TBT: Ahrq 2014 safety culture survey.

In adverse events, culture on April 3, 2014 at 10:03 am

I called this throw back thursday because it doesn’t seem we have made much progress over the years. This is concerning. And probably relates to HAI and other undesirable outcomes. Maybe it’s just a fantasy that if we fix these the other things will fall into place easier? see my same post in 2012!

Areas With Potential for Improvement for Most Hospitals

The three areas that showed potential for improvement, or with the lowest average percent positive responses, were:

Nonpunitive Response to Error (44 percent positive response)—the extent to which staff feel that their mistakes and event reports are not held against them and that mistakes are not kept in their personnel file.
Handoffs and Transitions (47 percent positive response)—the extent to which important patient care information is transferred across hospital units and during shift changes.
Staffing (55 percent positive response)—the extent to which there are enough staff to handle the workload and work hours are appropriate to provide the best care for patients.

Threats from Antibiotic Overuse…

In Antibiotic Resistance on March 13, 2014 at 1:00 pm


Infection kills 29 year old mom after childbirth

In adverse events on November 2, 2013 at 11:53 am

It is horrible that in today’s day and age, in the US, a mother dies after childbirth from necrotizing fasciitis. It’s even more horrible that hospitals let people suffer unnecessarily. All of the patient safety literature advocates apology, disclosure and compensation after a preventable event yet instead of doing this we leave families to deal with the death of their loved one and also the trauma of carrying on…worrying about daily life, providing for children, looking for answers..

While CMS makes never events that they wont pay for, this doesnt impact patients directly. Before never events there should have been the demanding of a fulldisclosure and fair compensation policy.
Not only is this the right thing to do, it directly forces hosptials to “pay up” so to speak which would make it likely that hospitals would truly invest in safety if for no other reason than the bottom line of expenditures..EMMC is a good hospital by many standards..but it cannot allow people to suffer any more than they have too when a mistake or preventable event occurs. Don’t listen to your lawyers, listen to your hearts and consciences…Pay up, involve the families in the investigation, be transparent and never let this happen again…and take care of the staff invovled as they are the second victims of this tragedy..dont let efficiency and productivity cause people to drift into unsafe conditions.


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