Blog & Articles

[3 MIN READ]

Do your clinicians have a plan for how to address a patient’s family if a medical error occurs?

Consider this true case that was shared with me by a California risk manager – a routine test that goes tragically wrong:

"Mrs. Woods is a 53-year old woman who goes to the hospital for a CT-guided biopsy of the liver. The staff assures Mrs. Woods the test is ‘no big deal’ so she tells her husband to go across the street to do some shopping during the test. The clinical team assures Mr. Woods they will call him when the test is complete. Mr. Woods is standing in Macy’s when his cell phone rings … he answers to hear a nurse frantically screaming, 'Come quickly!' Mr. Woods races across the street to the hospital where he learns his wife is dead."

After reading this case in my training programs, I challenged my healthcare audiences with the following: 

[6 MIN READ]

Is there really such a thing as a normal day on the OB unit? Highly doubtful. Unpredictability and uncertainty loom from the beginning of your shift to the end. But what if you could achieve some control over your day and try to decrease both your personal stress level and the stress of those in your immediate environment? While keeping your day 100% stress-free may not be possible, at least lowering the stress level for yourself and others is achievable and can help you to maintain stellar composure through the most grueling of patient scenarios.

[7 MIN READ]

As heightened U.S. maternal morbidity and mortality rates gain national attention, AWHONN and ACOG, as well as state perinatal quality collaboratives, notably California, have emphasized that hospitals need to focus on improving outcomes with specific attention to the leading causes of maternal mortality.

The RSQ® Assessment – Obstetrics provides the framework for the creation of a comprehensive obstetrics safety program within your organization, as well as the foundation for an obstetric culture of safety surrounding the key drivers of maternal mortality and morbidity.

[3 MIN READ]

The incidence of spinal epidural abscess (SEA) has doubled in the past 2 decades due to the epidemic of MRSA infections, the spread of IV drug use, and the increased number of spinal and vascular access procedures. Delayed or missed diagnosis of SEA leads to profound disability or death; lawsuits in this arena are exceptionally costly.

[3 MIN READ]

Patients with abdominal pain are a common and constant challenge to practitioners in primary care, pediatrics, urgent care, and emergency medicine. During the period of 2006 to 2014, there was a 32% increase in ED visits for the complaint of abdominal pain, so that as of 2014, abdominal pain is the most frequent diagnosis for an ED visit. The clinical presentations may be confusing; the differential diagnoses for abdominal pain are myriad; and not all patients with abdominal pain will have a serious underlying etiology.

Medical errors and litigation involving the care of patients with abdominal pain are all too frequent and can be costly for both patients and physicians. The cornerstone of high-quality, defensible care consists of a systematic approach coupled with compulsive documentation. The essence of liability reduction in the care of patients with abdominal pain is to construct a medical record that provides a thorough, clear and logical explanation for your thoughts and actions. Here are a few key items to address in the chart documentation.

[4 MIN READ]

Child physical abuse exists in all corners of the country and affects children of all ages, ethnicities, and socioeconomic groups.

Consider the following facts:

• More than 2 million reports of suspected child maltreatment are investigated each year in the United States. These reported cases represent only a fraction of the abuse that children experience.
• Child maltreatment includes neglect and abuse that may be physical, sexual, emotional, or psychological.
• There are more than 650,000 substantiated cases of child maltreatment annually.
• About 18% of child maltreatment involves physical abuse.
• More than 1,500 children die each year due to abuse or neglect. 80% of these deaths are children under 4 years old.
• The incidence of child abuse is underestimated since 17% of adults in the U.S. report that they were physically abused as a child.

[6 MIN READ]

Physicians, nurses and other “healers” have had special relationships with patients for centuries. This unique bond between those who provide medical treatment and those who receive their care is currently being endangered by a massive and impersonal healthcare delivery system that is becoming more dependent on automation and technology with each passing year. The good news is that patient attitudes, impressions, and subsequent compliance with treatment plans can be positively influenced when healthcare professionals improve their communication skills with their patients.

Studies show that there is a clear relationship between high patient satisfaction and healthcare organizations that provide safe, quality care. A report by Health Grades (May 2012) noted that hospitals that were ranked (by patients) in the top percentages for nursing and physician communication had lower rates of adverse patient safety events. For example, bed sores occurred approximately 46% more frequently in hospitals that patients had ranked in the lowest 10% for provider communication.

[1 MIN READ]

If your organization is navigating the onboarding and integration process for newly employed physicians, you're not alone.

The Physicians Advocacy Institute recently reported that U.S. hospitals bought 5,000 independent physician practices between July 2015 and July 2016. The percentage of hospital-employed physicians increased by more than 63% from mid-2012 to mid-2016.

TSG's RSQ® Education - Physician Integration Program is designed to put the best practices of patient safety and risk management at the fingertips of your physicians and systematize your ongoing compliance training.

[7 MIN READ]

Obtaining the informed consent of the patient is required in all states before an invasive procedure that carries a material risk of harm is performed.

This is a non-delegable duty of the practitioner who is going to perform the procedure; this means that the practitioner is ultimately responsible for the validity of the consent and cannot avoid liability by claiming that it was someone else’s responsibility.

However, obtaining informed consent should not be construed to be an obstacle. Obtaining informed consent can be a mechanism for reconciling the expectations of all parties involved.

[7 MIN READ]

The care of the surgical patient is dependent upon doctors, nurses, technicians and both office and hospital staff. Like all humans, despite their best efforts, they make mistakes. Encouraging them to “try harder” simply will not work.

To reduce surgical errors we need to identify root causes and institute system-based processes to prevent them.

Studies have suggested specific areas that offer opportunities for improvement. Kim et al.^[1] noted that adverse events from surgical intervention are more commonly due to preoperative and/or postoperative errors. These include delay in diagnosis and/or treatment and communication errors between the healthcare team and the patient/family or other members of the healthcare team. Process measures that can address these issues include: