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Perspectives on Safety > Perspective
with commentary by Ashish K. Jha, MD, MPH, The Transformation of Patient Safety at the VA, September 2006
Five years after the landmark Crossing the Quality Chasm report by the Institute of Medicine (IOM), the quality and safety of health care in the United States remains far from ideal.(1) It is easy to feel pessimistic. Can health care organizations really...
Journal Article > Study
Longo DR, Hewett JE, Ge B, Schubert S. JAMA. 2005;294:2858-2865.
To grade progress since release of the landmark Institute of Medicine (IOM) report, this AHRQ-funded study examined the status and evolution of patient safety systems through a survey of acute care hospitals in Missouri and Utah. Investigators characterized their assessment based on variables that included presence of computerized physician order entry systems, computerized test results, evaluation of adverse drug events, specific patient safety policies, use of data in patient safety programs, drug administration and safety procedures, error reporting processes, prevention policies, and root cause analyses. More than 100 hospitals completed the survey in 2002 and again in 2004. Findings demonstrated only modest improvements in certain areas with variability noted in others. For instance, surgical areas and medication processes seemed to embrace the greatest level of patient safety systems. However, the authors point out that the overall findings fall short of the IOM recommendations and necessitate a more intensive agenda for accelerated improvements. An accompanying editorial (link below) provides an overview of the factors and challenges involved in promoting change to improve patient safety.
Journal Article > Commentary
Smetzer J, Baker C, Byrne FD, Cohen MR. Jt Comm J Qual Patient Saf. 2010;36:152-163, 1AP-2AP.
This article discusses how a hospital responded to a fatal medication error that occurred when a nurse mistakenly administered epidural pain medication intravenously to a pregnant teenager. Findings from the root cause analysis of the error revealed underlying factors including fatigue (the nurse had worked a double shift the day before), failed safety systems (the hospital had recently implemented a bar coding system, but not all nurses were trained and workarounds were routine), and human factors engineering (bags containing antibiotics and pain medications were similar in appearance and could be accessed with the same type of catheter). A range of safety interventions were implemented as a result. However, the related editorials by leaders in the safety field (Drs. Sidney Dekker, Charles Denham, and Lucian Leape) take the hospital to task for focusing on narrow improvements rather than using complexity theory to solve underlying problems, and for creating a "second victim" by disciplining the nurse (who was fired and ultimately criminally prosecuted) rather than acknowledging the institution's responsibility and the caregiver's emotional distress. The article and commentaries provide a fascinating, in-depth look at the true impact of a never event.