[two_third]It’s been a long time since I helped care for someone post-op, and I learned many lessons recently. A friend of mine – let’s call him XY– had outpatient shoulder surgery on a Monday afternoon to remove bone spurs from his left shoulder; he had had similar surgery on the right shoulder about ten years…

[two_third] Patient safety and quality is ultimately the responsibility of our governance boards.  In the past, it was thought to be a clinical issue for the clinicians to figure out.  Today, with the increased recognition that preventable harm causes 200,000 patient deaths a year, it is clear that the ‘buck stops’ at the highest level…

[two_third] On May 15, 2012 the Washington Patient Safety Coalition sponsored its tenth regional conference, and among the outstanding speakers and presentations was a unique session. Chris Jerry and Eric Cropp spoke together about a terrible event that occurred several years ago:  Chris’ young daughter died as the result of a medication error for which…

[two_third] Safe patient hand-offs are a critical moment in time for everyone involved in the care of patients. The call to action inspired by the IOM White Paper, “To Err is Human,” emphasized the need to develop standardized methodologies that promote consistent communication amongst health care providers across the care continuum. As I reflect on…

[two_third] One of the sessions I attended at the Institute for Healthcare Improvement’s conference in early December really got me thinking. I enjoy it when I’m challenged on assumptions or my usual approach to doing things, and am given something new to think about. I registered for this session because, perhaps like many of us…

I think it is fair to say that the majority of us who work in the patient safety arena know what is happening in terms of patient care events. For example, those leaders who attend safety committee meetings know the fall rate, pressure ulcer prevalence data, and number of medication errors reported. In addition, if…

[two_third] I think it is fair to say that the majority of us who work in the patient safety arena know what is happening in terms of patient care events. For example, those leaders who attend safety committee meetings know the fall rate, pressure ulcer prevalence data, and number of medication errors reported. In addition,…

[two_third]Last week I attended the NPSF Congress for the second time and once again had significant dissonance: it’s exciting and heartening to see so many people gathered together to learn about patient safety, and to know that the Washington safety community is so advanced and innovative – and so distressing to see a conference full…