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  • HIPAA on My Mind
    they said to ask you No can do he says I relay this back to the medic alert company calling on my land line because by this time I m also using my cell phone to try and reach my mother on hers I m also about to jump into the car in case the 15 minute ride to my mother s apartment will at least give me the reassurance that she s not still home maybe lying on the floor unconscious Just as the medic alert company is telling me that the only thing they can offer is a list of my mother s preferred hospitals in case of an emergency my mother picks up She had a scare with her blood pressure but she s okay and waiting to be seen I also find out the name of the hospital I have recently run into HIPAA as an explanation for all sorts of reasons to be told nothing the latest instance with another family member who was hospitalized in an emergency Apparently being listed on health care proxy forms or being related to the individual is not a ticket to information when you may need it most I have always welcomed and supported the privacy protections the 1996 law ushered in but I m wondering whether others are now finding the very utterance of HIPAA has become the very opposite of what s needed for patient and family centered care Let me us know your thoughts Tags Patient Safety Best Practices for clinical areas Private Group Care Family caregivers and caregiving all aspects Blog Home Older Average Content Rating 2 user Your comments were submitted successfully Please enter a comment Please login to rate or comment on this content User Comments by Madge Kaplan 5 15 2013 3 48 27 PM Thank you both Rachel and Jill for your thoughtful comments I d love to see an exemplar training curriculum for staff that s very patient and family centered If you hear of anything let me know I ll also ask some others at IHI and let you know Thanks again Madge loading Did you find this user comment useful people found this user comment useful Report This by Rachel Wang Martínez 5 7 2013 1 39 58 PM My organization s bi annual HIPAA training suffers from the same issues mentioned below it covers the obvious don t leave patient documents out on a desk in a public space don t talk about cases in the elevator etc but doesn t ever touch on these exact grey area situations that we encounter almost daily family members who are very involved in the patient s care or many times are in fact the primary caregiver but happen to not have signed the official release of information document A better training curriculum or a decision tree about how to navigate these situations would be hugely beneficial loading Did you find this user comment useful people found this user comment

    Original URL path: http://www.ihi.org/communities/blogs/_layouts/ihi/community/blog/itemview.aspx?List=7d1126ec-8f63-4a3b-9926-c44ea3036813&ID=35 (2016-02-01)
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  • My Month-Long Experience with the IHI Open School
    current medications are identified on acute admission to the ward This process wasn t working well and led to prescribing errors in the past Improving medication reconciliation is also part of national patient safety initiative so this made finding a supervisor and establishing realistic measures within the time frame far easier I found it surprising how swiftly everything came together and how quickly we were completing our first PDSA cycles But I found it harder to adapt to this method of improvement than first imagined Due to my previous background in research I kept looking for tight fixed aims inclusion and exclusion criteria with in depth statistical analysis This was probably driving Ellie mad as she had done previous improvement work It was not until I began to run through the IHI online courses that I realized that I was completely missing the aim behind quality improvement and that it was specifically designed the way it was to allow for rapid change and analysis so that positive changes could be swiftly implemented This is something which could not happen using traditional clinical research methodology I found it rewarding that our results came so quickly and that we could progress forward and make further amendments and changes in an attempt to improve medication reconciliation on the ward Through this time I continued with the online courses At times I found them a little laborious but highly accessible They made the principles of quality improvement and patient safety clear and digestible I found that they especially helped when it came to completing and submitting the Practicum module I am just awaiting the final approval as I write this We must have completed endless PDSA cycles in our project which despite our best efforts to improve the process and checklist behind medication reconciliation didn t result in improvement We were miles away from achieving our outcome measure which although disheartening in some ways was also a great learning experience and highlighted the multiple human factors and system errors that were combining with the ward culture to result in this longstanding problem Using the PSDA cycle reports and driver diagrams helped to emphasize where the issues lay and what we could do in the future in attempt to further improve medicines medication reconciliation on the ASRU I hope to use the knowledge I gained during this month and through completing the IHI courses in the future as a junior doctor and continue with quality improvement projects on the wards I am based Finally through the project work we had done Ellie and I earned a poster presentation slot at the Scottish Safety Programme Regional Meeting in Dundee at the start of March By attending I was able to share the skills I had learned during the month through helping to facilitate and interactive Learning Loops session and discussing my experiences with the other delegates I believe this is one of the most attractive aspects of the IHI program Through joining you are instantly part

    Original URL path: http://www.ihi.org/education/ihiopenschool/blogs/_layouts/ihi/community/blog/itemview.aspx?List=9f16d15b-5aab-4613-a17a-076c64a9e912&ID=119 (2016-02-01)
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  • Is the Patient Safety Movement running out of steam?
    getting to the root of the problem and this is a recipe for patient safety fatigue Another problem amplifying feelings of burnout is that our success has often been siloed we ve achieved improvement in one or two areas but the successful practices or lessons learned there have not spread to other areas As a result we see improvement in the pilot area but not elsewhere Many have not developed the robust infrastructure and mechanisms to ensure that there is spread scale up and sustainability This gives the work of patient safety a Sisyphean feel and in that context it s hard not to feel burned out For instance a colleague recently told me that after years of hard work the infrastructure she had put in place had slowly been weakened and in some places no longer existed because people had moved on or taken on other duties because of changes in patient populations and because they lacked mechanisms to sustain the improvement Jim Conway captures a similar feeling of being overwhelmed in a comment on Wachter s blog writing that many clinicians feel as though they are at the bottom of a waterfall with no hope the water will ever stop crashing down on their heads Wachter s concern about the Accountable Care Act changing leadership priorities is likewise valid chief executives are concerned about how the proposed changes will impact their ability to function Developing ACOs medical homes and Medicaid expansions will greatly affect their revenue streams and so inevitably have become a focus So how do we respond to these worries about losing momentum Our responsibility to provide safe care and continually improve care processes is ongoing But as we make our case it is important to remember that safety is just one dimension of quality The IOM s other dimensions care that is effective equitable timely efficient and patient centered are critical as well And none of them exist in isolation indeed they are inherently co dependent When we talk about patient safety we should always be making the compelling case that it impacts all the dimensions of quality The stakes are high and we need to be clear about that We must also make room for people to work on improving quality In a hospital I visited in Qatar and in hospitals in the US physicians have dedicated time to work on an improvement project This allows them to work on those things that they see as problems and getting in their way of providing the care that they believe their patients should receive Beginning on March 7 2013 IHI will be hosting the 12 th Patient Safety Executive Development class I will be asking the participants for their comments on the future of the patient safety movement I d love to hear your comments as well Tags Patient Safety Quality Improvement Patient Safety Executive Development Program Blog Home Older Average Content Rating 1 user Your comments were submitted successfully Please enter a comment Please

    Original URL path: http://www.ihi.org/communities/blogs/_layouts/ihi/community/blog/itemview.aspx?List=0f316db6-7f8a-430f-a63a-ed7602d1366a&ID=6 (2016-02-01)
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  • Learning from failure
    reputation Ultimately this is not something that can be achieved by regulation it needs to be lived at hospital level Next time we have a death or serious incident we should benchmark our performance against a couple of examples One is from manufacturing and one from healthcare As Paul O Neill became CEO of Alcoa he said safety was his number one priority Alcoa is a large heavy manufacturing company and the general view was accidents happen When a worker died O Neill was called in the middle of the night The next day he summoned the plant executives and said We killed this man It s my failure of leadership I caused his death And it s the failure of all of you in the chain of command Overturning the view that tragic accidents happen O Neill made the executives work through it and take action There is more to the Alcoa safety story but the point here is about leadership accountability and action making the previously acceptable unacceptable In 12 years Alcoa reduced injuries by 90 and increased profits Beth Israel Deaconess Medical Center is one of several prestigious hospitals in Boston in a highly competitive market Consider how they responded to an incident of wrong site surgery something that should never happen in 2008 Dr Ken Sands Senior VP for HealthCare Quality and Paul Levy CEO emailed all employees and notified the local media to ensure that lessons were learned or more precisely re learned The quote at the top comes from that email sent by Ken Sands and Paul Levy Levy also included the full email in his blog to open up the discussion to the public This requires courage but it is essential if we are to build care around the needs of the patient

    Original URL path: http://www.ihi.org/communities/blogs/_layouts/ihi/community/blog/itemview.aspx?List=113a95c2-dffe-41ec-abee-93b4088068ac&ID=6 (2016-02-01)
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  • Drug Shortages Are Threatening Patient Safety: Here’s What We Can Do About It
    New York Times article notes And the problem may well be exacerbated by the close of a major compounding pharmacy following revelations of meningitis contamination this fall The Drug Shortage Crisis in the United States Causes Impact and Management Strategies by C Lee Ventola offers an overview of the factors contributing to the crisis and what can be done No longer should we consider our systems safe Whatever safeguards have been implemented must be examined as they may no longer be effective Another concern is the effectiveness of the substitute medications A recent study in the New England Journal of Medicine underscores the problem finding that substituting cyclophosphamide for the standard treatment with mechlorethamine resulted in significantly lower effectiveness 2 year event free survival 75 with cyclophosphamide SE 12 5 vs 88 with mechlorethamine As the author notes Our results suggest that even promising substitute regimens should be examined carefully before adoption what might appear to be a suitable alternative regimen may result in an inferior outcome an intolerable situation for young people with curable diseases In the long run I am confident that the FDA and local boards of pharmacy and public health departments will deal with the drug shortage problems now confronting us But in the meantime hospital and clinical leaders must be aware of the potential impact on patient safety Resources must be allocated to ensure that shortages are addressed not only in purchasing alternate medications but also in ensuring that the many safeguards that have been put in place are reviewed and updated as needed This must be a deliberate plan Patients should be informed of choices available to them and they should be reassured that no matter the setting the clinical staff will do all within their power to provide safe care This is a daunting task and we need to talk seriously about how to get it right In August of 2011 I participated in a WIHI broadcast with Mike Cohen from the Institute for Safe Medication Practices and Lynn Eschenbacher from Wakemed to discuss ways to mitigate the impact of drug shortages on patient safety But we need to think more comprehensively In the spirit of all teach all learn I ask that you share your own plans for dealing with the drug shortage so that others can benefit from your experience What have you done What s worked How would you counsel others to combat the pernicious effects of drug shortages Tags Medication Safety Patient Safety Drugs Therapeutics Committee Blog Home Older Average Content Rating 0 user Your comments were submitted successfully Please enter a comment Please login to rate or comment on this content User Comments by Michael Rie 2 5 2013 8 27 13 AM Chronic generic injectable drug shortages have finally arrived at the logical point of Continuous Quality Decrement CQD analysis The USA is not at war domestically and the laws of economics seem strangely violated with non existent supply and demand relationships adversely impacting conventional well established

    Original URL path: http://www.ihi.org/communities/blogs/_layouts/ihi/community/blog/itemview.aspx?List=0f316db6-7f8a-430f-a63a-ed7602d1366a&ID=4 (2016-02-01)
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  • Measuring Safety
    a systematic manner by looking at discharge codes discharge summaries medications lab results operation records nursing notes physician progress notes and other notes or comments to determine whether there is a trigger in the chart A trigger could be a notation indicating for example a burn a fall or a reaction to a medication Any notation of a trigger leads to further investigation into whether an adverse event occurred and how severe the event was A physician ultimately has to examine and sign off on this chart review We tested this system against other widely used methods to detect adverse events and the results were stunning The trigger tool detected 354 adverse events while tools based on automated chart review fared far worse The Agency for Healthcare Research and Quality s AHRQ Patient Safety Indicators detected only 35 adverse events The hospitals voluntary reporting systems Just four You ve all heard the old iceberg trope 10 percent above water 90 percent below Well here it is in sobering statistics And those errors that occur below the water line of measurement aren t actually invisible not to patients not to their families and not to providers or to the functioning of our health care system The trigger tool is less time intensive than some other chart review methods but as I mentioned earlier it is not as cheap as automated methods such as AHRQ s Patient Safety Indicators Manual review simply takes more time There is no way around that But nor is there a way around the danger of missing so many adverse events Think about what other audits you conducting at your hospital that may be just as time intensive Surely safety should rate the same level of attention and commitment So we want to hear from you How do you measure harm in your organization Do you believe that you are capturing the entire scope of harm The good news from our perspective is that hospitals and regulators are increasingly using the trigger tool to identify the broader universe of adverse events We will keep working to continue this trend because only by facing the reality of adverse events can we truly address them Tags Patient Safety Blog Home Average Content Rating 1 user Your comments were submitted successfully Please enter a comment Please login to rate or comment on this content User Comments by Peri Vitton 4 11 2013 8 50 09 AM Safety does not come with guarantee and is also not permanent So only we have to take care that we are safe replacement windows for homes loading Did you find this user comment useful people found this user comment useful Report This by Antonio Carvajal 2 3 2013 7 11 02 PM As far as I get it the Global Trigger Tool has more benefits for adverse event screening However would this necessarily mean to stop using AHRQ s indicators Is the broad spectrum of the GTT covering more percent of the iceberg trope

    Original URL path: http://www.ihi.org/communities/blogs/_layouts/ihi/community/blog/itemview.aspx?List=0f316db6-7f8a-430f-a63a-ed7602d1366a&ID=1 (2016-02-01)
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  • Celebrating 100,000 in the IHI Open School: Patient Voice
    NOW instead of continuing in the past Kari Dudley IHI Open School Patient Advisor As the new patient advisor to the IHI Open School I was also asked to answer this question about the next 100 000 students When I first saw it a rush of answers thoughts and ideas immediately came to mind And then suddenly I found that I wanted to add the following Why should the next 100 000 students and residents join the IHI Open School AND How can we better integrate patients into the curriculum Yes as a patient advisor you can assume that is always top of mind for me After all what better way to learn about patient safety and quality improvement skills that you will learn in the Open School than to include the patient in the conversation about patient safety and quality improvement The good news is that we and now you are in the right place IHI is making these connections You are at that pivotal point in your schooling and preparation of your career to make a difference By joining the IHI Open School you acknowledge that you are open to learning and open to new ideas You probably realize that the interactions you have now at this point in your education will affect your thoughts beliefs and openness to change in your future practice a practice that will be patient centered As a patient advocate I will commit alongside you to participate to communicate and to be the change agent that we are being asked to become Why should you join Why shouldn t you Tags IHI Open School for Health Professions Student Patient Safety Faculty Advisor Blog Home Older Average Content Rating 0 user Your comments were submitted successfully Please enter a comment Please login to rate

    Original URL path: http://www.ihi.org/education/ihiopenschool/blogs/_layouts/ihi/community/blog/itemview.aspx?List=9f16d15b-5aab-4613-a17a-076c64a9e912&ID=62 (2016-02-01)
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  • Drinks, Pizza, and a Little Basketball
    would share the court together But what this looked like on TV was confusion and a total lack of coordination The Big Three had their moments when they would each individually live up to their All Star reputations but these occurred in unpredictable and unreliable spurts The Miami Heat haphazardly played its way into the 2011 NBA Finals and an entire season s worth of bewilderment became obvious to the world as it was blown out by the Dallas Mavericks I distinctly remember watching the team disintegrate into a group of headless chickens that did not seem to know what to do even when it possessed the ball In retrospect the 2010 2011 season should not have come as a surprise to me In assembling The Big Three the Miami Heat committed the same mistake that many health care organizations make attempting to achieve greatness through cultivating great parts In a thought experiment to build the world s greatest car by assembling the world s greatest car parts Dr Don Berwick former CMS Administrator and CEO of IHI describes Anyone who understands systems will know immediately that optimizing parts is not a good route to system excellence We d connect the engine of a Ferrari the brakes of a Porsche the suspension of a BMW the body of a Volvo What we get of course is nothing close to a great car we get a pile of very expensive junk The basketball teams that want success to become an intrinsic characteristic of the team invest and develop not just individual talent but also create a reliable system of teamwork Examining the Miami Heat s run for the 2012 NBA Championship the Miami Heat has done just that built on the talents of The Big Three and transformed into a high functioning team For those that continue to carry Miami Heat antagonism I realize I am in the great minority being a Miami Heat fan I m not claiming perfection but improvement Although an abbreviated season the Miami Heat discovered a rhythm of teamwork that allowed The Big Three to play together as a more unified front The Miami Heat faced one of its first great tests in the second round of the playoffs against the Pacers Chris Bosh was injured and out of the picture and the Miami Heat was shut out of Game 3 falling behind in the series 1 2 The Miami Heat of 2011 probably would have been knocked out of the NBA Finals running But the Miami Heat of 2012 readjusted and Udonis Haslem stepped up to the plate to fill in the gap that Chris Bosh left The Miami Heat beat the Pacers 4 2 Improved teamwork was even seen off of the court In the wake of the Miami Heat taking the lead in Game 3 against the Thunder the drama that erupted in the media was when Kevin Durant of the Thunder was caught telling Dwyane Wade You re too small Although the

    Original URL path: http://www.ihi.org/education/ihiopenschool/blogs/_layouts/ihi/community/blog/itemview.aspx?List=9f16d15b-5aab-4613-a17a-076c64a9e912&ID=60 (2016-02-01)
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