HCPro.com: Briefings on Patient Safety

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June 2008 (Volume 9, Issue 6)	view entire issue

The second victim: Supporting staff members after a medical error
It has been almost a decade since Linda Kenney went into surgery to have her ankle replaced and ended up going into cardiac arrest and having her chest opened. Since then, she's dealt with a range of emotions, from shock to depression to thankfulness for being alive today. It wasn't until she had made it through the seemingly impossible first year after the incident that she began to consider how the clinicians involved in her case might be feeling. Kenney's specific case involved an error during anesthesia. "I was thinking, 'If I'm this emotionally distraught, I can just imagine how [the anesthesiologist] must be feeling,' " she says, adding that her medical error was barely discussed with her while she was in the hospital, highlighting the stigma regarding such events.

Proposed changes to Universal Protocol make goal more specific, add documentation requirements
Editor's note: This is the second in a series about The Joint Commission's proposed 2009 National Patient Safety Goals (NPSG). The Joint Commission's proposed changes to the Universal Protocol would make the NPSG much more prescriptive than it has been and require significantly more documentation. Perhaps most important of the proposed changes is the requirement that a staff member directly involved with performing the procedure mark the site with his or her initials. "Most controversial is the insistence on having the surgeon mark the site," says John Clarke, MD, professor of surgery at Drexel University in Philadelphia, clinical director for patient safety and quality initiatives at the ECRI Institute in Plymouth Meeting, PA, and clinical director of the Pennsylvania Safety Authority.

The effects of distractions on human performance
Editor's note: The following is part of a 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 effect of distractions in the work force, as well as sleep-related problems and how to manage them. We all work on a daily basis in environments prone to distractions. Some environments are more distracting than others, but, we can relate to the effect that distractions have on our performance.

Other recently-published articles from Briefings on Patient Safety:

Minnesota develops rules for preventing surgical errors

2009 Leadership standards tell hospital leaders to make patient safety a priority

Taking responsibility for building accountability among staff members

Work stress and its effect on a professional environment

Family-activated RRTs stress involvement

Early warning system to be surveyed in January

WalkRounds involve senior leaders with frontline staff

Infection control-related NPSG not new to field

The fundamentals of accountability

Three keys to ensuring your anticoagulant therapy program is ready

Pennsylvania association promotes standardized wristbands to prevent errors

Latest Sentinel Event Alert exposes disruptive behavior among staff members

Evolving titles in patient safety: Medication safety officer

Increased documentation added to 2009 NPSGs

California hospital team takes aim on VTE

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