Patient Safety, evolving from Compliance to Culture with McKesson http://www.mckesson.com/static_files/McKesson.com/MPT/Documents/PatientSafety_WHT260.pdf
Patient Safety: Evolving from Compliance to Cultureclinicalsolutions
Patient Safety, evolving from Compliance to Culture with McKesson http://www.mckesson.com/static_files/McKesson.com/MPT/Documents/PatientSafety_WHT260.pdf
This document discusses how Johns Hopkins Home Care Group (JHHCG) has built a culture of safety over 10 years. Key aspects of their culture include transparency, trust, empowering staff to report issues without fear of punishment, collaboration, learning from mistakes, and involving patients. JHHCG uses tools like checklists, safety rounds, training, and collaborating with hospital staff to continuously improve safety. Their focus on specialization, communication, and educating providers has strengthened relationships and avoided errors.
This document discusses using safety culture assessments as a tool to improve patient safety in healthcare organizations. It describes that healthcare organizations are increasingly aware of the importance of transforming their culture to prioritize patient safety. The paper outlines characteristics of existing safety culture assessment tools, which can measure perceptions, attitudes, and behaviors related to safety culture from both managerial and staff perspectives. It provides examples of organizations that have used such assessments and highlights key processes for healthcare systems to consider when deciding to conduct a safety culture assessment. The overall aim of these tools is to help organizations understand and improve their safety culture.
The document discusses the need for an ethical framework to address the use of wearable devices in healthcare as their capabilities increase. It notes that currently no standards exist to guide practitioners and addresses questions around implications for different types of patients and devices. Experts argue an ethical framework needs to focus on patient benefit, do no harm, consider more than just medical impacts like privacy and anxiety, and take into account patient capacity and consent. Security of data collected is also a crucial issue to address.
The document summarizes a report from a committee on health IT and patient safety. The committee found that while health IT can improve safety, it also poses new risks that are not fully understood. The committee makes 10 recommendations, including that HHS develop a plan to assess health IT risks, create a mandatory reporting system for health IT adverse events, establish an independent investigation entity, and ensure regulation of health IT if sufficient safety progress is not made. The goal is for all stakeholders to work together to understand and address health IT patient safety issues.
A pivotal trademark of evolution is the ability to adapt to the environment for survival. The health care industry, as a living system, is not immune to the effects of an ever-changing environment. Present environmental concerns affecting health care organizations include government policy, advances in technology, the need for stable finances, and patient/public perceptions of health care quality. Any one or all of these conditions could thwart the continued existence of a health care facility. A primary approach to adapting to the environment for health organizations is in the adoption of electronic health records. The benefits of electronic records could also pose risk to viability, due to the potential for fraud, theft, and abuse of data by both external and internal forces. Despite these risks, the benefits of electronic health systems, if used properly, can contribute to financial stability, employee retention, quality patient care, and patient satisfaction. As the environment continues to change, so will the demands upon the health care industry, ensuring continuous change in methods, as true and total development (apotheosis) can never be achieved.
Three key trends are forcing a change in today's health models: 1) Rising chronic diseases among both young and old are driving up health costs and creating future liabilities. 2) Technology is enabling mass customization of healthcare similar to other industries. 3) Broader factors like behavior, socioeconomics, and genetics are recognized as influencing health beyond medical care. To address these issues, health will be customized around six vectors: incentives, regulations, funding, patient communication, information technology, and workforce models to personalize diagnosis, care and cure for individuals.
FINAL APPROVED Digital transformation of the health sector - summary record o...SochaBlue
The document discusses the opportunities and challenges of digital transformation in the health sector. It states that transformation is fundamentally a cultural change where technology provides tools to improve healthcare outcomes. While the role of doctors will change with new technologies, they are unlikely to be replaced. For health systems to successfully adopt digital tools, organizations need capabilities in their workforce, an understanding of customer needs, and courage to change practices. Key drivers of digital health include rising healthcare costs of aging populations and a shift towards preventative care models over the traditional treatment of sickness.
Patient Safety: Evolving from Compliance to Cultureclinicalsolutions
Patient Safety, evolving from Compliance to Culture with McKesson http://www.mckesson.com/static_files/McKesson.com/MPT/Documents/PatientSafety_WHT260.pdf
This document discusses how Johns Hopkins Home Care Group (JHHCG) has built a culture of safety over 10 years. Key aspects of their culture include transparency, trust, empowering staff to report issues without fear of punishment, collaboration, learning from mistakes, and involving patients. JHHCG uses tools like checklists, safety rounds, training, and collaborating with hospital staff to continuously improve safety. Their focus on specialization, communication, and educating providers has strengthened relationships and avoided errors.
This document discusses using safety culture assessments as a tool to improve patient safety in healthcare organizations. It describes that healthcare organizations are increasingly aware of the importance of transforming their culture to prioritize patient safety. The paper outlines characteristics of existing safety culture assessment tools, which can measure perceptions, attitudes, and behaviors related to safety culture from both managerial and staff perspectives. It provides examples of organizations that have used such assessments and highlights key processes for healthcare systems to consider when deciding to conduct a safety culture assessment. The overall aim of these tools is to help organizations understand and improve their safety culture.
The document discusses the need for an ethical framework to address the use of wearable devices in healthcare as their capabilities increase. It notes that currently no standards exist to guide practitioners and addresses questions around implications for different types of patients and devices. Experts argue an ethical framework needs to focus on patient benefit, do no harm, consider more than just medical impacts like privacy and anxiety, and take into account patient capacity and consent. Security of data collected is also a crucial issue to address.
The document summarizes a report from a committee on health IT and patient safety. The committee found that while health IT can improve safety, it also poses new risks that are not fully understood. The committee makes 10 recommendations, including that HHS develop a plan to assess health IT risks, create a mandatory reporting system for health IT adverse events, establish an independent investigation entity, and ensure regulation of health IT if sufficient safety progress is not made. The goal is for all stakeholders to work together to understand and address health IT patient safety issues.
A pivotal trademark of evolution is the ability to adapt to the environment for survival. The health care industry, as a living system, is not immune to the effects of an ever-changing environment. Present environmental concerns affecting health care organizations include government policy, advances in technology, the need for stable finances, and patient/public perceptions of health care quality. Any one or all of these conditions could thwart the continued existence of a health care facility. A primary approach to adapting to the environment for health organizations is in the adoption of electronic health records. The benefits of electronic records could also pose risk to viability, due to the potential for fraud, theft, and abuse of data by both external and internal forces. Despite these risks, the benefits of electronic health systems, if used properly, can contribute to financial stability, employee retention, quality patient care, and patient satisfaction. As the environment continues to change, so will the demands upon the health care industry, ensuring continuous change in methods, as true and total development (apotheosis) can never be achieved.
Three key trends are forcing a change in today's health models: 1) Rising chronic diseases among both young and old are driving up health costs and creating future liabilities. 2) Technology is enabling mass customization of healthcare similar to other industries. 3) Broader factors like behavior, socioeconomics, and genetics are recognized as influencing health beyond medical care. To address these issues, health will be customized around six vectors: incentives, regulations, funding, patient communication, information technology, and workforce models to personalize diagnosis, care and cure for individuals.
FINAL APPROVED Digital transformation of the health sector - summary record o...SochaBlue
The document discusses the opportunities and challenges of digital transformation in the health sector. It states that transformation is fundamentally a cultural change where technology provides tools to improve healthcare outcomes. While the role of doctors will change with new technologies, they are unlikely to be replaced. For health systems to successfully adopt digital tools, organizations need capabilities in their workforce, an understanding of customer needs, and courage to change practices. Key drivers of digital health include rising healthcare costs of aging populations and a shift towards preventative care models over the traditional treatment of sickness.
The document discusses medical errors and patient safety. It notes that medical errors result in tens of thousands of deaths each year in the US, costing billions of dollars. Underreporting of errors is a problem due to fear of punishment and a "sweep it under the rug" attitude. National organizations are working to improve safety through initiatives to reduce infections, falls, and other hospital events. Reporting of errors and "near misses" can help analyze root causes and improve systems to prevent future occurrences.
PSO's Improve Nursing Care Delivery and PerformanceiCareQuality.us
Nurses are well-positioned to support Patient Safety Organizations (PSOs) in improving patient care and outcomes. PSOs were created by the Patient Safety and Quality Improvement Act of 2005 to enable healthcare providers to voluntarily report patient safety issues without fear of legal discovery. This allows organizations to identify risks and implement best practices to enhance safety. By 2017, hospitals over 50 beds must report to PSOs. Working with PSOs provides legal protections and supports a culture of transparency and learning to advance quality improvement. As frontline caregivers, nurses can help PSOs achieve their mission through initiatives like audits, education, and data collection to strengthen practice and reduce harm.
Improving Patient Safety - Five years after the IOM ReportISOB
Five years after an influential IOM report brought attention to medical errors, there have been some improvements in patient safety but also lingering concerns. Various public and private organizations have implemented new programs and policies focused on error reduction. However, over half of Americans remain dissatisfied with healthcare quality and 40% believe it has gotten worse. Reaching consensus on effective safety strategies, including reporting methods, remains challenging due to ideological differences. Continued progress will require further investment in information technology solutions and data sharing across the fragmented system.
Precision medicine and AI: problems aheadNeil Raden
This document discusses the challenges of using AI and machine learning in healthcare due to issues with data silos and lack of data sharing. Healthcare data is fragmented across different organizations, making it difficult to access enough high-quality data needed to train accurate AI models. This fragmentation was caused by organizations independently developing their own IT systems, and impacts the ability to develop personalized medicine models that need access to diverse patient data sources. Overcoming these challenges will require addressing issues of data governance like ownership, responsibility and privacy.
Using technology-enabled social prescriptions to disrupt healthcareDr Sven Jungmann
As chronic diseases are increasingly straining healthcare systems, social factors are gaining importance. Since the birth of social medicine (19th century), we saw many failed attempts to beat the dominance of the biomedical model. Social prescriptions have come, raising hopes that non-biomedical solutions will improve outcomes and optimise resource use. Social Prescriptions connect citizens to support to address social determinants of health and encourage self-care for physical and mental health. Social prescriptions can make us healthier cheaper and with fewer side effects than most drugs. Social prescriptions can become a disruptive force as they can be personalised, improve lifestyle-related diseases, and support non-biomedical issues affected by social determinants of health.
Emerging into E-Health Information Management pdfkatnick56
Kathy is excited about the benefits of e-health initiatives like electronic health records and health information management. She believes these can help both individual patients and communities affected by health conditions. However, there are barriers to implementing these initiatives. As a health information management professional, Kathy's mission is to help break down barriers to adopting electronic health information management. She wants to find a specific barrier and help remove it. E-health involves applying e-commerce principles to healthcare to improve efficiency, quality of care, patient empowerment and more.
The document discusses four pressures that are shaping the future of post-acute care: 1) the pressure to serve patients in the lowest-cost setting using telemedicine, telehealth, and mobile technologies; 2) the pressure to avoid readmissions and improve patient compliance; 3) the pressure to remove friction from data and workflow exchange; and 4) the pressure to prove the value of post-acute care. It recommends that post-acute care providers identify challenges, do a reality check on needed changes, and embrace pressures as opportunities to invest in technologies that improve data access, workflows, and care coordination across settings.
Nuance Guide to Advancing the mHealth ecosystem3GDR
This document discusses the potential for mobile technology to advance the healthcare ecosystem by addressing the needs of patients, providers, and payers. It features perspectives from industry experts on how mobile technology is currently being used in healthcare and its future applications. Experts discuss how mobility can help humanize healthcare by improving workflow efficiency for physicians, increasing access to health information and services for patients, and empowering consumers to better manage their health. The document outlines both successes and challenges in adopting mobile technologies and emphasizes the importance of collaboration across the healthcare system to leverage innovations and advance the mobile health ecosystem.
Call for a standard framework for clinical risk management program to ensure ...Ruby Med Plus
Globally, the patient safety movement got focused in risk management by the publication of “To Err Is Human: Building a Safer Health System”, in 1999, which articulated the findings of a study of Institute of Medicine (IOM) of the devastating consequences of widespread medical error in the hospitals in USA. In addition to the unfortunate health consequences of medical error, there are direct and indirect costs borne by society as a whole. Patient Safety is the fundamental of the health care system. If care is not provided in a safe manner in a safe environment, the chances for a good outcome are lessened significantly.
As, Institute of Medicine (IOM) noted, “Patients should not be harmed by the care that is intended to help them, nor should harm come to those who work in health care.” The goal of risk management in health care must be to prevent harm from reaching patients and those involved in providing care to those patients and the place where the care is being provided . The aim of Clinical Risk Management is to improve both the safety and quality of care for patients and to reduce the costs of such risks for health care providers ” Hence, the Clinical Risk Management program needs a standard framework to fulfill this objective of Clinical Risk Management in clinical Dentistry. It gives the realization to the Dentist / Dental Team that fallibility is part of the human condition and human condition can’t be changed, but the conditions under which people work can be changed. That explains the need of Clinical Risk Management in Dentistry.
This document discusses health information technology (HIT) problems at Universiti Teknologi Malaysia's clinic. It begins with an introduction to HIT and its benefits, including cost reduction, quality improvement, and better patient experience. However, HIT implementation can be difficult and introduce new issues. The document then examines specific problems, including new errors from HIT systems, such as incorrect drug selections, and information overload for clinicians. It also notes challenges from the variety and complexity of clinic workflows. Interviews with clinic staff and doctors identified current HIT system problems at the Universiti Teknologi Malaysia clinic.
Nearly 50% of patients in U.S. hospitals experience some form of harm during their stay, costing the economy $17.1 billion per year. The article proposes three simple rules that hospitals can adopt to reduce patient harm and improve safety: 1) Treat all patients and staff with respect to overcome a poor safety culture, 2) Develop a preoccupation with potential failures in order to prevent them, and 3) Ensure an open and transparent culture where staff are comfortable reporting errors without fear of reprisal. Following these three rules can help transform hospitals into high reliability organizations with improved patient safety.
Digital health tools are rapidly innovating and becoming more widely adopted. Over 350,000 health-related mobile apps now exist, with over 90,000 added in 2020. Digital therapeutics that treat diseases are being approved by regulators globally. New digital biomarkers are being developed using consumer wearables and sensors to remotely monitor health. Over 250 digital therapeutic products now exist, with many gaining regulatory approval and reimbursement pathways established. Clinical evidence for digital health tools is maturing, with over 2,000 studies published assessing effectiveness. Wearables and sensors are also being used in decentralized clinical trials to reduce patient burden and accelerate timelines.
Hospitals are charged with the dual task of keeping patients well while also keeping patients safe. The two are inextricably linked, as patient safety concerns often tie directly into patient health concerns — hand hygiene, transitions of care and medication errors are a few such concerns that come to mind.Looking prospectively, these concerns, and many others, will flow into the next calendar year. Some of the patient safety issues are long established, and will remain in the forefront of healthcare's mind for years to come. Here, in no particular order, are 10 important patient safety issues for providers to consider in the upcoming year.
Held each year in Boston, Medical Informatics World connects more than 400 healthcare, biomedical science, health informatics, and IT leaders to navigate emerging trends and opportunities in the evolving industry. The event responds to the challenges in collaborating and maximizing the benefit of enabling technologies with inspiring plenary keynotes combined with focused expert-led presentations and discussions. Coverage includes population health management, predictive analytics, payer-provider-pharma data collaborations, patient care and engagement, mobile and wearable technologies, care delivery models, enterprise hospital information systems, clinical decision support, error and readmission reduction, and healthcare data security. The 2015 program features six conference tracks, two interactive dinner workshops and six plenary keynote presentations, providing attendees with the connections, tools and strategies for taking their research and care delivery to the next level. Learn more at http://www.medicalinformaticsworld.com
This document summarizes the key findings of an EMC-commissioned study by IDC on integrated care delivery models in Western Europe, the Middle East, and Africa. The study found that traditional hospital-centric healthcare systems are inefficient for treating chronic conditions like non-communicable diseases. An integrated care model coordinates care across hospitals, primary care, clinics, and other providers. Information sharing through integrated patient records is critical to enable coordination among different care providers. However, integrated care faces challenges related to governance, data quality, legacy systems, and cultural change. The document discusses how solutions for electronic medical records, big data analytics, cloud computing, and document lifecycle management can help overcome barriers by facilitating information sharing across the healthcare system.
This document summarizes the key findings of an EMC-commissioned study by IDC on integrated care delivery models in Western Europe, the Middle East, and Africa. The study found that traditional hospital-centric healthcare systems are inefficient for treating chronic conditions like non-communicable diseases. An integrated care model coordinates care across hospitals, primary care, clinics, and other providers. Information sharing through integrated patient records is critical to enable coordination among different care providers. However, integrated care faces challenges related to governance, data quality, legacy systems, and cultural change. The document discusses how solutions for electronic medical records, big data analytics, cloud computing, and document lifecycle management can help overcome barriers by improving information capture, access, and insights
1) Regulatory reforms are expected to promote accountable care organizations and increased usage of healthcare IT. This is driving merger and acquisition activity as providers consolidate to form ACOs.
2) Accountable care organizations are networks of providers that share responsibility for patient care costs and quality. The Medicare Shared Savings Program aims to incentivize ACOs beginning in 2012.
3) Increased adoption of electronic health records is also being driven by incentives from the HITECH Act. EHRs are expected to improve care coordination and reduce costs over the long run. However, providers face significant upfront costs to develop EHR systems.
Memorial Health System Innovative Approach to CPOE Earns Robust Resultsclinicalsolutions
1) Memorial Health implemented McKesson's Horizon Expert Orders computerized physician order entry (CPOE) system to improve order accuracy, reduce medication errors and turnaround times, and automate clinical processes.
2) They first rolled it out to nurses to create a support system for physicians before rolling it out unit by unit, starting with neonatology who volunteered to go first.
3) Using CPOE, Memorial has increased order legibility and accuracy to 100%, reduced medication turnaround times by two hours on average, and reduced pharmacy call backs related to illegibility by 30%.
Baptist Health Systems: Uses Technology to Improve Medication Management, Eli...clinicalsolutions
Baptist Health Systems uses McKesson Nursing Documentation to improve medication management and administration.
http://www.mckesson.com/en_us/McKesson.com/For%2BHealthcare%2BProviders/Hospitals/Nursing%2BSolutions/Nursing%2BSolutions.html
Memorial Health System Innovative Approach to CPOE Earns Robust Results clinicalsolutions
Memorial Health System Innovative Approach to CPOE Earns Robust Results
http://www.mckesson.com/en_us/McKesson.com/For%2BHealthcare%2BProviders/Hospitals/Patient%2Band%2BMedication%2BSafety/Patient%2Band%2BMedication%2BSafety.html
Safety Culture Definitions and Enhancement ProcessISOB
This document provides a proposed definition of safety culture and a process for enhancing an organization's safety culture. It defines safety culture as "the enduring value, priority and commitment placed on safety by every individual and every group at every level of the organisation." The document outlines eight key elements of a safety culture: informed culture, reporting culture, just culture, learning culture, flexible culture, risk perception, attitudes to safety, and safety-related behavior. It then presents a systematic five-step process for enhancing safety culture: define the safety culture, identify drivers of the culture, measure the culture, evaluate the measures, and improve the culture.
The document discusses medical errors and patient safety. It notes that medical errors result in tens of thousands of deaths each year in the US, costing billions of dollars. Underreporting of errors is a problem due to fear of punishment and a "sweep it under the rug" attitude. National organizations are working to improve safety through initiatives to reduce infections, falls, and other hospital events. Reporting of errors and "near misses" can help analyze root causes and improve systems to prevent future occurrences.
PSO's Improve Nursing Care Delivery and PerformanceiCareQuality.us
Nurses are well-positioned to support Patient Safety Organizations (PSOs) in improving patient care and outcomes. PSOs were created by the Patient Safety and Quality Improvement Act of 2005 to enable healthcare providers to voluntarily report patient safety issues without fear of legal discovery. This allows organizations to identify risks and implement best practices to enhance safety. By 2017, hospitals over 50 beds must report to PSOs. Working with PSOs provides legal protections and supports a culture of transparency and learning to advance quality improvement. As frontline caregivers, nurses can help PSOs achieve their mission through initiatives like audits, education, and data collection to strengthen practice and reduce harm.
Improving Patient Safety - Five years after the IOM ReportISOB
Five years after an influential IOM report brought attention to medical errors, there have been some improvements in patient safety but also lingering concerns. Various public and private organizations have implemented new programs and policies focused on error reduction. However, over half of Americans remain dissatisfied with healthcare quality and 40% believe it has gotten worse. Reaching consensus on effective safety strategies, including reporting methods, remains challenging due to ideological differences. Continued progress will require further investment in information technology solutions and data sharing across the fragmented system.
Precision medicine and AI: problems aheadNeil Raden
This document discusses the challenges of using AI and machine learning in healthcare due to issues with data silos and lack of data sharing. Healthcare data is fragmented across different organizations, making it difficult to access enough high-quality data needed to train accurate AI models. This fragmentation was caused by organizations independently developing their own IT systems, and impacts the ability to develop personalized medicine models that need access to diverse patient data sources. Overcoming these challenges will require addressing issues of data governance like ownership, responsibility and privacy.
Using technology-enabled social prescriptions to disrupt healthcareDr Sven Jungmann
As chronic diseases are increasingly straining healthcare systems, social factors are gaining importance. Since the birth of social medicine (19th century), we saw many failed attempts to beat the dominance of the biomedical model. Social prescriptions have come, raising hopes that non-biomedical solutions will improve outcomes and optimise resource use. Social Prescriptions connect citizens to support to address social determinants of health and encourage self-care for physical and mental health. Social prescriptions can make us healthier cheaper and with fewer side effects than most drugs. Social prescriptions can become a disruptive force as they can be personalised, improve lifestyle-related diseases, and support non-biomedical issues affected by social determinants of health.
Emerging into E-Health Information Management pdfkatnick56
Kathy is excited about the benefits of e-health initiatives like electronic health records and health information management. She believes these can help both individual patients and communities affected by health conditions. However, there are barriers to implementing these initiatives. As a health information management professional, Kathy's mission is to help break down barriers to adopting electronic health information management. She wants to find a specific barrier and help remove it. E-health involves applying e-commerce principles to healthcare to improve efficiency, quality of care, patient empowerment and more.
The document discusses four pressures that are shaping the future of post-acute care: 1) the pressure to serve patients in the lowest-cost setting using telemedicine, telehealth, and mobile technologies; 2) the pressure to avoid readmissions and improve patient compliance; 3) the pressure to remove friction from data and workflow exchange; and 4) the pressure to prove the value of post-acute care. It recommends that post-acute care providers identify challenges, do a reality check on needed changes, and embrace pressures as opportunities to invest in technologies that improve data access, workflows, and care coordination across settings.
Nuance Guide to Advancing the mHealth ecosystem3GDR
This document discusses the potential for mobile technology to advance the healthcare ecosystem by addressing the needs of patients, providers, and payers. It features perspectives from industry experts on how mobile technology is currently being used in healthcare and its future applications. Experts discuss how mobility can help humanize healthcare by improving workflow efficiency for physicians, increasing access to health information and services for patients, and empowering consumers to better manage their health. The document outlines both successes and challenges in adopting mobile technologies and emphasizes the importance of collaboration across the healthcare system to leverage innovations and advance the mobile health ecosystem.
Call for a standard framework for clinical risk management program to ensure ...Ruby Med Plus
Globally, the patient safety movement got focused in risk management by the publication of “To Err Is Human: Building a Safer Health System”, in 1999, which articulated the findings of a study of Institute of Medicine (IOM) of the devastating consequences of widespread medical error in the hospitals in USA. In addition to the unfortunate health consequences of medical error, there are direct and indirect costs borne by society as a whole. Patient Safety is the fundamental of the health care system. If care is not provided in a safe manner in a safe environment, the chances for a good outcome are lessened significantly.
As, Institute of Medicine (IOM) noted, “Patients should not be harmed by the care that is intended to help them, nor should harm come to those who work in health care.” The goal of risk management in health care must be to prevent harm from reaching patients and those involved in providing care to those patients and the place where the care is being provided . The aim of Clinical Risk Management is to improve both the safety and quality of care for patients and to reduce the costs of such risks for health care providers ” Hence, the Clinical Risk Management program needs a standard framework to fulfill this objective of Clinical Risk Management in clinical Dentistry. It gives the realization to the Dentist / Dental Team that fallibility is part of the human condition and human condition can’t be changed, but the conditions under which people work can be changed. That explains the need of Clinical Risk Management in Dentistry.
This document discusses health information technology (HIT) problems at Universiti Teknologi Malaysia's clinic. It begins with an introduction to HIT and its benefits, including cost reduction, quality improvement, and better patient experience. However, HIT implementation can be difficult and introduce new issues. The document then examines specific problems, including new errors from HIT systems, such as incorrect drug selections, and information overload for clinicians. It also notes challenges from the variety and complexity of clinic workflows. Interviews with clinic staff and doctors identified current HIT system problems at the Universiti Teknologi Malaysia clinic.
Nearly 50% of patients in U.S. hospitals experience some form of harm during their stay, costing the economy $17.1 billion per year. The article proposes three simple rules that hospitals can adopt to reduce patient harm and improve safety: 1) Treat all patients and staff with respect to overcome a poor safety culture, 2) Develop a preoccupation with potential failures in order to prevent them, and 3) Ensure an open and transparent culture where staff are comfortable reporting errors without fear of reprisal. Following these three rules can help transform hospitals into high reliability organizations with improved patient safety.
Digital health tools are rapidly innovating and becoming more widely adopted. Over 350,000 health-related mobile apps now exist, with over 90,000 added in 2020. Digital therapeutics that treat diseases are being approved by regulators globally. New digital biomarkers are being developed using consumer wearables and sensors to remotely monitor health. Over 250 digital therapeutic products now exist, with many gaining regulatory approval and reimbursement pathways established. Clinical evidence for digital health tools is maturing, with over 2,000 studies published assessing effectiveness. Wearables and sensors are also being used in decentralized clinical trials to reduce patient burden and accelerate timelines.
Hospitals are charged with the dual task of keeping patients well while also keeping patients safe. The two are inextricably linked, as patient safety concerns often tie directly into patient health concerns — hand hygiene, transitions of care and medication errors are a few such concerns that come to mind.Looking prospectively, these concerns, and many others, will flow into the next calendar year. Some of the patient safety issues are long established, and will remain in the forefront of healthcare's mind for years to come. Here, in no particular order, are 10 important patient safety issues for providers to consider in the upcoming year.
Held each year in Boston, Medical Informatics World connects more than 400 healthcare, biomedical science, health informatics, and IT leaders to navigate emerging trends and opportunities in the evolving industry. The event responds to the challenges in collaborating and maximizing the benefit of enabling technologies with inspiring plenary keynotes combined with focused expert-led presentations and discussions. Coverage includes population health management, predictive analytics, payer-provider-pharma data collaborations, patient care and engagement, mobile and wearable technologies, care delivery models, enterprise hospital information systems, clinical decision support, error and readmission reduction, and healthcare data security. The 2015 program features six conference tracks, two interactive dinner workshops and six plenary keynote presentations, providing attendees with the connections, tools and strategies for taking their research and care delivery to the next level. Learn more at http://www.medicalinformaticsworld.com
This document summarizes the key findings of an EMC-commissioned study by IDC on integrated care delivery models in Western Europe, the Middle East, and Africa. The study found that traditional hospital-centric healthcare systems are inefficient for treating chronic conditions like non-communicable diseases. An integrated care model coordinates care across hospitals, primary care, clinics, and other providers. Information sharing through integrated patient records is critical to enable coordination among different care providers. However, integrated care faces challenges related to governance, data quality, legacy systems, and cultural change. The document discusses how solutions for electronic medical records, big data analytics, cloud computing, and document lifecycle management can help overcome barriers by facilitating information sharing across the healthcare system.
This document summarizes the key findings of an EMC-commissioned study by IDC on integrated care delivery models in Western Europe, the Middle East, and Africa. The study found that traditional hospital-centric healthcare systems are inefficient for treating chronic conditions like non-communicable diseases. An integrated care model coordinates care across hospitals, primary care, clinics, and other providers. Information sharing through integrated patient records is critical to enable coordination among different care providers. However, integrated care faces challenges related to governance, data quality, legacy systems, and cultural change. The document discusses how solutions for electronic medical records, big data analytics, cloud computing, and document lifecycle management can help overcome barriers by improving information capture, access, and insights
1) Regulatory reforms are expected to promote accountable care organizations and increased usage of healthcare IT. This is driving merger and acquisition activity as providers consolidate to form ACOs.
2) Accountable care organizations are networks of providers that share responsibility for patient care costs and quality. The Medicare Shared Savings Program aims to incentivize ACOs beginning in 2012.
3) Increased adoption of electronic health records is also being driven by incentives from the HITECH Act. EHRs are expected to improve care coordination and reduce costs over the long run. However, providers face significant upfront costs to develop EHR systems.
Memorial Health System Innovative Approach to CPOE Earns Robust Resultsclinicalsolutions
1) Memorial Health implemented McKesson's Horizon Expert Orders computerized physician order entry (CPOE) system to improve order accuracy, reduce medication errors and turnaround times, and automate clinical processes.
2) They first rolled it out to nurses to create a support system for physicians before rolling it out unit by unit, starting with neonatology who volunteered to go first.
3) Using CPOE, Memorial has increased order legibility and accuracy to 100%, reduced medication turnaround times by two hours on average, and reduced pharmacy call backs related to illegibility by 30%.
Baptist Health Systems: Uses Technology to Improve Medication Management, Eli...clinicalsolutions
Baptist Health Systems uses McKesson Nursing Documentation to improve medication management and administration.
http://www.mckesson.com/en_us/McKesson.com/For%2BHealthcare%2BProviders/Hospitals/Nursing%2BSolutions/Nursing%2BSolutions.html
Memorial Health System Innovative Approach to CPOE Earns Robust Results clinicalsolutions
Memorial Health System Innovative Approach to CPOE Earns Robust Results
http://www.mckesson.com/en_us/McKesson.com/For%2BHealthcare%2BProviders/Hospitals/Patient%2Band%2BMedication%2BSafety/Patient%2Band%2BMedication%2BSafety.html
Safety Culture Definitions and Enhancement ProcessISOB
This document provides a proposed definition of safety culture and a process for enhancing an organization's safety culture. It defines safety culture as "the enduring value, priority and commitment placed on safety by every individual and every group at every level of the organisation." The document outlines eight key elements of a safety culture: informed culture, reporting culture, just culture, learning culture, flexible culture, risk perception, attitudes to safety, and safety-related behavior. It then presents a systematic five-step process for enhancing safety culture: define the safety culture, identify drivers of the culture, measure the culture, evaluate the measures, and improve the culture.
St. Vincent's Hospital implemented McKesson's clinical solutions including their electronic medical record, clinical data repository, pharmacy information system, medication administration system, and clinical documentation system to improve patient safety and access to information. This integrated clinicians with real-time patient data at the point of care. It helped reduce medication errors through automated dispensing cabinets, clinical alerts, and computerized physician order entry. These solutions supported St. Vincent's goals of safer, higher quality, and more efficient care through improved access to patient information for clinicians.
McKesson Delivers Medication Safety to St. Vincent's High-Tech, High-Touch Careclinicalsolutions
discover how St. Vincent's improved medication safety with healthcare it solutions from McKesson Medication Safety http://www.mckesson.com/en_us/McKesson.com/For%2BHealthcare%2BProviders/Hospitals/Patient%2Band%2BMedication%2BSafety/Patient%2Band%2BMedication%2BSafety.html
Discover how clinical and financial data can be combined to develop better strategies for performacne improvement to increase patient and medication safety Medication Safety http://www.mckesson.com/en_us/McKesson.com/For%2BHealthcare%2BProviders/Hospitals/Patient%2Band%2BMedication%2BSafety/Patient%2Band%2BMedication%2BSafety.html
Patient Safety: Evolving from Compliance to Cultureclinicalsolutions
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Patient Safety: Evolving from Compliance to Cultureclinicalsolutions
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Closing the Gap Toward a Culture of Safetycourtemanche
In its landmark 1999 publication, To Err Is Human, the Institute of Medicine defined patient safety as “freedom from accidental injury.” In 1999, estimated deaths from medical errors in United States hospitals were 98,000 per year thus the expectation to be free from accidental injury was more than a reasonable expectation for those accessing the health care system.
A SPECIAL S U P P L E H E N T TO THE HHTIHGS CENTEH REPOUT.docxbartholomeocoombs
This document provides an overview and summary of a report from The Hastings Center on promoting patient safety through policy deliberation. Some key points:
- The report was prompted by the 1999 IOM report "To Err is Human" which estimated medical errors result in up to 98,000 deaths per year in the US.
- The IOM report recommended establishing a national patient safety center and mandatory reporting of serious medical errors to track safety performance. This sparked significant policy debate and reform efforts.
- This Hastings Center report discusses the ethical values and principles underlying patient safety efforts such as beneficence, non-maleficence, and fiduciary responsibility to patients. It also addresses tensions between individual accountability and systemic
Simple and Safe Approaches Towards Patient SafetyEhi Iden
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Computer Technology’S Effect On The Practice Of Nursing EssayJessica Deakin
Computer technology has significantly impacted the practice of nursing. At one hospital, nurses use electronic documentation to record patient information and chart vital signs, medications, and other care. Computerized systems integrate various functions like lab results, prescribing medications, and patient tracking. While this hospital currently uses paper charting, it plans to implement online computerized documentation and physician order entry within a year to further improve patient care.
Six Steps to Managing an Infection Control BreachHealth Catalyst
Despite widespread efforts to improve patient safety, infection control breaches still happen at an alarming rate. In order to improve patient safety and prevent infections, healthcare organizations need to have infection control procedures in place and regularly assess protocols and adherence to these policies. In the case of an infection control breach, organizations need to be prepared to act quickly and follow a six-step evaluation procedure outlined by the CDC:
1. Identify the infection control breach.
2. Gather additional data.
3. Notify and involve key stakeholders.
4. Perform a qualitative assessment.
5. Make decisions about patient notification and testing.
6. Handle communications and logistical issues.
This document discusses the need for increased patient safety in the U.S. healthcare system. It notes that medical errors have increased significantly in recent decades. While suggestions have been made to improve policies, procedures, and oversight, leadership within individual organizations will be key to implementing new patient safety protocols. Research is also needed to better understand errors and develop solutions. A focus on leadership, data, education, and continuous improvement can help healthcare organizations strengthen patient safety standards over time.
Transparency is vital for quality care and informed decision making and it begins with accurate medical records provided by medical transcription services.
Implementing The Affordable Care Act EssayMichelle Love
The document discusses the benefits of implementing electronic health record (EHR) systems. It provides perspectives from a physician who was an early adopter of EHR technology. The physician found that the EHR system improved clinical quality measures through automated feedback on adherence to evidence-based standards of care. It also reduced administrative burdens on physicians and staff, improving productivity and income. Additional benefits discussed include increased patient engagement through access to health records online and fewer calls and visits to medical records offices. Keeping EHRs error-free is also important to maintain integrity of patient information.
November 1999I N S T I T U T E O F M E D I C I N E S.docxIlonaThornburg83
November 1999
I N S T I T U T E O F M E D I C I N E
Shaping the Future for Health
TO ERR IS HUMAN:
BUILDING A SAFER HEALTH SYSTEM
Health care in the United States is not as safe as it should be--and can be. At least 44,000 people, and perhaps as many as 98,000 people, die in hospitals each year as a result of medical errors that could have
been prevented, according to estimates from two major studies. Even using
the lower estimate, preventable medical errors in hospitals exceed attributable
deaths to such feared threats as motor-vehicle wrecks, breast cancer, and
AIDS.
Medical errors can be defined as the failure of a planned action to be
completed as intended or the use of a wrong plan to achieve an aim. Among
the problems that commonly occur during the course of providing health care
are adverse drug events and improper transfusions, surgical injuries and
wrong-site surgery, suicides, restraint-related injuries or death, falls, burns,
pressure ulcers, and mistaken patient identities. High error rates with serious
consequences are most likely to occur in intensive care units, operating rooms,
and emergency departments.
Beyond their cost in human lives, preventable medical errors exact
other significant tolls. They have been estimated to result in total costs (in
cluding the expense of additional care necessitated by the errors, lost income
and household productivity, and disability) of between $17 billion and $29
billion per year in hospitals nationwide. Errors also are costly in terms of loss
of trust in the health care system by patients and diminished satisfaction by
both patients and health professionals. Patients who experience a long hospi
tal stay or disability as a result of errors pay with physical and psychological
discomfort. Health professionals pay with loss of morale and frustration at
not being able to provide the best care possible. Society bears the cost of er
rors as well, in terms of lost worker productivity, reduced school attendance
by children, and lower levels of population health status.
A variety of factors have contributed to the nation’s epidemic of medi
cal errors. One oft-cited problem arises from the decentralized and frag
mented nature of the health care delivery system--or “nonsystem,” to some
observers. When patients see multiple providers in different settings, none of
whom has access to complete information, it becomes easier for things to go
Errors…are costly
in terms of loss of
trust in the health
care system by pa
tients and dimin
ished satisfaction
by both patients
and health profes
sionals.
Types of Errors
Diagnostic
Error or delay in diagnosis
Failure to employ indicated tests
Use of outmoded tests or therapy
Failure to act on results of monitoring or testing
Treatment
Error in the performance of an operation, procedure, or test
Error in administering the treatment
Error in the dose or method of using a drug
Avoidable delay in treatmen.
The document discusses weaknesses in current approaches to patient safety and how data-driven tools can help address these weaknesses. It describes how health systems currently take a fragmented approach to safety that focuses on specific metrics rather than reducing all-causes of harm. New tools using integrated data, machine learning, and predictive analytics allow a more proactive approach by identifying risks, recommending interventions, and enabling improvements across the care continuum. The document advocates for a sociotechnical approach combining improvements to safety culture, processes, and technology.
The panel convened by the National Patient Safety Foundation to discuss the current state of patient safety 15 years after the seminal IOM report To Err Is Human identified several key points:
1) While awareness of patient safety issues has increased, progress has been slower than anticipated and the scale of improvement has been limited.
2) A total systems approach is needed to move beyond reactive, piecemeal interventions to prioritizing safety culture, developing the science of safety, and ensuring coordination across the care continuum and settings.
3) Specific recommendations include establishing safety leadership, centralized oversight, common safety metrics, increased research funding, addressing safety across all care settings, supporting the healthcare workforce, partnering with patients and families, and optim
Health care organizations strive to create a culture of.docxstudywriters
Despite efforts to improve patient safety, medical errors continue to occur. Some errors result in minor issues, while others can permanently alter or end a patient's life. Many errors stem from ineffective communication between caregivers. This document discusses analyzing a medical error or near miss to identify contributing factors, preventability, stakeholder impacts, team responsibilities, quality improvement measures taken, and proposed additional solutions to prevent similar incidents.
Nephrology Nursing Journal September-October 2014 Vol. 41, No. 5 447
Patient Safety and Patient Safety
Culture: Foundations of Excellent
Health Care Delivery
Primum non nocere. First do no harm.
Patient safety forms the founda-tion of healthcare delivery justas biological, physiological,and safety needs form the
foundation of Maslow’s hierarchy
(Maslow, 1954). Little else can be
accomplished if the patient does not
feel safe or is, in fact, not safe. But the
healthcare system is extremely com-
plex, and ensuring patient safety
requires the ongoing, focused efforts
of every member of the healthcare
team.
Patient safety moved to the fore-
front in health care with the release in
1999 of the Institute of Medicine (IOM)
landmark report, To Err is Human:
Building a Safer Health System, which
estimated that annually in the United
States, up to one million people were
injured and 98,000 died as a result of
medical errors (IOM, 2000). The re -
port caught the attention of the media,
and there were headlines across the
nation about the safety (or lack of safe-
ty) for patients in healthcare organiza-
tions. In 2013, James updated the esti-
mate of patient harms associated with
Beth Ulrich
Tamara Kear
Continuing Nursing
Education
Beth Ulrich, EdD, RN, FACHE, FAAN, is
Editor, the Nephrology Nursing Journal, and a
Professor, the University of Texas Health Science
Center at Houston School of Nursing. She is a Past
President of ANNA and a member of ANNA’s
Sand Dollar Chapter. She may be contacted direct-
ly via email at [email protected]
Tamara Kear, PhD, RN, CNS, CNN, is an
Assistant Professor of Nursing, Villanova
University, Villanova, PA, and a Nephrology
Nurse, Liberty Dialysis. She is on the Editorial
Board for the Nephrology Nursing Journal,
serves as the ANNA Research Committee chairper-
son, and is a member of ANNA’s Keystone Chapter.
Statements of Disclosure: Please refer to page
457.
Note: Additional statements of disclosure and
instructions for CNE evaluation can be found on
page 457.
This offering for 1.4 contact hours is provided by the American Nephrology Nurses’
Association (ANNA).
American Nephrology Nurses’ Association is accredited as a provider of continuing nursing
education by the American Nurses Credentialing Center Commission on Accreditation.
ANNA is a provider approved by the California Board of Registered Nursing, provider number
CEP 00910.
This CNE article meets the Nephrology Nursing Certification Commission’s (NNCC’s) continu-
ing nursing education requirements for certification and recertification.
Copyright 2014 American Nephrology Nurses’ Association
Ulrich, B., & Kear, T. (2014). Patient safety and patient safety culture: Foundations of ex -
cellent health care delivery. Nephrology Nursing Journal, 41(5), 447-456, 505.
In 1999, patient safety moved to the forefront of health care based upon astonishing sta-
tistics and a landmark report released by the Institute of Medicine (IOM). This report,
To Err.
MHA6999 SEMINAR IN HEALTHCARE CASES-- WEEK 2 LECTURE, DISCUSSION, DioneWang844
MHA6999 SEMINAR IN HEALTHCARE CASES-- WEEK 2 LECTURE, DISCUSSION, AND PROJECT INSTRUCTIONS
Page | 1
Quality
Nearly fifteen years ago, the Institute of Medicine published the “To Err Is Human” report, which exposed the substantial impact of medical errors in the US healthcare system and called for a dramatic system change, including an improved understanding of those errors (McCarthy, Tuiskula, Driscoll, & Davis, 2017). Medical errors are considered to be failure to achieve the original goal or plan of action, and these errors may range from a patient falls to a mistake in the operating room. Not only do medical errors cause harm to the patient and jeopardize the patient’s trust, but they also cause a financial strain for the health system (“To Err is Human,” 1999). One of the contributing factors to medical errors is the lack of effective communication between doctors who are treating the same patient. This results in healthcare providers overprescribing medications for patients as well as increases the possibility of a patient having unnecessary tests or procedures performed. The report’s four-tiered approach includes:
· Focusing on creating a stronger foundation of education on patient safety
· Mandating a nationwide reporting system to encourage timely reporting of errors
· Increasing the standards of performance for healthcare providers
· Taking advantage of the security that safety systems offer (“To Err is Human,” 1999)
Creating a strong educational foundation for patient safety is most important. Healthcare personnel are much more likely to actively participate in reporting systems, encourage one another to perform at a higher level, and take advantage of safety systems when they are well educated on patient safety and the implications of medical errors. The reporting system seems to provide the least amount of impact on patient safety as they can result in losing patient trust in certain healthcare systems. The healthcare system as a whole has made progress in establishing a safe environment for patients when they are in need of care.
Challenges for Patient Safety and Steps for Improvement
Despite continuing evidence of problems in patient safety and gaps between the care that patients receive and the evidence about what they should receive, efforts to improve quality in healthcare show mostly inconsistent and patchy results.
Tap each image to know more.
Data Collection and Monitoring Systems
This always takes much more time and energy than anyone anticipates. It is worth investing heavily in data from the outset. Assess local systems, train people, and have quality assurance.
Tribalism and Lack of Staff Engagement
Overcoming a perceived lack of ownership and professional or disciplinary boundaries can be very difficult. Clarify who owns the problem and solution, agree roles and responsibilities at the outset, work to common goals, and use shared language.
Convince People That There's a Problem
Use hard data to secure emotional e ...
1) A personal health record (PHR) allows patients to access and manage their own health information to participate more actively in their care.
2) There are two main types of PHRs - tethered PHRs connected to healthcare providers and untethered standalone PHRs.
3) PHRs can empower patients, improve communication between patients and providers, and increase patient safety through better access to health information. However, they also face challenges regarding data security, privacy, and digital literacy.
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Patient Safety: Evolving from Compliance to Culture
1. Patient Safety: Evolving from Compliance to Culture
Introduction
Hospital-acquired infections. Adverse drug events. Pressure ulcers. Falls.
Patient safety is top of mind among patients, providers, payors and policy
makers, not to mention quality organizations and the media. No one in
healthcare comes to work to harm a patient. Yet providers and patients
are put in situations where something can go wrong because modern
healthcare and the healthcare system are so complex.
Any examination of patient safety invariably begins with a reference to the
Institute of Medicine’s (IOM’s) landmark report To Err Is Human: Building a
Safer Health System.i Controversial when released in 2000, the report’s
findings are all too familiar now, and more widely accepted. The headline-
grabbing finding was that more than 2 million serious medical errors occur
annually, accounting for between 44,000 and 98,000 deaths, making them
the fourth leading cause of death in the United States. Subsequent IOM
reports drove home the messages in the first report. They also introduced
the importance of leadership, culture, the work environment and process
design, while calling for a national health information infrastructure that
captures patient safety information as a byproduct of care and uses this
information to design increasingly safer delivery systems.
From Compliance to Culture
With so much pressure being brought to bear from so many quarters, the
much heralded “tipping point” needed to reinvent healthcare may be
upon us. When the focus is purely regulatory compliance, patient safety is
relegated to a tactical role. Particularly before the Joint Commission switched
to the current, unannounced survey methodology in 2006, patient safety
was part of the overall presurvey “fire drill,” with a return to business as
usual once the surveyors left. Like U.S. healthcare overall, the focus has
been reactive rather than proactive — performing often heroically in
discrete, vertical episodes of acute, (expensive) intervention rather than
transforming the system to excel at prevention, wellness and disease
management. Likewise with patient safety — an ounce of prevention is
worth a pound of cure.
Providers face ever greater demands to track and report safety and
quality performance in order to receive accreditation, secure higher rates
of reimbursement and help consumers make informed choices. The result
is a shift from regulatory compliance to culture as mission.
2. 2
Managing the Evolution from Compliance to Culture
The chart above depicts the shift from regulatory compliance to culture as mission, plus
the drivers and key steps as healthcare organizations move along the continuum from a
compliance-driven organization to an organization driven by a culture of patient safety.
Patient Safety Drivers
Increased awareness of the issue of patient safety both within the healthcare
industry and among policy makers, politicians and the media, coupled with
the rise of consumerism, pay for performance and the increased transparency
and publication of safety scores, have all resulted in increased pressure on
healthcare providers, their management and staffs to improve patient safety
and outcomes.
While the preceding drivers have certainly encouraged providers to improve
patient safety, they pale when compared with pending reimbursement
changes. In May 2006 the Centers for Medicare and Medicaid Services
(CMS) announced that it is reviewing its authority and working with
Congress to reduce or eliminate payments for what the National Quality
Foundation calls “never events,” and to provide more reliable information
to the public when these situations occur.ii
Beginning in October 2008, CMS will no longer reimburse for hospital-
acquired infections (HAIs). In one of the most comprehensive reports to
date, the Pennsylvania Health Care Cost Containment Council found that
patients in Pennsylvania who developed HAIs in 2004 incurred hospital
charges that were more than seven times higher than those who did not.iii
3. 3
Key Steps to Safety
Launching a comprehensive patient safety initiative and keeping it alive
involves strong leadership from the top down. As the Institute for Healthcare
Improvement (IHI) recommends in its 5 Million Lives Campaign, organizations
must get “boards on board” by educating members on key issues to ensure
patient safety initiatives are included in strategic plans and adequately funded.
It also means continued attention from senior executives to overcome skepticism
from staff inured by a steady diet of fleeting initiatives. Committed leaders
likely have a percentage of their pay tied to patient safety performance.
Only recently have a handful They make frequent safety walkarounds to determine where the next error
of organizations that employ is likely to occur, and they personally call or meet with the people involved
sophisticated analytics tools when one does.
that tie clinical outcomes
to financial outcomes been Yet patient safety efforts have been slowed by a punitive culture that focuses
able to assess the true cost on action after an incident rather than on creating a “just culture” that
of medical errors and to recognizes the difference between human error, at-risk behavior and reckless
recognize patient safety as actions.iv An approach that appropriately addresses these three types of
a business driver. actions fosters a culture of accountability in which caregivers feel safe
speaking up about unsafe practices and recommending changes.
A closely related key to success involves embracing disclosure to patients and
families when errors occur. Such disclosure – to patients, families, staff and
the community (including board members and the media) – is still new to an
industry in which physicians are all but trained to believe they are infallible
and fear of legal repercussions dominate practice. However, many organizations
are now adopting best practices for disclosure, thanks to the efforts of
Lucian Leape, M.D., and others, whose research has found that disclosure
does not increase the odds of litigation and in many instances reduces them.v
Data fragmentation and siloed operations have also made taking a holistic
view nearly impossible. Only recently have a handful of organizations that
employ sophisticated analytics tools that tie clinical outcomes to financial
outcomes been able to assess the true cost of medical errors and to recognize
patient safety as a business driver.
4. 4
The Ideal “End State”
What, then, do the most patient-safe organizations look like? For starters,
they are committed to building a culture of safety, from the top down. All
employees understand that patient safety is their responsibility. Patient safety
is a core strategic principal of the organization, not a tactical initiative du jour.
They have invested in electronic health records (EHRs) that accurately identi-
fy and track a patient from the physician practice across the healthcare continu-
um. They use pharmacy automation and clinical information technology (IT)
including computerized physician order entry (CPOE), bar-code point-of-care
The most patient-safe medication administration (BPOC) and electronic charting. These solutions
organizations have taken have been implemented only after processes have been carefully redesigned
a systems approach and based on evidence-based practice, with much of the evidence embedded in
have hardwired patient that technology to support clinical decision-making. They employ alerts,
safety, making it easy for reminders and tools that help clinicians organize their day and prioritize
caregivers to do the right tasks to ensure all patients receive all the care prescribed. In short, they have
thing and difficult for them taken a systems approach and have hardwired patient safety, making it easy
to do the wrong thing. for caregivers to do the right thing and difficult for them to do the wrong thing.
These organizations also expect patients to take a vested interest in their
care, ensuring they are properly educated about necessary steps for recovery
and empowering them with at-home technology that enables them to
proactively manage and monitor their progress.
At the managerial level, end-state organizations monitor compliance with
expected behavior and associated outcomes using scorecards that enable
managers to determine root causes of variances and quickly take appropriate
action. At the executive level, the organization has a patient safety officer
who reports directly to the CEO or who is part of a centralized C-level
quality office.
At the board level, members with backgrounds from industries employing
safety and quality initiatives, who well understand the relationship between
patient safety and financial goals, can offer meaningful guidance. They
begin each meeting by reviewing a balanced scorecard that offers a holistic
view of the organization, and they openly discuss with clinical leadership
specific cases in which errors have occurred.
A New Framework for Patient Safety
Definitions of patient safety abound, some rooted in medication safety, others
buried in a larger definition of quality. Many are too vague or overly academic.
Yet, there is still no commonly accepted industry definition of patient safety
beyond the general notion from the Hippocratic Oath to “First, do no harm.”
A comprehensive definition is sorely needed, along with an appropriate
5. 5
framework within which to address and implement a comprehensive solution.
McKesson proposes the following definition:
Patient safety is the sustained, proactive process of identifying, avoiding and
rapidly resolving errors, omissions, mishaps and miscommunications that
could affect a patient’s healing, health or well-being at any point, at any
time, in any care setting.
This definition sets the stage for the following framework, which represents
patient safety across the entire healthcare continuum and is designed to help
leaders communicate all of the necessary components of a comprehensive
patient safety program. Such a program must have broad initiatives and
integrated solutions for each of the identified areas. This framework can
help guide their implementation.
Patient Safety Framework
As illustrated above, culture, information safety and communications safety
are the joists, girders and struts that support the entire framework.
Information safety refers to the availability of secure, up-to-date, complete
and accurate medical records for every patient. Those records must be
permanent, portable and trustworthy, with longitudinal data on allergies,
medication history and so on. The information must move with the patient
across settings so that all providers – including retail pharmacists – are aware
of the patient’s current and past condition, ongoing treatments and possible
changes or complications that should be monitored closely.
6. 6
Communications safety refers to the sharing of relevant, real-time information
to all authorized, interested parties, with particular focus on the need to
improve hand-off communications. According to the Joint Commission,
breakdowns in communication remain by far the root cause of most sentinel
events.vi “Substantial and ubiquitous deficits” in discharge communication
between hospital-based providers and primary care physicians resulting in
“suboptimal patient care” have also been called out recently.vii
Medication safety refers to an end-to-end medication management strategy
designed to ensure the “five rights” — that the right patient receives the
A single lab slide can hold right medication in the right dose at the right time via the right route.
30 gigabytes of data. How do Medication safety requires a comprehensive solution that helps ensure safety
the laboratorian, radiologist at each stage where errors can occur — prescribing, transcribing, administering,
and physician decide what to dispensing and monitoring. More broadly, medication safety involves safe-
look at and what to act on? guarding the integrity of the distribution supply chain, to ensure that life-saving
drugs are available when and where needed.
Diagnostic safety refers to the gathering and interpretation of data supporting
or leading to optimal care planning and treatment. In an area second perhaps
only to genetics (where the explosion of available information threatens to
overwhelm the capacity to make sense of it), image management is not just
a safety issue but a liability issue. A single lab slide can hold 30 gigabytes of
data. How do the laboratorian, radiologist and physician decide what to
look at and what to act on? And how do providers defend themselves when
accused of misdiagnoses because they failed to run the appropriate tests?
Strategies to promote evidence-based diagnosis are essential.
Treatment safety refers to the accurate capture, recording, executing and
sharing of data to support optimal care delivery. Treatment safety also
means electronic capture of the treatment that occurs to the permanent
patient record for all the care team to see and preventing the objection,
“If you didn’t document it, you didn’t do it.” And if the other care team
members or the next shift can’t see that someone provided a treatment,
that treatment can’t be considered in light of patient status or, perhaps
worse, it might be done again.
Environmental safety refers to a very broad view of the patient’s environment.
It requires that caregivers identify patients who are at risk of falling and
follow appropriate protocols, and that they follow strict hand hygiene
rules and other protocols to prevent surgical site, central line and other
preventable infections. Environmental safety also ensures that appropriate
levels and mix of staff are on hand to care for patients based on their acuity,
and that staff have ready access to supplies. Evidence-based building design
will also play a large role here, particularly given the unprecedented
construction boom in healthcare.
7. 7
On the Path to Patient Safety
What can be done to replicate a patient safety model industrywide? At
McKesson we’re passionate about taking a leading role in improving patient
safety in our nation’s healthcare system. As the nation’s oldest and largest
healthcare services company, with pharmaceutical wholesaling roots dating
back 175 years, we provide pharmaceuticals, medical supplies, information
systems and technologies that enable caregivers across the continuum to
make healthcare safer while reducing costs. We believe this new framework
of information, communication, medication, diagnostic, treatment and
environmental safety has the potential to unite the entire care team in its
ongoing quest to provide the safest, best possible care for its patients. To
learn more about how we can help you achieve your patient safety goals,
contact us at 800.981.8601 or visit our Web site at www.mckesson.com/mcksafe.
i
To Err Is Human: Building a Safer Healthcare System (2000). Institute of Medicine: National
Academies Press. http://www.iom.edu/CMS/8089/5575.aspx
ii
CMS Fact Sheet: Eliminating Serious, Preventable, and Costly Medical Errors - Never Events,
May 18, 2006
http://www.cms.hhs.gov/apps/media/press/factsheet.asp?Counter=1863&intNumPerPage=
10&checkDate=&checkKey=&srchType=&numDays=3500&srchOpt=0&srchData=&keywordType=
All&chkNewsType=6&intPage=&showAll=&pYear=&year=&desc=false&cboOrder=date
iii
Pennsylvania Health Care Cost Containment Council, “Hospital-Acquired Infections in
Pennsylvania.” November 2006. http://www.phc4.org/reports/hai/05/default.htm
iv
Model developed by David Marx, JD, president, Outcome Engineering.
http://www.justculture.org/
v
When Things Go Wrong: Responding to Adverse Events: A Consensus Statement of the
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