Patient Safety--Overview

“Jaded Julie, if you were going technical mountain or rock climbing out in the Rockies or down at Devil’s Lake, this is the advice that I would give you: ‘Climb on good rock, with good equipment, and with good people.’”

“That sounds like excellent advice, Curmudge, but why are you giving it and what does it have to do with health care?”

“If you are climbing, I want you to be protected against misfortunes that might befall you (no pun intended) that are no fault of your own. The same should hold true for health care. If I am experiencing anything from a simple injection to major surgery, I want it done according to an evidence-based protocol, and by a person who is well trained, has done the procedure hundreds of times, and is not distracted by the hospital surroundings or problems at home.”

“I’ve got it, Curmudge. It’s our job to protect our patients against errors just like it’s the climbing guide’s job to protect his clients against falls. In health care we’ve got to do it right the first time every time; in climbing the first false step may be a long way down.”

“We’ve already laid the foundation for our discussion and talked about the importance of having a culture that allows one to report errors safely. It’s time now to consider some specific threats to patient safety.”

“This ought to be old stuff to most everyone working in patient care. Is there really any value in our taking time to talk about this?”

“Consider this, Julie. Would you prefer to be cared for by someone who is completely up to date on safe practices or one who reads this blog and says, ‘I didn’t know about that.’? We want to get inside the head of anybody who is even the slightest bit uninformed.”

“Okay, Curmudge, let’s do it. Where do we start?”

“Let’s begin with AHRQ’s 20 Tips to Help Prevent Medical Errors (1). A medical error is when something planned as a part of medical care doesn’t work out, or when the wrong plan was used in the first place. Errors can involve medicines, surgery, diagnosis, equipment, or lab reports. Sometimes errors can occur when doctors and their patients have problems communicating. LucidMED (2) is an example of new technology that can reduce communication problems. The 20 tips cover such things as medicines, hospital stays, surgery, and other topics. AHRQ (Agency for Healthcare Research and Quality) says that the single best way a patient can help to prevent errors is to be an active member of his/her health care team.”

“That sounds like something that everyone should read. All that is required is a computer connected to the Web.”

“Here are some other topics that patients as well as caregivers should have in mind:
· Accurate patient identification
· Labeling and administration of medications
· Reconciled medications across the continuum of care
· Effective communication among caregivers
· Reduced health care-associated infections
· Reduced risks of patient injury from falls.”

“I presume that we’ll talk more about some of these in the coming weeks. But Curmudge, how can you, a retired chemist, hope to tell anyone in health care about patient safety?”

“It’s pretty simple, Julie. I read, write, and tell other people where to find the information. As long as I have your help, it’s an easy job even for a curmudgeon.”

Affinity’s Kaizen Curmudgeon

(1)http://www.ahrq.gov/consumer/20tips.htm

(2)http://www.lucidmed.com