcare consumer has a mouthful.
And something that rankles:
Brian Ahier wrote a short must-read piece You don't have to use EHR, in which he quotes Dr. David Blumenthal, National Coordinator of Healthcare IT at HHS. Brian puts the facts out, so I'll simply ask this follow-up question: "Would any other contemporary high consequence industry contemplate operations that bypassed electronic transmission of high-stakes data?"
In healthcare, when we finally get a Model T, we immediately tie an ass to the bumper. Here we go again.
My guess is that Dr. Blumenthal is hand-patting those who have fears, probably legitimate, about the misuse of health data. But he would be better served to act to shore up the security of EHRs. Providers cannot be responsive given the complexity modern healthcare absent data automation. Outcomes will suffer until the data-sink is resolved. People who are hand-patting about security concerns should take a turn alongside the clinical people who hand-pat the families of people who die as a result of lousy communication.
What I'm watching this week:
Grand Rounds, the weekly blog carnival, is taking on participatory healthcare this week. I expect to learn more about the power of patients to shape healthcare and improve safety.
Patient safety is a natural fit with participatory medicine. And not because initiatives that include the word "patient" should seek to involve patients in some nominal, "so glad you could make it" fashion. I don't picture patients manning the Guest Book at the reception when I consider the potential of patients to improve the safety of care.
Patient safety is a scientific discipline, one that seeks to make complex systems work reliably. Systems turn intention into outcome whether you're flying a plane or reconstructing a breast.Transparency, disclosure, error reporting, and an urge to prevent errors by learning from the mistakes of others are hallmarks of patient safety. People who champion the science of patient safety borrow from cognitive psychology, systems engineering, and human factors, recognizing the inherent fallibility of humans and looking for ways to mitigate the consequences of human error. These are principles patients should know.