Ever since the Institute of Medicine’s report To Err is Human was released in 2000, healthcare has seen a surge in patient safety initiatives. Analysis of medical errors has become increasingly widespread, with several different methods being used by hospitals and practitioners. Of these methods, I suggest that cognitive error analysis may prove to be one of the most valuable in determining the real underlying reasons for medical errors that lead to unexpected adverse patient outcomes.
Blog & Articles
The Ultimate Healthcare Loss Prevention Strategy
As the healthcare industry constantly evolves and “return on investment” remains a focus, it is becoming more imperative that risk managers allocate their budgets in areas that have the greatest impact on mitigating claims and litigation.
Fortunately, The Sullivan Group has the luxury of working with many large, sophisticated, self-insured hospital systems as well as smaller single-site facilities and physician groups. This experience has helped us identify four key areas that an organization should consider when developing its loss prevention strategy.
The Focus of Patient Safety in 2017
The healthcare industry will continue to have its radar locked on the issue of Patient Safety in 2017. Some of the targets and goals are only vaguely visible from the 30,000-foot level, while others are in clear focus on the ground before us. Depending on where you stand (or fly), opportunities abound to improve patient safety. Let’s take a forward look into 2017, starting high in the clouds and descending eventually to earth.
Hot Topics: Top 10 Blogs of 2016
We've featured a variety of topics, cases, and missed diagnoses on our blog this year, and we hope that you've found the content useful and relevant.
In case you missed some of 2016's most popular posts, here are the top 10 articles from the blog this year, according to our website visitor statistics. What was your favorite article?
[Infographic] 5 Ways to Minimize Cyber Risk
Download infographic as PDF. Content provided in partnership with John West, JD, MHA, CPHRM, DFASHRM.
Very Abnormal Vital Signs & Death after Discharge
The majority of malpractice suits in acute care and emergency medicine involve patients who were discharged home.
These patients experienced an unexpected adverse outcome after they left the ED such as worsening of their illness or even death.
For many of these patients, the “bad outcome” could not have been foreseen — the workup was appropriate, the diagnosis and treatment were correct, and the patient was stable for discharge.
A number of discharged patients, however, might have been misdiagnosed and had red flags present at the time of discharge that were either ignored or not recognized.
In some of these patients with adverse outcomes, preventable hospital discharge medical errors existed.
Case: Failure to Diagnose Sepsis
Download audio of this case here.
Sepsis is a regular visitor in the news as cases of flesh-eating bacteria and the dramatic speed with which victims deteriorate hit the headlines. The failure to diagnose sepsis remains a critical issue as delays in diagnosis significantly increase morbidity and mortality.The entire emergency department, urgent care and primary care teams must be focused on early recognition and intervention. This has never been so important as today since evidence now points to interventions that can truly save lives.
The Ring of Death: Patient Safety in Radiology
It is a routine practice for hospital-based practitioners to order radiology studies during the evaluation of sick or injured patients. The information gained from these imaging studies provides crucial information needed to make a diagnosis and guide treatment. As many as 50% of ED patients get a plain X-ray during their visit. It is well known that utilization of CT has greatly increased over the past decade. The end result is millions of patients in the ED and inpatient units who are transported to and from the radiology department.
Paint a Picture: EMR Documentation of Appearance & Activity
A few years ago, I invited one of our malpractice defense attorneys to shadow me for a shift in the emergency department. At the end of the day, after he had seen every patient with me and watched me document every chart, I asked him to share any observations. He said, “It shocks me that so little of what you see and do is actually documented.” And I thought my documentation was outstanding!
Veterans Healthcare: What Civilian Physicians Need to Know
There are approximately 21 million living U.S. military veterans, and the Veterans Health Administration (VHA) is the largest health care system in the country. Despite its size, the VHA is overwhelmed by the need to provide healthcare to the huge number of eligible veterans.
As a consequence of this high demand for care, Congress enacted the Veterans Access, Choice, and Accountability Act of 2014, which allows veterans to seek government-funded care in the private sector under certain circumstances. This act may cause an influx of veterans into private physician practices.