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Search results for "Risk Managers"

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Newspaper/Magazine Article

Why empathy may be the best risk management strategy.

Hertz BT. Med Econ. 2015;92:40-44.

Communication and response strategies have been shown to improve how organizations, clinicians, and patients and their families recover from adverse incidents. This news article discusses apology laws which protect certain statements regarding disclosure from being admissible in court and highlights how sensitivity to patients and transparent communication about the failure can be beneficial for both clinicians and patients after a medical error.

Newspaper/Magazine Article

The role of failure mode and effects analysis in health care.

Fibuch E, Ahmed A. Physician Exec. Jul-Aug 2014;40:28-32.

Failure mode and effects analysis (FMEA) has been recommended as a method to detect safety hazards and proactively address system flaws. This article reviews the initial purpose of FMEA, provides a breakdown of the process, describes a scoring tool applying Six Sigma designations to determine probability of failure, and discusses how FMEA is used in health care settings.

Newspaper/Magazine Article

The right and wrong way to talk to patients about adverse events.

Beaulieu-Volk D. Med Econ. 2014;91:52-55.

Apology laws have been explored as a tactic to encourage conversations between patients and clinicians involved in errors, and many states have instituted laws that protect certain statements regarding disclosure from being used in court. This article describes efforts to improve error disclosure and transparency, such as policies to disclose, apologize, and offer compensation to patients who experience adverse events.

Newspaper/Magazine Article

Accreditation essentials: getting proactive about reducing adverse events and safety risks. 

Joint Commission: The Source. September 2005;3:3-4,11.

This article provides tips for implementing a program to proactively assess risk in hospitals.

Newspaper/Magazine Article

When is the surgeon too old to operate?

Span P. New York Times. February 1, 2019.

Cognitive and functional decline can occur as individuals age. Concerns have been raised regarding the need to assess skills of aging physicians. This newspaper article reports on the implementation of mandatory evaluation programs to assess competencies of older surgeons and the profession's response to them.

Newspaper/Magazine Article

Doctors make mistakes. A new documentary explores what happens when they do—and how to fix it.

Park A. Time Magazine. January 24, 2019.

This news article reports on the documentary To Err Is Human, which was produced and directed by the son of patient safety leader Dr. John M. Eisenberg. The film is structured around patient safety advocate Sue Sheridan's experience with diagnostic errors that resulted in harm for both her son and husband. It features a wide range of experts who discuss the impact of error on all involved, the role of culture in facilitating both mistakes and progress, and why continued work in health care safety is needed.

Newspaper/Magazine Article

Insulin pumps have most reported problems in FDA database.

Mohr H, Weiss M. Associated Press. November 27, 2018.

Usability issues, poor design, and lack of effective instruction hinder safe use of medical equipment. This news article reports on problems associated with ambulatory use of insulin pumps submitted to a Food and Drug Administration database.

Newspaper/Magazine Article

Fixing a broken EHR: HIM working in the spotlight to solve common EHR issues.

Butler M. J AHIMA. March 2015;86:18-23.

Although health information technology presents opportunities to improve patient safety, it can also introduce risks. This commentary discusses how insufficient interoperability, data integrity, training, and protection against copy-and-paste errors can hinder optimal use of electronic health record systems.

Newspaper/Magazine Article

Robotic-assisted surgery: focus on training and credentialing.

Dubeck D. PA-PSRS Patient Saf Advis. September 2014;11:93-101.

Research has documented a substantial learning curve for surgeons as they develop skills to use robotic technologies. Drawing from data submitted to the Pennsylvania Patient Safety Authority, this article analyzes the 722 safety events involving robotic-assisted surgery reported since 2005—approximately 75% of these incidents did not result in harm but 10 patient deaths were recorded—and discusses the challenges introduced as robotic-assisted surgery becomes accepted as standard surgical practice.

Newspaper/Magazine Article

Community-based health coaches and care coordinators reduce readmissions using information technology to identify and support at-risk Medicare patients after discharge.

Agency for Healthcare Research and Quality. Health Care Innovations Exchange. July 30, 2014.

This article describes an intervention that trained health coaches to use mobile technology to assess the health status of recently discharged Medicare patients, first during an in-home visit 48 hours after leaving the hospital and then with weekly phone calls over a 3-week period. The program resulted in decreased readmission rates and significant cost savings.

Newspaper/Magazine Article

Physician: 'I almost killed a patient' because of an advance directive.

Betbeze P. HealthLeaders Media. May 2, 2014.

Reporting on how misinterpretation of advance directives and living wills can detract from patient safety, this news article reveals insights from a physician who developed a checklist poster to provide decision support for clinicians and recommends standardization of the forms to reduce risks.

Newspaper/Magazine Article

Improving reliability with root cause analysis.

Latino RJ. Patient Saf Qual Healthc. September/October 2013;10:32-34,36-37.

This article relates how root cause analysis, typically used after an adverse event, can be utilized as a proactive risk assessment tool to enhance reliability.

Newspaper/Magazine Article

Using Six Sigma to improve patient safety in the perioperative process.

Galli BJ, Riebling N, Paraso C, Lehmann G, Yule M. Patient Saf Qual Healthc. July/August 2013;10:36-41.

This magazine article describes how Six Sigma methods can be applied to enhance compliance with time outs and measures to improve surgical safety.

Newspaper/Magazine Article

Drug shortages still at crisis levels.

Talsma J. Drug Topics. June 15, 2013.

Discussing the current state of and efforts to address drug shortages, this news article notes a reduction in chemotherapy delays and reveals persistent barriers to improvement.

Newspaper/Magazine Article

Fatal PCA adverse events continue to happen...better patient monitoring is essential to prevent harm.

ISMP Medication Safety Alert! Acute Care Edition. May 30, 2013;18:1-3.

Describing an adverse event involving patient-controlled analgesia (PCA), this newsletter article highlights risks around PCA use and recommends practices to enhance monitoring and prevent accidental overdose.

Newspaper/Magazine Article

Medical errors are hard for doctors to admit, but it's wise to apologize to patients.

Jain M. Washington Post. May 27, 2013.

This newspaper article reports on disclosure and apology for medical errors, recounts a physician's personal experience with disclosure, and discusses how training and policies can improve the practice.

Newspaper/Magazine Article

Management of drug shortages in the perioperative setting.

Murray C, Rycek W, Johnson D, Sifuentes-Tovar F. Pharm Purch Prod. January 2013;10:12.

This magazine article details how one academic medical center used a collaborative approach and implemented policies and procedures to address perioperative drug shortages.

Newspaper/Magazine Article

SWIFT: a new tool for identifying prospective hazards.

Joint Commission: The Source. September 2012;10:1-19.

This newsletter piece describes a proactive risk assessment tool designed to address process concerns and to be more efficient than failure mode and effect analysis.

Newspaper/Magazine Article

Massachusetts hospitals launch patient apology program.

Gallegos A. American Medical News. May 21, 2012.

This news article reports on a disclosure and apology program implemented in Massachusetts hospitals to reduce liability lawsuits.

Newspaper/Magazine Article

Alarm fatigue hazards: the sirens are calling.

Welch J. Patient Saf Qual Healthc. May/June 2012;9:26-29,32-33.

This article reports on alarm fatigue in clinical care, including the risks associated with it, and describes tactics to help reduce nuisance alarms.

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