HCPro.com: Briefings on Patient Safety

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May 2008 (Volume 9, Issue 5)	view entire issue

HHS proposes patient safety organizations
Since the passage of the Patient Safety and Quality Improvement Act of 2005, hospitals around the country have been waiting for an announcement of the proposed rule, laying the groundwork for the creation of Patient Safety Organizations (PSO). Two and a half years later, the U.S. Department of Health and Human Services (HHS) announced its Notice of Proposed Rulemaking on the Patient Safety Act and gave the Agency for Healthcare Research and Quality (AHRQ) the reins on implementing part of the proposed rules.

Program focuses on most difficult transition: Going home
Most hospitals have addressed the transition of patients from one hospital setting to another: emergency room to radiology, radiology to inpatient, etc. These transitions in care, known as handoffs, are areas in which facilities have tried to improve, especially since The Joint Commission (formerly JCAHO) made them part of National Patient Safety Goal #2 in 2006. However, one of the most significant transitions in care, the transition to the home, has not been paid as much attention.

In-field supervision can reduce error rates
Editor's note: The following is part of an ongoing series about human error and its role in medical error. This month, author Robert J. Latino, executive vice president of the Reliability Center, Inc., in Hopewell, VA, discusses the advantages of supervision oversight in the field and its effect on human error rates. Sometimes, supervision is done from afar, with the supervisor removed from the employee's work environment. The following statistics demonstrate that in-field supervision is not a common practice: 16% of floor/field work was surveyed by supervisors 3% of supervisors knew what to look for during survey 1.3% of floor/field work was improved by supervisors

Other recently-published articles from Briefings on Patient Safety:

The effects of distractions on human performance

Proposed changes to Universal Protocol make goal more specific, add documentation requirements

The second victim: Supporting staff members after a medical error

In-field supervision can reduce error rates

Program focuses on most difficult transition: Going home

HHS proposes patient safety organizations

’Leaps’ to safety include public reporting

The supervisor’s role in reducing human error

Joint Commission proposes many changes to Goal #7 for 2009

Transparency, job satisfaction among topics at Leape roundtables

Patient Safety Q&A

The supervisor’s role in lowering human error

Changing the view on health literacy

Perfecting stroke care through certification

Contributors to human error and how to lower rates of committing error

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