Dr Safety

Today's post comes to us from the 19 th Century. “Ignaz Philipp Semmelweis (1818-65) a Hungarian obstetrician educated at the universities of Pest and Vienna, introduced antiseptic prophylaxis into medicine. In the 1840s, puerperal or childbirth fever, a bacterial infection of the female genital tract after childbirth, was taking the lives of up to 30% of women who gave birth in hospitals. Women who gave birth at home remained relatively unaffected. As assistant professor on the maternity ward of the Vienna General Hospital, Semmelweis observed that women examined by student doctors who had not washed their hands after leaving the autopsy room had very high death rates. When a colleague who had received a scalpel cut died of infection, Semmelweis concluded that puerperal fever was septic and contagious. He ordered students to wash their hands with chlorinated lime before examining patients; as a result, the maternal death rate was reduced from 12% to 1% in 2 years.  ...

Human factors research has shown that even highly skilled, motivated professionals are vulnerable to error due to human limitations.   Research has also shown that teams that communicate effectively and back each other up reduce the potential for error, which results in enhanced safety and improved performance.       Teamwork principles and training techniques apply to a hospital as well as every other healthcare organization. • Leadership – how to direct and coordinate, assign tasks, motivate team members, facilitate optimal performance. • Situation monitoring – how to develop common understandings of team environment, apply strategies to monitor teammate performance and maintain a shared mental model. • Mutual support – how to anticipate other team members’ needs through accurate knowledge and shift workload to achieve balance during periods of high workload or stress. • Communication – h...

Patient safety is paramount in our quest for high quality and reliable healthcare. As caregivers, we struggle with an inconvenient truth: Humans make mistakes. No human performs perfectly 24 hours per day, seven days a week. Unfortunately, perfection is expected of physicians and nurses. Such unrealistic expectations lead us to use a system of training and punishment that operates under the myth of perfect medical performance. The goal is not attainable, yet we perpetuate this myth day after day. The myth also precludes us from properly examining the systems issues that fail to protect patients from human error. A medical error is defined as the “failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim…including problems in practice, products, procedures and systems.” Even after more than 10 years of national effort, medical errors persist at alarming rates. A group of investigators reported there were approximately 37,600,000 annual...

It is imperative to the safe care of our patients that an accurate and complete medication history is taken at every visit. Medications must be reviewed for compliance with the agreed upon treatment plan as well as for drug interactions and side effects. National Patient Safety Goals:  *Take extra care with patients who take medicines to thin their blood. *Record and pass along correct information about a patient’s medicines.   Find out what medicines the patient is taking. Compare those medicines to new medicines given to the patient. Make sure the patient knows which medicines to take when they are at home. Tell the patient it is important to bring their up-to-date list of medicines every time they visit a doctor. This is especially important for patients prescribed anticoagulation therapy. If an adequate medication history is not taken, patients may be prescribed warfarin and continue to take an over the counter drug like aspirin. This dangerous ...

Our patients are at the center of every decision we make. All members of the healthcare team must be willing and able to advocate for their patients’ safety. Advocacy and assertion are crucial tools in the fight to protect patients from harm. All team members are empowered to “STOP THE LINE!” when something is amiss in the care of their patient. Every team member, [Nurses, physicians, technicians, therapists, medical students, nursing students, aides, pharmacists and other professionals] must be ready to advocate for their patients’ best interests when their viewpoints do not coincide with that of the decision maker. You must make your concerns known at once in a constructive manner. Your concerns should be voiced at least twice to make sure you are heard. Alert your supervisor if your voice is not heard by the team leader or decision maker. A helpful communication empowerment tool is known as CUSS . In using CUSS one should state clearly:     ...