71 research outputs found
System Safety in Healthcare: The Right and Wrong Ways to Perform Failure Mode and Effects Analysis (FMEA)
No full textThe objective of performing Failure Mode and Effects Analysis (FMEA) is to use sound risk management principles, coupled with innovative solutions that can assure high return on investment (ROI). Quality Guru Philip Crosby wrote in his book, Quality is Free, that quality is free if you do the right things at the right time. Essentially, the savings from avoiding fixes, process changes and lawsuits are much higher than the cost of doing things right. The principles of sound risk management, experienced by this paper’s co-author Dev Raheja as an international engineering management consultant over 30 years, include:
Identifying risks
Assessing risks
Mitigating risks
Orchestrating risk management
Aiming at high ROI without compromising safet
System Safety in Healthcare: Risk Prevention in Laparoscopic Surgeries
No full textLaparoscopic robotic surgeries allow surgeons to make much smaller incisions than those used in traditional surgeries. When surgeons insert special instruments through small cuts in a patient’s body, they can use a video monitor and laparoscope (a tiny video camera) to view what’s happening inside the body and perform the operation. Using these instruments, the surgeon doesn’t have to manually reach into the patient, leading to a minimally invasive experience. Surgeons can make several small cuts instead of one large cut, each typically no more than a half-inch long.
Yet laparoscopic surgeries are not without risk. Even highly used surgical robots, such as the da Vinci robot, have had their share of issues. Complications can occur due to the patient’s condition and the type of surgery being performed
System Safety in Healthcare: How Good Are Patient Surveys for Safety?
No full textRecently, I was invited to give my opinion as a patient advocate during a retreat organized by three U.S. federal government groups: The Centers for Medicare & Medicaid Services (CMS), the Agency for Healthcare Research and Quality (AHRQ) and the Office of Health and Human Services. The topic was “Partnership for Patients.” The AHRQ showed data on the significant progress made in the last four years on Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) measures. The data showed that more and more hospitals are achieving higher scores
System Safety in Healthcare: Unique Device Identification (UDI): A New Government Initiative to Improve Patient Safety
No full textUnique Device Identification (UDI) is a recent development to protect patients from hazards in medical devices. The UDI relates to adverse event reporting, identifying and analyzing devices in use. Currently, hospitals are unable to report many adverse events because the device identification has to be manually located — and often, they are not easily readable, or the person reporting makes an error in reading or documenting the identification information. If a cardiac monitor malfunctions, it’s critical for the information in the adverse event report to match the manufacturer’s product identification system; otherwise, the adverse event may go unreported to U.S. Food and Drug Administration (FDA), and the device may not be recalled as soon as it should. The same urgency holds for a product recall sent from a manufacturer to the doctor, hospital or patient. An inability to identify the device affected by the recall could have potentially disastrous results for patients. In addition, if the device is for personal use, the user may not have access to information about the hazards other users of the device have experienced. With this new system, a user can easily search for hazards
System Safety in Healthcare: The Challenges of Sign-offs
No full textWith increasing demand for efficiency and productivity from a clinical team that’s often overworked and understaffed, provision of seamless patient care is challenging. Clinicians need to hand off — or sign off — essential information to the next provider to help transition care. An effective hand-off supports the transition of critical information, along with continuity of care and treatment. This article offers an overview of sign-offs, hazards and suggestions for quality improvement initiatives, as well as recommendations for potential remedies
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