AUG/SEPT 2004
Volume 28 • No. 8

 

Recent Highlights, Compiled in Jule, of Performance Improvement at SHC

-From the SHC Quality Improvement and Patient Safety Department Joseph Hopkins, associate chief of staff, chairs the Quality Improvement and Safety Committee.

PCA (patient controlled analgesia)
The PCA FMEA (Failure Mode and Effects Analysis) Team will have accomplished all recommendations when a conversion to recommended pumps is completed by January. The program components include:

House-wide protocols for prescribing, administration and monitoring
Double check protocol
New order sets
POE and written
Physician and staff education
Revised documentation forms
Extensive education on new pumps

ICU Credentialing
ICU Medical Director Norman Rizk reports that a new ICU Credentialing policy should go into effect by the end of September. The ICU protocols are being incorporated into Physician Order Entry (POE), and there will be regular reporting of changes in outcomes based on the adoption of the new model.

U.S. News and World Report Ratings
SHC compares with other hospitals currently rated by the news magazine in July as "honor roll hospitals". SHC ranked 14th in the national ratings. (See related article this issue).

Crew Resource Management
The Operating Room Committee is discussing adopting concepts from Crew Resource Management to improve processes in the OR. Originally developed in the airline industry, CRM is increasingly finding applicability in medicine. Important aspects of CRM include:

A program designed to improve the use of people, information and equipment in high risk, high stress environments
A focus on safety and morale
Simulation and feedback on how fatigue, emergencies and work load contribute to errors
"Crew" participation without "pilot" relinquishing authority
Seeking additional information, communication and decision making
Intensive study of anonymously reported incidents and near misses
Shifting the culture - emphasis on communication coupled with technical proficiency; culture values input regardless of the status of person providing input

Medicare warns
of provider scam

Unacceptable abbreviations chart

Revised & renewed protocols need IRB review, dean says

US News and World Reports Hospital Rankings

Common charges available for patient perusal on request

Role of clinician educators reviewed

Report needle sticks

From Tumor Board to Public Affairs, liver suregon believes in outreach

Infusion treatment area

Hematopathology Moment