Archive for August, 2010
Joint Commission releases sentinel event stats, most challenging standards
The Joint Commission has released the 10 most frequently reported sentinel events. The Joint Commission gathers the information from its data base of voluntarily reported events since 1995, and cautions that the actual reported number of events “represent only a small proportion of actual events.” The top five are:
- Wrong-site surgery
- Suicide
- Operative/post-operative complication
- Delay in treatment
- Medication error
However, it’s worth noting that between March 31, 2010 and June 30, 2010 the most reported event was unintended retention of a foreign body (this even was not added to the list until 2005).
The Joint Commission also announced the top five requirements most frequently cited as non compliant for the first half of 2010. For hospitals, these included:
- RC.01.01.01, which requires complete medical records
- LS.02.01.20, which requires a means of egress
- LS.02.01.10, which requires proper fire protection features
- EC.02.03.05, which requires proper maintenance of fire equipment and features
- LS.02.01.30, which requires the building to have properly maintained building feature to protect individuals from fire dangers
It’s worth noting that no National Patient Safety Goals were included in the top five cited for hospitals
For more information, read The Joint Commission’s online publication, Joint Commission Online.
Boston Med shows medical error in patient case
This Friday I wanted to follow up on a previous post Heather Comak wrote on the premier of Boston Med. Boston Med can, at times, be cheesy reality TV—especially when the spotlight focuses on private lives of residents and music you’d most likely here on Grey’s Anatomy plays to help move the emotion. But ultimately, it’s snippets of real, actual healthcare staff doing what they do best: everything possible to improve the lives of their patients.
The series wrapped up last night with the second face transplant performed in the country—and the first recorded for network TV. It was truly amazing to watch, and I plan to post about it in the future.
However for this post, I was wondering your thoughts on the sixth episode of the eight-episode series. A critical heart defect of a newborn plagues a family, who put their faith in the hands of a pediatric heart surgeon at Mass General Hospital. Weeks after the surgery, the newborn is still struggling. The team of physicians discuss the problem, and then, on camera, the lead surgeon’s hands raise to his face as his jaw drops. The arteries were not connected in the surgery as expected. An error has occurred.
In the end, the audience is told that surgeon apologized to the newborn’s family and performed surgery again to fix the mistake. The family discusses the error on camera and seems to genuinely forgive the surgeon who, afterall, made it possible for them to bring their newborn baby home.
Striking though, that in a series that filmed a man’s near-dying moments with his family in a previous episode, the surgeon’s apology to the newborn’s family was not aired. There are undoubtedly plenty of legal reasons to leave such a conversation out of the series, and I’m sure part of the decision was to save the surgeon from even more stress. But for a series that shows dying moments, failed attempts to save lives, face transplants and the dating lives of doctors, I was surprised this very real moment with the family—a moment that, judging by the results, was an effective application of physician-patient communication, wasn’t aired.
Thoughts?
TJC releases new free monograph on patient-centered care
The Joint Commission has released its most recent free downloadable monograph. This document, entitled “Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care: A Roadmap for Hospitals,” is intened to help hospitals to comply with new standards addressing patient-centered communication.
The three key areas hospitals must focus on to achieve excellence in these standards are communication, cultural competence, and patient- and family-centered care. The Joint Commission’s official statement indicates that although this new monograph is not all-inclusive in addressing every aspect of these standards, it does target key issues hospitals should look at when working to meet unique needs for every patient.
For more information on the monograph, visit The Joint Commission’s site.
ED interpreters improve satisfaction
Patients in the ED are often distressed and on edge. It’s well noted that communicating with the patient, whether that means telling them the expected wait time or giving explicit discharge directions, is one of the best ways to increase patient satisfaction. But when the patient does not speak fluent English, good communication can be harder to come by.
A new study shows just how important that communication is by surveying patients who received professional on-site interpreters in the emergency department. Out of these 242 patients, 96% were “very satisfied” with their ability to communicate during the ER visit, compared to 24% in the control group. The study, Examining Effectiveness of Medical Interpreters in Emergency Departments for Spanish-Speaking Patients with Limited English Proficiency: Results of a Randomized Controlled Trial, also showed that clinicians who worked with the patients with professional on-site interpreters were on average more satisfied.
