In healthcare we talk about never events. Things such as surgeries done on the wrong side of a body, or the wrong body part, or even the wrong organ. These are horrible mistakes that we say should never happen. Yet, this article reminds us that these things keep happening (If you can’t see the New…
Author: RRHemphill
I am an emergency medicine physician by training, but have spent much of my career with a focus on trying to improve patient safety and quality of patient care. I have worked in government, military and large academic systems.
Tools to Help Patients Engage in their Healthcare
The Joint Commission’s “Ask” Campaign has been discussed previously. The idea of engaging with patients as while they are in the hospital setting (and elsewhere) is important, but difficult. I have had concerns about the “Ask” campaign, not because it isn’t important, but rather because it can seem to place the burden of engagement on…
The Joint Commission’s “Ask” Campaign
The Joint Commission’s *Speak Up* program, also referred to as the “Ask Campaign,” is a patient safety initiative aimed at encouraging patients and their families to play an active role in their healthcare. The program emphasizes the importance of open communication between patients, families, and healthcare providers to prevent errors, improve care, and ensure patient…
Communicating With Our Patients
Ensuring that patients both understand and engage with their healthcare. Yet, when we talk to patients, particularly in the hospital setting, it can be very challenging to be certain that patients (and their families) can engage. If we can pause in our busy days it might help to try and walk a bit in the…
Prevention of Catheter Associated Urinary Tract Infections
Patients who are admitted for medical problems or surgical procedures may have a urinary catheter placed because of the difficulty that patients have getting up to urinate or using localized methods to urinate. For this reason catheter associated urinary tract infections (CAUTI) remain a concerning source of infection in hospitalized patients, causing both morbidity and…
The Ongoing Issue of Catheter Associated Urinary Tract Infections (CAUTI)
I thought I would take a break from the ECRI top 10 lists of bad things causing safety related concerns and return to an issue that remains problematic within hospitals. It is now a bit over a year since my father suffered a broken knee cap, underwent surgery to repair the fracture and was then…
Barcode Administration – Recommendations
As already discussed, barcode medication administration (BCMA) systems, while valuable tools for preventing medication errors, can be vulnerable to staff developing workarounds when encountering scanning or labeling issues. These workarounds, while sometimes perceived as helpful, can compromise patient safety and lead to serious consequences. As mentioned previously, examples of unsafe BCMA practices include administering a medication…
Barcode Administration – Creative Workarounds
When the systems we are told to use don’t work as expected, people create workarounds to get their work completed. Some of these workarounds are discussed below (and there are probably a few more not mentioned here): Manual Entry of Bar Codes One common workaround is the manual entry of bar codes when the scanner…
Workarounds for Barcode Administration – Frustrations that Encourage Workarounds
The next significant safety issue on ECRI’s 2024 Top Patient Safety List is on the topic of the workarounds that people use to get past a key safety tool, the barcode administration tool. Bar code medication administration (BCMA) systems are implemented in hospitals to enhance patient safety by ensuring the right patient receives the right…
Challenges Transitioning Newly Trained Clinicians from Education into Practice – Part 3
I have discussed my own thoughts related to transitions in training in a prior post, but the ECRI document (click here to access the site and register for the report) also delves into the nuances of transitioning newly trained clinicians from their educational environments into clinical practice and provides some additional strategies. As discussed, the…
Challenges Transitioning Newly Trained Clinicians from Education into Practice – Part 2
This section will continue to discuss the #1 Patient Safety Concern from ECRI 2024 – Clinician’s Transition to Practice. Last time I discussed what was happening to people in training during COVID. Individuals were impacted by COVID in that they were shunted away from bedside training opportunities. Training programs certainly tried to respond in a…
Challenges Transitioning Newly Trained Clinicians from Education into Practice – Part 1
The opportunity for discussing the top patient safety risks over the years is a gift that will keep giving for awhile. While I will spend time on some of the most persistent and recurrent of safety issues, it is worth looking at many of the other topics as well. The concern about bringing new clinicians…
Medication Reconciliation – with some help from ChatGPT
Medication Reconciliation (Chat GPT): I have spent a few days looking back at the various years of ECRI safety lists. I have re-looked at the recurrent safety concerns and…they are daunting! Yet, even those that may not appear on the list of recurrent issues, they don’t seem easier. Each represent past harms and the possibility…
And…The 2024 ECRI Top 10 Patient Safety List
ECRI recently released their top 10 patient safety list for 2024. For more information follow this link.
Recurrent Themes in ECRI Patient Safety Lists
As you look through the last several years of ECRI Patient Safety List, you will see some recurring themes. They may change slightly, but in general they keep coming up. If you review these and you consider how difficult it may be to address some of these, I think it is understandable that they remain…