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<br /> May/June 2012 Volume 9, Issue 3<br /> THE SIRENS ARE CALLING<br /> THE HAZARDS OF Alarm Fatigue<br /> Just Culture<br /> Drug Shortages<br /> Cause Harm<br /> Fall Prevention<br /> Stories of Success !<br /> <br /> <br /> 46 26<br /> CONTENTS<br /> may/June 2012 Volume 9, Issue 3<br /> Features<br /> 26 Alarm Fatigue Hazards: The Sirens Are Calling<br /> By James welch<br /> 34 Mitigate Risk and Drive Organizational Change with Just Culture<br /> By Barbara Lightizer, ms, ma, cphRm, and<br /> Bert Thurlo-walsh, Rn, mm, cphq<br /> 40 Virtual Patient Platforms<br /> By James B. mcGee, mD<br /> 46 Preventing Falls: The A-B-C Approach<br /> By Tom Inglesby<br /> Cover photo<a title="PSQH May/June 2012 page 1" href="http://viewer.zmags.com/publication/cde0997d?page=1"> May/June 2012 </a> <a title="PSQH May/June 2012 page 2" href="http://viewer.zmags.com/publication/cde0997d?page=2"> </a> <a title="PSQH May/June 2012 page 3" href="http://viewer.zmags.com/publication/cde0997d?page=3"> </a> <a title="PSQH May/June 2012 page 4" href="http://viewer.zmags.com/publication/cde0997d?page=4"> 46 26 CONTENTS may/June 2012 Volume 9, Issue </a> <a title="PSQH May/June 2012 page 5" href="http://viewer.zmags.com/publication/cde0997d?page=5"> </a> <a title="PSQH May/June 2012 page 6" href="http://viewer.zmags.com/publication/cde0997d?page=6"> </a> <a title="PSQH May/June 2012 page 7" href="http://viewer.zmags.com/publication/cde0997d?page=7"> </a> <a title="PSQH May/June 2012 page 8" href="http://viewer.zmags.com/publication/cde0997d?page=8"> SPONORING ORGANIZATIONS </a> <a title="PSQH May/June 2012 page 9" href="http://viewer.zmags.com/publication/cde0997d?page=9"> </a> <a title="PSQH May/June 2012 page 10" href="http://viewer.zmags.com/publication/cde0997d?page=10"> NEWS Mayo Clinic Study Reports on Incidence and</a> <a title="PSQH May/June 2012 page 11" href="http://viewer.zmags.com/publication/cde0997d?page=11"> News from the ONC NEW pOSITIONS CREaTED: CHIEf M</a> <a title="PSQH May/June 2012 page 12" href="http://viewer.zmags.com/publication/cde0997d?page=12"> NEWS lallie Kemp Regional Medical Center to Rece</a> <a title="PSQH May/June 2012 page 13" href="http://viewer.zmags.com/publication/cde0997d?page=13"> Six authors of Winning patient Safety Essays Reco</a> <a title="PSQH May/June 2012 page 14" href="http://viewer.zmags.com/publication/cde0997d?page=14"> CORPORATE COMPlIANCE OIG Report Critical of CMS</a> <a title="PSQH May/June 2012 page 15" href="http://viewer.zmags.com/publication/cde0997d?page=15"> learning about alleged events, which may be “near</a> <a title="PSQH May/June 2012 page 16" href="http://viewer.zmags.com/publication/cde0997d?page=16"> HEAlTH IT & QuAlITy print me a pill By Bar</a> <a title="PSQH May/June 2012 page 17" href="http://viewer.zmags.com/publication/cde0997d?page=17"> the inside of the bioprinted blood ves- sel, the </a> <a title="PSQH May/June 2012 page 18" href="http://viewer.zmags.com/publication/cde0997d?page=18"> ISMP Short of Everything Except Errors: harm as</a> <a title="PSQH May/June 2012 page 19" href="http://viewer.zmags.com/publication/cde0997d?page=19"> </a> <a title="PSQH May/June 2012 page 20" href="http://viewer.zmags.com/publication/cde0997d?page=20"> </a> <a title="PSQH May/June 2012 page 21" href="http://viewer.zmags.com/publication/cde0997d?page=21"> </a> <a title="PSQH May/June 2012 page 22" href="http://viewer.zmags.com/publication/cde0997d?page=22"> t t T ( fi ( i i t T i </a> <a title="PSQH May/June 2012 page 23" href="http://viewer.zmags.com/publication/cde0997d?page=23"> </a> <a title="PSQH May/June 2012 page 24" href="http://viewer.zmags.com/publication/cde0997d?page=24"> AMERICAN COllEGE OF SuRGEONS Four critical eleme</a> <a title="PSQH May/June 2012 page 25" href="http://viewer.zmags.com/publication/cde0997d?page=25"> 1. Set the standards. The core for any quality im</a> <a title="PSQH May/June 2012 page 26" href="http://viewer.zmags.com/publication/cde0997d?page=26"> should be used as part of a four-step cycle of </a> <a title="PSQH May/June 2012 page 27" href="http://viewer.zmags.com/publication/cde0997d?page=27"> </a> <a title="PSQH May/June 2012 page 28" href="http://viewer.zmags.com/publication/cde0997d?page=28"> Alarm Fatigue Hazards: The Sirens Are Calling By</a> <a title="PSQH May/June 2012 page 29" href="http://viewer.zmags.com/publication/cde0997d?page=29"> N urses often compare their pa</a> <a title="PSQH May/June 2012 page 30" href="http://viewer.zmags.com/publication/cde0997d?page=30"> AlARM FATIGuE HAZARDS Manufacturers have advanc</a> <a title="PSQH May/June 2012 page 31" href="http://viewer.zmags.com/publication/cde0997d?page=31"> figure 2. framework for alarm Management each </a> <a title="PSQH May/June 2012 page 32" href="http://viewer.zmags.com/publication/cde0997d?page=32"> </a> <a title="PSQH May/June 2012 page 33" href="http://viewer.zmags.com/publication/cde0997d?page=33"> </a> <a title="PSQH May/June 2012 page 34" href="http://viewer.zmags.com/publication/cde0997d?page=34"> AlARM FATIGuE HAZARDS (Welch, 2011). Reducing t</a> <a title="PSQH May/June 2012 page 35" href="http://viewer.zmags.com/publication/cde0997d?page=35"> cue event (surveillance) versus ICU alarms that w</a> <a title="PSQH May/June 2012 page 36" href="http://viewer.zmags.com/publication/cde0997d?page=36"> Mitigate Risk and Drive Organizational C</a> <a title="PSQH May/June 2012 page 37" href="http://viewer.zmags.com/publication/cde0997d?page=37"> </a> <a title="PSQH May/June 2012 page 38" href="http://viewer.zmags.com/publication/cde0997d?page=38"> RISk, CHANGE, AND JuST CulTuRE </a> <a title="PSQH May/June 2012 page 39" href="http://viewer.zmags.com/publication/cde0997d?page=39"> </a> <a title="PSQH May/June 2012 page 40" href="http://viewer.zmags.com/publication/cde0997d?page=40"> RISk, CHANGE, AND JuST CulTuRE sizing the James</a> <a title="PSQH May/June 2012 page 41" href="http://viewer.zmags.com/publication/cde0997d?page=41"> </a> <a title="PSQH May/June 2012 page 42" href="http://viewer.zmags.com/publication/cde0997d?page=42"> Virtual Patient Platforms Virtual patients offer </a> <a title="PSQH May/June 2012 page 43" href="http://viewer.zmags.com/publication/cde0997d?page=43"> </a> <a title="PSQH May/June 2012 page 44" href="http://viewer.zmags.com/publication/cde0997d?page=44"> vIRTuAl PATIENT PlATFORMS fig</a> <a title="PSQH May/June 2012 page 45" href="http://viewer.zmags.com/publication/cde0997d?page=45"> tive approach. The author may also choose to comb</a> <a title="PSQH May/June 2012 page 46" href="http://viewer.zmags.com/publication/cde0997d?page=46"> vIRTuAl PATIENT PlATFORMS Virtual patients can</a> <a title="PSQH May/June 2012 page 47" href="http://viewer.zmags.com/publication/cde0997d?page=47"> </a> <a title="PSQH May/June 2012 page 48" href="http://viewer.zmags.com/publication/cde0997d?page=48"> Preventing Falls: The A-B-C Approach By Tom In</a> <a title="PSQH May/June 2012 page 49" href="http://viewer.zmags.com/publication/cde0997d?page=49"> L ittle kids play at falling do</a> <a title="PSQH May/June 2012 page 50" href="http://viewer.zmags.com/publication/cde0997d?page=50"> PREvENTING FAllS ‘We were having about one fal</a> <a title="PSQH May/June 2012 page 51" href="http://viewer.zmags.com/publication/cde0997d?page=51"> </a> <a title="PSQH May/June 2012 page 52" href="http://viewer.zmags.com/publication/cde0997d?page=52"> PREvENTING FAllS ing. At Burke Rehabilitation H</a> <a title="PSQH May/June 2012 page 53" href="http://viewer.zmags.com/publication/cde0997d?page=53"> sues bright yellow socks (with sole grips) to pat</a> <a title="PSQH May/June 2012 page 54" href="http://viewer.zmags.com/publication/cde0997d?page=54"> STORIES OF SuCCESS! Case Studies Show Health IT</a> <a title="PSQH May/June 2012 page 55" href="http://viewer.zmags.com/publication/cde0997d?page=55"> Standards for Quality Improvement Reporting Excel</a> <a title="PSQH May/June 2012 page 56" href="http://viewer.zmags.com/publication/cde0997d?page=56"> ABQAuRP NEWS Quality Conundrums Lynn Helmer, MD,</a> <a title="PSQH May/June 2012 page 57" href="http://viewer.zmags.com/publication/cde0997d?page=57"> Member Spotlight marvin stein, mD, mmm, Facs, chc</a> <a title="PSQH May/June 2012 page 58" href="http://viewer.zmags.com/publication/cde0997d?page=58"> Patient Safety and Quality Healthcare (PSQH) welc</a> <a title="PSQH May/June 2012 page 59" href="http://viewer.zmags.com/publication/cde0997d?page=59"> </a> <a title="PSQH May/June 2012 page 60" href="http://viewer.zmags.com/publication/cde0997d?page=60"> </a>