Stories about: patient safety

RNSafe: Remote video checks of bedside drug dosing

RNSafe-Bunker nurse view Screenshot_2015-04-16-10-31-32When a nurse gives a complex medication at the bedside, a second nurse must come in to observe and verify the dose. But flagging down a nurse on a busy hospital floor can be pretty challenging, especially when the nurse has to “suit up” because of infection control precautions in the patient’s room. During a Nursing Morbidity and Mortality (M&M) Conference at Boston Children’s Hospital, a group of nurses expressed concern that this arrangement could potentially jeopardize safety. “We thought we should be able to do better,” says project co-developer Jennifer Taylor, MSEd, BSN, RN-BC, CPN.

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‘Handoff’ tool cuts harmful medical errors 30 percent

Patient handoff I-PASSIt’s increasingly clear that good health care is as much about communication as about using the best medical or surgical techniques. That’s especially true during the “handoff”—the transfer of a patient’s care from provider to provider during hospital shift changes. It’s a time when information is more likely to fall through the cracks or get distorted.

Now there’s solid proof that focusing on communications counts. Last week, The New England Journal of Medicine (NEJM) published a paper showing that implementing a set of handoff procedures and training tools led to a 30 percent drop in injuries from medical errors across the nine participating sites.

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Improved ‘handoff’ communication curbs medical errors

A bundled "handoff" program reduced medical errors in a study reported in JAMA.Medical errors are a leading cause of death and injury in America, and an estimated 80 percent of serious medical errors involve some form of miscommunication, particularly during the transfer of care from one provider to the next. However, a study published this week in the Journal of the American Medical Association demonstrates that standardizing written and verbal communication during these patient “handoffs” can substantially reduce medical errors without burdening existing workflows.

The study followed 1,255 patient admissions to two separate inpatient units at Boston Children’s Hospital—half occurring before a new verbal and written handoff program was introduced (July to September 2009) and half after (from November 2009 to January 2010).

After implementation, providers spent more time communicating face-to-face in quiet areas conducive to conversation. There were fewer omissions or miscommunications about patient data during handoffs. And medical errors decreased 45.8 percent.

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I-PASS this patient to you: Can standardizing “handoffs” make care safer?

(Kenny Louie/Flickr)

National data suggest that up to 70 percent of sentinel events—the most serious errors in hospitals—stem at least in part from miscommunications. Communication problems are especially apt to occur during hospital shift changes, when a patient’s care is transferred to incoming doctors and nurses—known in health care as the “handoff.”

More than a year ago, a team led by Amy Starmer, MD, MPH, of the Division of General Pediatrics at Boston Children’s Hospital, developed and began testing a bundle of interventions to ensure that the hospital’s residents were thoroughly and accurately briefed on each patient’s medical history, status and treatment plan in a standardized way.

Through measures such as communications training, a mnemonic to help residents remember key information to pass on and a computerized handoff tool that integrated with the patient’s electronic medical record, they managed to move the needle: Medical errors fell by 40 percent—from 32 percent of admissions at baseline to 19 percent of admissions three months after the program started.

But that wasn’t all.

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Improving patient safety: Overcoming clinical biases and misperceptions

Context can create bias: Squares A and B are the same shade of gray (created by Edward Adelson, professor of vision science, MIT)

Before you read this post, look at squares A and B in the image to the left. Which is darker?

Next, answer the following questions:

  1. A bat and a ball cost $1.10 in total. The bat costs $1.00 more than the ball. How much does the ball cost? 
  2. If it takes 5 machines 5 minutes to make 5 widgets, how long would it take 100 machines to make 100 widgets? 
  3. In a lake, there is a patch of lily pads. Every day, the patch doubles in size. If it takes 48 days for the patch to cover the entire lake, how long would it take for the patch to cover half of the lake? 

Did your mind leap to these quick answers — 10 cents, 100 minutes, 24 days?

Such errors on this Cognitive Reflection Test are quite common, and not so different from the lapses in thinking that underlie medical errors.

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