Patient Safety Day -- July 25th

Our friend, John McCormack, passed this along...

PATIENT SAFETY DAY

National, World, Global Patient Safety Day

JULY 25th - CANDLELIGHT MOMENT OF SILENCE AND HOPE

Remembering patients and families who have lost their life (or quality of life) due to medical errors -and in tribute to those who work to improve the safety and quality of healthcare for future patients."Together, lighting the path to safe healthcare - today and everyday: safe, high quality healthcare is neither accidental nor static."

Time: Moment of Silence at Noon and 6 p.m. your timezone

There will be a meeting in Boston in front of the statehouse this Saturday, July 25th, at 11 am for a moment of silence remembering those who have been harmed by medical error.

rL Solutions to Sponsor 2nd Annual MITSS HOPE Award

MITSS is proud to announce that rL Solutions will sponsor its Second Annual HOPE Award. The HOPE Award was established in 2008 to recognize people -- patients, families, healthcare providers, hospitals (or teams or departments therein), academic institutions, community health centers, grass roots organizations, EAP programs, etc. -- who exemplify the mission of MITSS: Supporting Healing and Restoring Hope to patients, families, and clinicians impacted by adverse medical events. The winner will receive a $5,000 cash prize to continue their work.

Nominations are due by September 14, 2009, and the award will be presented at the MITSS 8th Annual Dinner and Fundraiser to be held at the Boston Marriott Copley Place on Thursday, November 12th, 2009.

For more information about the award, or to nominate someone, visit us at http://www.mitss.org/; call Winnie Tobin at (617) 232-0090 or e-mail wtobin@mitss.org; or, mail us at MITSS, 830 Boylston Street, Suite 206, Boston, MA, 02467.

About rL Solutions:

rL Solutions provides proven risk management, patient feedback, claims and infection control software to help healthcare organizations improve patient safety and healthcare quality. rL Solutions brings together innovative technologies, stellar client service, and a broad ecosystem of partners to give its 500 clients a complete safety and quality solution. With products that are easy to use and easy to implement, rL Solutions is a world leader in the healthcare market. For more information, visit http://www.rl-solutions.com/.

Progress Slow in Stopping Hospital Harm

MITSS Executive Director, Linda Kenney, is featured on a Channel 5 (WCVB Boston) news story on hospital errors. Included is the compelling story of a nurse harmed at the hospital where she works.

Check out the video at -- http://www.thebostonchannel.com/video/19984320/index.html

Listen In to Rhode Island Public Radio

Rhode Island Public Radio's Megan Hall produced a wonderful piece on the emotional impact of adverse events. It highlights the work that MITSS is doing with patients and families. Tune-in to the link below!

http://www.wrni.org/content/first-do-no-harm-part-3

A Great Resource for Consumers

The Institute for Safe Medication Practices has put together a useful and informative consumer website regarding medication safety. Here is the link:

http://www.consumermedsafety.org

The site has a lot of features like error reporting, safety tools, many safety articles for consumers, etc. The ISMP just got a grant to do a full section on insulin safety for patients with diabetes. They are also adding a number of safety videos for consumers, a new FDA-ISMP partnership page, and a lot more is planned. The stories you will see are all original and mainly derived from the error reports that the ISMP receives through their reporting programs.

Consumers can also sign up for customized medication safety alerts.

The ISMP is a federally certified patient safety organization (PSO), providing legal protection and confidentiality for submitted patient safety data and error reports.

Systemic Error at Philadelphia VA

Today, the New York Times provides a detailed article on a disturbing case of medical error and failure of oversight at the Philadelphia VA Hospital where a practitioner failed to correctly perform 92 of 116 prostate procedures, leaving patients with radioactive seeds in tissue outside of their prostate. The mistakes were ignored and covered up until an administrative error drew the attention of the VA's national radiation safety unit.

The article correctly focuses on the lack of administrative oversight and "safety culture" that allowed these problems to continue. The article is also accompanied by a great video that highlights the personal impact on one patient.

It's a rogue's gallery of systemic problems, including:
- continued practitioner error and substandard equipment
- contractors from a well-regarded academic institution do not receive the normal level of oversight
- continuing errors are tolerated or undetected by supervisors and institutional oversight boards, and there is lack of peer review (swiss cheese at its best)
- lack of external authority to question alteration of medical records
- practitioner seen by the patient is not the practitioner performing the procedure
- patient undergoes more suffering due to subsequent misdiagnosing of the medical error by other practitioners.
- the error is finally acknowledged by the institution, but no apology or support is provided.

The unit was shut down in June 2008, and results of an investigation were recently released. Interestingly, this article is currently the #3 most forwarded article on the New York Times site.

Update: New York Times is hosting a discussion of radiation treatments. Many stories of negative experiences, but also discussion of the value of radiation treatment and treatment with few negative effects.

Patient Centered Care -- Reality or Fantasy?

There was an interesting piece in last week’s Well Blog of the New York Times. In “Letting Patients Call the Shots,” Dr. Pauline Chen talks with Dr. Don Berwick about his definition of patient-centered care. Many clinicians believe their care is “patient-centered,” but is it really? Are Dr. Berwick’s ideas too radical? Is patient-centered care a really good idea, but just not practical or realistic? Would a true commitment to patient-centered care transform the American healthcare system? What can patients do now to improve their healthcare? The questions seem endless. We’d like to hear what you think.