[6 MIN READ]

(adapted with permission from the original by Dr. Tim Kubacki at https://kubackisinangola.com/)

Dr. Tom Syzek: These days we hear so much about the importance of communication and teamwork in avoiding medical errors and how we deliver care at the end of life, I thought for perspective, I would share this case presentation from Dr. Tim Kubacki. Tim is a friend and colleague who left behind the comfortable life of an emergency physician in central Ohio to serve with his family as a medical missionary for 6 years in the jungle interior of Brazil, and for the past 5 years in medically underserved rural Angola. Tim recounts beautifully this medical case of mistaken identity, driving home the point that communication and teamwork are the essence of patient safety, while at the same time describing the only “end-of-life care” available.

[5 MIN READ]

Education is a vital to your department’s ongoing clinical performance improvement plans. But the presence of a plan alone isn’t the change catalyst. Through our twenty years of working with large health systems across the country, we have seen that facilities that successfully engage their staff in a new training program have a much higher likelihood of implementing change and positively impacting patient outcomes.

Here are 8 strategies to engage learners in your training program so your staff, patients and facility can receive the benefit you intend.

Adapted from an original blog by Paul Culler, MD, FACEP, FAAFP

[2 MIN READ]

I believe that having a good shift is a choice. In other words, I think that your mental outlook will influence whether you have a good shift or not. I recently heard someone use the phrase, “If you think you will or you think you won’t, you’re right!” This statement alludes to the fact that events will often unfold as self-fulfilling prophecies.

[4 MIN READ]

Behavioral neuroscientists talk about the moment, the exact second we make a decision and act upon it. They describe in almost obsessive detail all the neuronal pathways and neuronal firings that occur in our brain. They talk about influences of past and present, knowledge acquired and remembered, skills honed and sculpted, abilities, beliefs, social backgrounds, immediate stressors, mood, medications, current/immediate/past circumstances, possible future implications, and so much more. If you stop to think about it, what goes into that second of acting upon a decision, whether by words or actions, is really a reflection of present, past and future in all of us. Such a truly amazing phenomenon.

Now, take a minute to ask the patient if he or she cares about it?

[4 MIN READ]

The Problem

The term “Never Events” was used in 2001 to describe a subset of medical errors that, ideally, should never occur. Also known as “Serious Reportable Events,” they encompass a wide variety of surgical, device, patient protection, care management, environmental, radiologic and criminal events. The Agency for Healthcare Research and Quality currently defines 29 such events,[i] one of which is defined as “Unintended retention of a foreign object in a patient after surgery or other procedure.” The Joint Commission (TJC) lists 31 types of sentinel events; of such events voluntarily reported to TJC, the most common is “Unintended Retention of a Foreign Body.”[ii] In a review of paid malpractice claims from the National Practitioner Data Bank, Mehtsun and associates[iii] found that of 1,126 surgical retained foreign body events, 5% resulted in death, 16% in permanent injury, and 78% in temporary injury. This simply cannot be allowed to continue.

[3 MIN READ]

According to Sir William Osler, “Medicine arose out of the primal sympathy of man with man; out of the desire to help those in sorrow, need and sickness.” I will highlight two words: “primal sympathy.”

Empathy and sympathy have been researched extensively in the human brain. To summarize, being altruistic, having sympathy, and being empathetic are primal instincts in us; these instincts are no different than hunger or thirst. 

In 2014, there were 885 million physician office visits. Over half of these visits occurred in primary care –family medicine, internal, medicine, pediatrics and others – but there are still hundreds of millions of visits to medical and surgical specialists as well.

Based on information available from journal publications and claims data, we assembled this list of the top ten risk and safety issues pertinent to ambulatory care settings. While this list is not exhaustive, it represents the majority of errors and pitfalls in ambulatory patient safety.

World Breastfeeding Month gives us an opportunity to highlight the benefits of breastfeeding as a life-saving infant feeding practice. In support of the importance of breastfeeding exclusivity and skin-to-skin (STS) for the reduction of infant morbidity and mortality, Bill Gates recently wrote, “Some of the best breakthrough ideas don’t involve technology at all. There is a solution that is readily available, requires no special equipment, and is so cheap any government can support it.”

How do you determine who is actually competent to triage? If you do have a competency assessment plan, is it documented in writing? How do you know it is effective? Is it up to date?

These and many other questions arise when exploring the development and documentation of a triage competency validation process. Answers to these questions are imperative, as they not only impact litigation that may arise, but are also essential for ensuring the highest quality patient care.

Medical errors related to vascular emergencies are common and costly. From head to toe, the vascular system is a fertile field for risk and error waiting to entangle the unwary practitioner.

• Starting at the top, the high-risk vascular entities include a trio of hemorrhages (subarachnoid, subdural, and epidural) and the ischemic duo of TIA and stroke. 
• In the chest reside some of the big hitters – acute coronary syndrome, pulmonary embolism, and thoracic aortic dissection. 
• Moving south into the abdomen, we find abdominal aortic aneurysm, mesenteric ischemia, GI bleeds, retroperitoneal bleeds and traumatic hemorrhages.