by Sean Power
With Patient Safety Awareness Week behind us, we’ve taken a moment to share a few of the best articles or resources. Please let us know if we missed any that you consider must-reads!
Saying Sorry Works
For Patient Safety Week: The Tyler Kahle Story
Doug Wojcieszak, Founder of Sorry Works, highlights the story of 19-year-old Tyler Kahle, who died because of a misdiagnosed aortic dissection. According to Mr. Wojcieszak, Tyler’s parents repeatedly shared their family history of aortic dissection with Tyler’s doctors. According to Wojcieszak, doctors involved discussed “how owning the mistakes that took Tyler’s life have led to life-saving changes in their system.”
Medical Error Involving Monitors
Transparency as Healing: A Powerful TED Talk
Massachusetts Alliance for Communication and Resolution following Medical Injury
The Massachusetts Alliance for Communication and Resolution following Medical Injury (MACRMI) shared a TEDx Talk by Leilani Schweitzer about the death of her son, Gabriel. Gabriel died because of a medical error involving the monitors that would have normally alarmed nurses of his cardiac arrest. The TEDx Talk, and MACRMI’s article, calls for a culture change.
Need for Improved Communication
Safe Health Care for All During Patient Safety Awareness Week
Kim Siarkowski Amer
Kim Siarkowski Amer, a pediatric nurse, nursing professor, and writer for the Huffington Post, explores some of the more complex challenges to safe patient care.
Most errors result from multifaceted problems such as poor communication, inadequate staffing of nurses, or records and charting that is not up to date with technology.
Rising Trend of Anesthesia Near Misses
Near-Miss Data Show Signs of Trouble Outside OR
Anesthesiology News covered a new study by California researchers showing that near misses in non-operating room anesthesia might be rising. A team of researchers led by Angela Lipshutz, MD, MPH, a critical care fellow at the University of California, San Francisco School of Medicine, examined the hospital’s near misses from 2009 to 2011. The study uncovered primary causes of near misses originating from non-operating room anesthesia. Among the top causes were a failure to execute a skill at the expected level, equipment malfunction, poor culture of safety, and faulty design, among others.
We’ll be covering our thoughts about the study’s findings in more detail in a later article.
22 Recommended Patient Safety Strategies
Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices
Agency for Healthcare Research and Quality, Rockville, MD
Updating the 2001 report by the same name, the Agency for Healthcare Research and Quality shared its conclusions about improvements in patient safety practices over the last decade. The article points to 22 patient safety strategies discussed in the report that are ready for adoption. Number 1 on the list:
Preoperative checklists and anesthesia checklists to prevent operative and postoperative events.
Anesthesia Patient Safety Checklist
6 Steps to Improved Pain Pump Safety: New checklist can help prevent 14,000 adverse events annually
Our own news re-announcing the PCA Safety Checklist makes the list of must-read articles because of its reception from media, suggesting that many audiences have not yet been exposed to the free resource. The following media outlets picked up the news:
What other articles did you come across during Patient Safety Awareness Week?