“Many of the proposals for improving the quality and curbing the rising costs of health care call for radically changing either the players or the rules governing them. Those approaches won’t work. Regardless of what happens to reform efforts, the… Read more
Month: January 2017
Medical Mistake Mitigation Syllogism
Major Premise: Medical mistakes are the third leading cause of patient deaths (http://www.bmj.com/content/353/bmj.i2139). Minor Premise: Cognitive overload is the root cause of medical mistakes (inferred from RCA2: Improving Root Cause Analyses and Actions to Prevent Harm, a Report issued by… Read more
PSMF APSS Challenge 11: Optimal Resuscitation
N.B. — This post is based on one of the continuously expanding roster of Actionable Patient Safety Solutions (APSS) a.k.a. “Challenges” as defined and described by the Patient Safety Movement Foundation (PSMF) and published at its web site (http://patientsafetymovement.org/challenges-solutions/actionable-patient-safety-solutions-apss/). Because… Read more
PSMF APSS Challenge 10: Early Detection Of Sepsis
N.B. — This post is based on one of the continuously expanding roster of Actionable Patient Safety Solutions (APSS) a.k.a. “Challenges” as defined and described by the Patient Safety Movement Foundation (PSMF) and published at its web site (http://patientsafetymovement.org/challenges-solutions/actionable-patient-safety-solutions-apss/). Because… Read more
PSMF APSS Challenge 9: Airway Safety
N.B. — This post is based on one of the continuously expanding roster of Actionable Patient Safety Solutions (APSS) a.k.a. “Challenges” as defined and described by the Patient Safety Movement Foundation (PSMF) and published at its web site (http://patientsafetymovement.org/challenges-solutions/actionable-patient-safety-solutions-apss/). Because… Read more
PSMF APSS Challenge 8: Failure to Detect Critical Congenital Heart Disease (CCHD)
N.B. — This post is based on one of the continuously expanding roster of Actionable Patient Safety Solutions (APSS) a.k.a. “Challenges” as defined and described by the Patient Safety Movement Foundation (PSMF) and published at its web site (http://patientsafetymovement.org/challenges-solutions/actionable-patient-safety-solutions-apss/). Because… Read more
PSMF APSS Challenge 7: Suboptimal Neonatal Oxygen Targeting
N.B. — This post is based on one of the continuously expanding roster of Actionable Patient Safety Solutions (APSS) a.k.a. “Challenges” as defined and described by the Patient Safety Movement Foundation (PSMF) and published at its web site (http://patientsafetymovement.org/challenges-solutions/actionable-patient-safety-solutions-apss/). Because… Read more
PSMF APSS Challenge 5: Anemia and Transfusion – A Patient Safety Concern
N.B. — This post is based on one of the continuously expanding roster of Actionable Patient Safety Solutions (APSS) a.k.a. “Challenges” as defined and described by the Patient Safety Movement Foundation (PSMF) and published at its web site (http://patientsafetymovement.org/challenges-solutions/actionable-patient-safety-solutions-apss/). Because… Read more
PSMF APSS Challenge 4: Failure to Rescue – Monitoring for Opioid-Induced Respiratory Depression
N.B. — This post is based on one of the continuously expanding roster of Actionable Patient Safety Solutions (APSS) a.k.a. “Challenges” as defined and described by the Patient Safety Movement Foundation (PSMF) and published at its web site (http://patientsafetymovement.org/challenges-solutions/actionable-patient-safety-solutions-apss/). Because… Read more
PSMF APSS Challenge 3: Medication Errors
N.B. — This post is based on one of the continuously expanding roster of Actionable Patient Safety Solutions (APSS) a.k.a. “Challenges” as defined and described by the Patient Safety Movement Foundation (PSMF) and published at its web site (http://patientsafetymovement.org/challenges-solutions/actionable-patient-safety-solutions-apss/). Because… Read more