The Safety Blog | Washington Patient Safety Coalition

Becoming Deeply Safe

One of the sessions I attended at the Institute for Healthcare Improvement’s conference in early December really got me thinking. I enjoy it when I’m challenged on assumptions or my usual approach to doing things, and am given something new to think about. I registered for this session because, perhaps like many of us who have been working on improving safety, I had been feeling stuck. The speaker was Carol Haraden, PhD, a Vice President at the IHI, and I’ll summarize what I took away from her talk – this blog may not represent...

Deeper Meaning of “dissemination”

I think it is fair to say that the majority of us who work in the patient safety arena know what is happening in terms of patient care events. For example, those leaders who attend safety committee meetings know the fall rate, pressure ulcer prevalence data, and number of medication errors reported. In addition, if we went around the table we could all cite the policies and procedures we have in place to prevent falls, pressure ulcers, and medication errors. Leaders appear to feel comfortable knowing these policies and procedures have been...

Once more, with feeling… On being a passenger on the way to the NPSF Congress

Last week I attended the NPSF Congress for the second time and once again had significant dissonance: it’s exciting and heartening to see so many people gathered together to learn about patient safety, and to know that the Washington safety community is so advanced and innovative – and so distressing to see a conference full of interventions billed as “creative” and “innovative” that we have been doing in our state for years. I did not see or hear anything that is not being done somewhere in Washington. If you look at my first...

You’re In…….But what about them?

It is pretty clear that the leaders of our organizations are in on the latest healthcare issues, such as the electronic healthcare record and meaningful use, healthcare reform, reimbursement issues and accountable care organizations. There are usually meetings daily that cover those key issues that will impact the future of hospitals in the state. Have you thought about your front line staff? How are they learning about the changes coming down the pike? The media does not always depict the truth. The frontline staff are like the soldiers...

National Patient Safety Awareness Week – I’m In

Each year the National Patient Safety Foundation designates a “National Patient Safety Awareness Week.” For those of us who work in safety and are devoted to or consumed with the topic, it may seem unnecessary or redundant – if this is our professional life, why focus on it for a week when we already do so every day? Why do extra work? I’m a former skeptic, but I now believe that there are some really good reasons to focus, and also that there is no ‘extra’ work required: First, it’s an opportunity...

“Oh Yes We Did”

The other day I was watching television and a commercial for Domino’s pizza came on. You may have seen it. If not, when you do I hope similar thoughts go through your head. It wasn’t how good the pizza looked that made me hungry to eat one, but the message that was portrayed made me hunger for more hospital efforts around transparency. So let me give you a sneak peak about this commercial. The commentator is talking about all the negative feedback and complaints about their pizza (and I had heard that Domino’s wasn’t doing all that...

How can we make health information understandable?

We endure a daily barrage of confusing and contradictory medical information: emails, banner ads, news articles, TV shows. It can be overwhelming. How can we make health information understandable? That’s what Health Literacy Month (October) is about. Founded by Helen Osborne in 1999, this is a “time for organizations and individuals worldwide to promote the importance of understandable health information (www.healthliteracymonth.org).” What can you do to help your loved ones understand their treatment programs, insurance...

Accountability is not always about one person

I have found during my experience as both a nurse and quality professional that frontline staff’s perception of medical errors is of a punitive nature. Even questions asked about what could potentially harm your patient today, while in your care, provoke that look of fear and sometimes even defensiveness. There truly appears to be a “wall” of some kind, a resistance to wanting to “go there.” So I change the subject and might ask them to show me how medications are retrieved from the med room/dispensing station. We...

Oil well blow-outs and other disasters

The deep-water oil blow-out and recently capped “leak” (which seems like an inadequate word) in the Gulf is nauseating in its own right when one considers the environmental effects. Because this is a patient safety blog I’ll turn my thoughts a bit to disasters and tragedies and how they make me reflect on safety issues. As I’ve read and thought about space shuttle failures, coal mine disasters, plane crashes, and oil wells some shared themes pop out, grossly simplified as follows: Communication and authority: There were...

On being a passenger on the way to the NPSF Congress

Welcome to the inaugural blog of the Washington Patient Safety Coalition! We welcome your comments and suggestions for topics. In May I had the opportunity to attend the National Patient Safety Foundation Congress for the first time. I’ll share my two major impressions, one of which is directly related to the event’s content and the other to the process of travelling to Orlando. First, regarding content: my overall impression is that we in Washington are far ahead of the rest of the country. It doesn’t mean that we are perfect...