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The President’s Corner is a monthly column presenting the insights and reflections of Tejal K. Gandhi, MD, MPH, CPPS, president of the National Patient Safety Foundation. This month, Dr. Gandhi writes about Health Literacy Month, and the many resources available to help us all improve in this area.


By Tejal K. Gandhi, MD, MPH, CPPS

Dr. Tejal Gandhi

Earlier this year, the National Patient Safety Foundation’s Lucian Leape Institute issued a report about how patient and family engagement is critical for patient safety, citing health literacy problems as one of the barriers to effective patient partnerships. With Health Literacy Month in progress, there is no better time to learn more about this topic and to work to improve communication. Read More »

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Bob Wachter Talks of Hope, Hype, and Harm

On Sep 23, 2014 · Comments (0)

Keynote presentation at NPSF Lucian Leape Institute Forum & Gala looks at the digitization of medicine.

By By Patricia McTiernan, MS

Anyone who trained as a physician 20 years ago probably recalls spending a lot of time on the hospital medical-surgical units, making notes in patients’ charts after rounds. There was one physical chart for each patient, and it lived at the nurses’ station or outside the patient rooms, where interns, residents, and attending physicians spent time—among nurses and other staff—and where team interactions could occur naturally.

Today, with the widespread use of computers in medicine, records can be read or updated from virtually anywhere. Consequently, the chances of running into a colleague in the hall have largely diminished. According to Bob Wachter, MD, the withering of these social interactions is only one downside of the digitization of medicine. In an enlightening (and entertaining) keynote presentation at the 7th Annual NPSF Lucian Leape Institute Forum & Gala in Boston last week, Dr. Wachter made the case for why health professionals and systems need to take a closer look at implementation of electronic records. Read More »

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The President’s Corner is a monthly column presenting the insights and reflections of Tejal K. Gandhi, MD, MPH, CPPS, president of the National Patient Safety Foundation. This month, Dr. Gandhi writes about using positive deviance to advance patient safety practices.


By Tejal K. Gandhi, MD, MPH, CPPS

Dr. Tejal Gandhi

A highlight of the NPSF Patient Safety Congress last May was a lively debate about accountability for patient safety. Two noted safety experts—Gregg Meyer, MD, MSc, and Bob Wachter, MD—each took a position on the question of whether punitive measures (fines, suspensions) should be applied when health care workers fail to consistently follow established safety procedures. Dr. Meyer argued we would make more progress if we did not solely focus on poor performers, but also celebrated those who were performing at the highest levels. “We need to laud them in front of their colleagues. We need to get people excited about trying to emulate them,” he said.

In an article in the July issue of BMJ Quality & Safety, Rebecca Lawton and colleagues make a similar argument, suggesting that focusing on positive deviance is a tactic well worth trying in health care. “Patient safety management…can feel like a relentlessly negative treadmill,” they write. “Behaviours that produce errors are variations on the same processes that produce success, so focusing on successful practices may be a more effective tactic.” Read More »

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On the need for a patient safety checklist to ensure that we avoid overtreatment or undertreatment—in all care settings.


By Ferdinando Mirarchi, DO, FAAEM, FACEP

Joe is a 59-year-old male who presents to a local emergency room with chest pain. He is pale and sweaty. The emergency medicine physician reviews his EKG, which shows Joe is actively having a heart attack. Joe’s heart becomes irritable and erratic, and he goes into full-blown cardiac arrest. Saving him will require shocking his heart. Joe has a living will, which the nurse gives to the physician. What should occur next? Does Joe get shocked and live, or does Joe not get shocked and die? What treatment is right for Joe?

These are questions that had never been asked or answered through research prior to the TRIAD (The Realistic Interpretation of Advance Directives) studies (Mirarchi et al. 2012), which showed widespread misunderstanding among clinicians about advance directives. We now know that this area represents a nationwide patient safety issue. Read More »

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The President’s Corner is a monthly column presenting the insights and reflections of Tejal K. Gandhi, MD, MPH, CPPS,  president of the National Patient Safety Foundation. This month, Dr. Gandhi writes on the importance of learning about current research in patient safety science and practice.


By Tejal K. Gandhi, MD, MPH, CPPS

Dr. Tejal Gandhi

At the NPSF Patient Safety Congress in May, Dr. Kaveh Shojania, editor-in-chief of BMJ Quality & Safety, provided an overview of key studies in patient safety research over the prior year. I have heard from many attendees that they really learned a lot from his presentation. To fully understand the implications of research, nothing beats having an expert summarize the finer points of an important study. Read More »

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Comments on the session “The High Reliability Chassis: Improving Patient and Employee Safety” at the 2014 NPSF Patient Safety Congress in May (Orlando).


By Lorri Zipperer, MA

I have been intrigued by high reliability and organizations that foster it as a direction for patient safety improvement since reading Weick and Sutcliff’s classic business text Managing the Unexpected (2001). Building on that interest, I have since led and participated in efforts to apply high-reliability concepts to my consulting interests, professional development, and local community building (Zipperer 2006, 2014; Attaining High Reliability 2014). Read More »

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The Doctors Company Foundation Young Physicians Patient Safety Award is conferred in partnership with the National Patient Safety Foundation’s Lucian Leape Institute. The award recognizes young physicians for their deep personal insight into the significance of patient safety work. Awards are given for the best essays on the most instructional patient safety event that was a personal, transformational experience during the third or fourth clinical year in medical school or the first year in residency. Essays are judged by a distinguished panel of experts in patient safety.

Awardees for 2014 are:

Maria Czarina Acelajado, MD, University of South Alabama College of Medicine
Jennifer Bruno, BS, University of South Florida, Morsani College of Medicine
Daniel Leifer, BS, University of California Davis School of Medicine
John Nguyen, MD, University of Arizona College of Medicine
Samantha Wang, BA, Yale University School of Medicine
Emily Yue Wu, BS, Baylor College of Medicine

NPSF is proud to publish the 2014 essays on the P.S. Blog. For assurance of privacy, names of individuals and organizations have not been associated with the individual essays. Read the essays.

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