Perspectives, Jan '09 Vol 29 #1 Pg10-Sentinel Event ALERT: Safely Implementing Health Information and Converging Technologies[**REF**] This article is essentially a reprint of Sentinel Event Alert #42 which focuses on the prevention of 'technology-related adverse events. Although most of the 13 recommendations are pro-active new implementation strategies, a number are specific to the post-implementation phase making this a must read for IT and LDR. In addition, if like approximately 83% of hospitals in the US, you have an automated dispensing cabinet (ADC), your P&T, RNx, MDx should also download and review a copy of the Institute for Safe Medication Practices (ISMP) Guidance on the Interdisciplinary Safe Use of Automated Dispensing Cabinets (PDF). This contains an additional 12 guidelines on such issues as ADC location, number, security, stocking procedures, inventory, etc.
Feb 2009
Source Feb 2009 Vol 7 #2 Pg05-Featured Standard: Integrating Leaders Into Activities [**REF**] StandardLD.04.04.05 emphasizes the need for leaders to ensure that patient safety activities throughout the organization are integrated, rather than operating in compartments or “silos”. [Pearl] JCSC, LDR and PIshould note that surveyors will be looking for evidence of the following as they survey this standard:
1. An effective connection of all activities that may have something to do with patient safety and quality so that safety is promoted, problems are reported, and failures are corrected.
2. Example of an RCA (preferably proactive), including effectiveness of follow-up that has generated learning throughout the hospital which is integrated into practice.
3. A blame-free internal reporting system so that staff members are comfortable reporting what seems to be sentinel event.
Mar 2009
Patient Safety, Mar 2009 Vol 9 #3 Pg02-Patient Safety Pulse: Your Patient Safety News[*ALERT: IC*] The US Department of Health and Human Services has established a set of five-year “national prevention targets” to prevent HAIs. The plan targets some infections that many state hospitals have experienced, including MRSA, Clostridium difficile, and catheter associated infections The HHS plan includes prioritized, recommended clinical practices and can be accessed at www.hhs.gov/ophs/initiatives/hai/index.html. Also remember that the Joint Commission NPSG #7 requires management of identified HAI cases as sentinel events.
Apr 2009
May 2009
Jun 2009
July 2009
Aug 2009
Sep 2009
Oct 2009
Perspectives, Oct. 2009, Vol 29 #10 Pg10-Sentinel Event Alert: Leadership Committed to Safety[••REF••] TJC revised this SEA (#43) on 9/8/09 after we published our September review of the announcement in JC Online. It now provides a clarification of staff acts requiring discipline based in part on the work of James Reason. The article provides a summary of the SEA's 14 recommendations. However, the actual SEA#43 is the reference we would encourage LDR to read. See also Assessing Unsafe Acts (A table Developed by the MissouriBaptistMedicalCenter based on Managing the Risks of Organizational Accidents by James Reason)
Nov 2009
No articles referenced
Dec 2009
Recent (Relevant) SE Alerts
Perspectives, Jan '09 Vol 29 #1 Pg10-Sentinel Event ALERT: Safely Implementing Health Information and Converging Technologies[**REF**] This article is essentially a reprint of Sentinel Event Alert #42 which focuses on the prevention of 'technology-related adverse events. Although most of the 13 recommendations are pro-active new implementation strategies, a number are specific to the post-implementation phase making this a must read for IT and LDR. In addition, if like approximately 83% of hospitals in the US, you have an automated dispensing cabinet (ADC), your P&T, RNx, MDx should also download and review a copy of the Institute for Safe Medication Practices (ISMP) Guidance on the Interdisciplinary Safe Use of Automated Dispensing Cabinets (PDF). This contains an additional 12 guidelines on such issues as ADC location, number, security, stocking procedures, inventory, etc.
• SL1: 1030.20 - SE Alert: Issue 40 - July 9, 2008: Behaviors that undermine a culture of safety [SE Alert] [JCR Resources] [8-Min Podcast] [**REF**] JCSC, LDR, HR, StEd, RNx and MDxbe sure to pick up on the Alert's 11 recommendations.
