VOLUME 3 - ISSUE 21
MAY 10, 2012



Welcome to the Patient Safety Update eNewsletter
This issue sponsored by The Quality Colloquium



An NTSB for Health Care - Learning from Innovation: Debate and Innovate or Capitulate
There is a growing interest in how lessons from the airline industry's successes with safety can be applied to healthcare. This two-part article from the Journal of Patient Safety digs into airline safety practices and transfers the knowledge to healthcare including the formation of a national agency similar to the National Transportation Safety Board (NTSB). Of note is that fact that Chelsey "Sully" Sullenberger, the US Air pilot who famously landed his plane in the Hudson River, and Dennis Quaid, the actor whose 12-day old twins received an overdose of heparin, are co-authors of the paper. (Journal of Patient Safety, March, 2012) See also a related Wall Street Journal blog entitled "Aviation is an Inspiration for Improving Patient Safety."

Note as well the video (found in the side-bar at right) by Edward Walker, MD from last year's Patient Safety Conference entitled "Deadliest Plane Crash: How Aviation Became a High Reliability System" which offers a compelling argument for learning from the airline industry.

I-PASS: Standardizing Patient "Handoffs" to Reduce Medical Errors
An innovative new process for improving the "hand off" process of patients has been developed at Boston Children's Hospital. The process, called I-PASS, was developed as the result of a patient safety and medical education initiative aimed at improving the transition of patients during shift changes. Medical errors have been found to be reduced by as much as 40% researchers reported at the Pediatric Academic Societies annual meeting in Boston. (MarketWatch, April 29, 2012)

Patient Safety Advocacy Group to Cut Hospital Mistakes Gets $1.6 Million Grant
The Pennsylvania Patient Safety Authority in partnership with the Hospital and Healthsystem Association of Pennsylvania received a $1.6 million federal grant from the program "Partnership for Patients." The Authority, a safety advocacy group that works to reduce hospital mistakes, will receive the monies over a two-year period. (MedCity Hospitals, April 30, 2012)

Administration Errors Most Common Type of Error During Medication Process
The ECRI Institute PSO (Patient Safety Organization) studied nearly 700 medication events from participating hospitals and found the most common medication errors occurring during the administration process. More than one third of the errors involved intravenous medications. (Becker's Hospital Review, May 8, 2012)

Physician-Patient Alliance for Health & Safety: Monitoring Technology for PCA Pumps Can Prevent Adverse Events: So Why Are Hospitals Not Using It
Adverse events may occur in the use of PCA (Patient Controlled Analgesia) notes Frank Federico, RPh of the Institute for Healthcare Improvement. In the study harmful adverse events (opiod related) were determined to be cost $13,803 while non-harmful event costs were estimated to be only $28. LeRoy Hicks, PHD, a professor at Western University College, advises that "..[p]ractitioners should capitalize on capnography and future innovations, such as linking monitoring alarms to the hospital's network..." (MarketWatch, May 8, 2012)

NJ Oncology Nurses Develop Method to Enhance Patient Safety in Outpatient Area
The Cancer Institute of New Jersey has developed a teaching method which creates mock situations that closely resemble actual emergency events. The nurses employed the rapid response procedure to determine specific roles and utilized a 'code cart' with emergency medications, equipment and a defibrillator. It was noted that the method can be adapted for use by all nurses in the outpatient setting. (Newswise, April 30, 2012)

ACOs and Patient Safety: Dos and Don'ts
This brief podcast from H&HN Daily raises some patient safety concerns that Becky Miller, Executive Director of the Missouri Center for Patient Safety believes ACOs must consider. Among her recommendations is carefully mitigating concerns over confidentiality arising from collaboration in addressing the conflict that arise from such issues as isolating the cause of a pressure ulcer during the transfer of a patient between facilities. (HHN, May 2, 2012)





TeamSTEPPS®: National Implementation

TeamSTEPPS® is a teamwork system for healthcare professionals developed by Agency for Healthcare Resources of the US Department of Health & Human Services. The tools are designed to facilitate a culture of patient safety.



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Deadliest Plane Crash: How Aviation Became a High Reliability System

Edward Walker, MD, MHA
University of Washington Healthcare Leadership Development Alliance, Seattle, WA