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Zmags
September/October 2013 Volume 10, Issue 5
PREVENTING
PATIENT VIOLENCE
Root Cause Analysis
Plan Ahead to Prevent
Slips, Trips and Falls
Readmissions, Nursing Homes
and Primary Care
Special Section: Incident Reporting
CONTENTS
September/October 2013 Volume 10, Issue 5
Features
26 Lessons from the Frontline: Compassionate Approaches to
Preventing Patient Violence
By Ruth Ison, MDiv, STM
32 Improving Reliability with Root Cause Analysis
By Robert J. Latino
38 Usability Testing of a U-500 Insulin Syringe:
A Human Factors Approach
By Kelly Abraham, MPH; Bryanne Patail, BS, MLS, FACCE; and
Danielle Wurth, MSE
44 Plan Ahead t
September/October 2013
CONTENTS September/October 2013 Volume 10, Issu
SPONSORING ORGANIZATIONS Amer
NEWS ANA Issues Standards for Safe Patient Hand
HIE to Transform Clinical and Financial Outcomes
PATIENT- AND FAMILY-CENTERED CARE Partnering wit
leadership. An accurate assessment of the curr
ANALYTICS Predictive Analytics Drives Patient E
It smacks of Big Brother and the deper- sonalized
it won’t be good enough to analyze past performan
ADVERTISEMENT
READMISSIONS Nursing Home Tackles Readmissions
we deal with ongoing patient issues. We can circu
HEALTH IT & QUALITY Evolving to Health 3.0 By
from various clinical transactional sys- tems and
ISMP FentaNYL Patch Fatalities Linked to ‘Bysta
ministration (FDA) evaluated 26 cases of pediatri
2001). Studies have shown that people are less li
LESSONS FROM THE FRONTLINE: Compassionate Ap
vent and manage patient violence. Because actual
PREVENTING PATIENT VIOLENCE common are confront
Boarding of acutely ill patients in the ED wi
PREVENTING PATIENT VIOLENCE and other professio
Improving Reliability with Root Cause Analysi
In 1972, Allied Chemical Corporation pioneer
ROOT CAUSE ANALYSIS Figure
ROOT CAUSE ANALYSIS Figure
Root Cause Analysis In this approach, the fo
USABILITY TESTING OF A U-500 INSULIN SYRINGE: A H
sponding dose; applicable volume; ease of use; le
USABILITY TESTING Table 1. Demographic distrib
USABILITY TESTING Table 2. Distribution of part
For example: in order to deliver 0.75 mL of
Plan Ahead to Prevent Slips, Trips,
Before (left): Blankets on wet operating room floo
SLIPS, TRIPS, AND FALLS It may take some effort
SPECIAL ADVERTISING SECTION Incident Reporting
SPECIAL ADVERTISING SECTION “The system is ac
SPECIAL ADVERTISING SECTION AHRQ has deve
SPECIAL ADVERTISING SECTION changes and the
SPECIAL ADVERTISING SECTION Once trust is est
SPECIAL ADVERTISING SECTION Looking Toward t
SPECIAL ADVERTISING SECTION Next year, 50-bed
SPECIAL ADVERTISING SECTION as needed. We ac
NEWS Quality Conundrums Lynn Helmer, MD, MBA, CH
American Board of Quality Assurance and Utilizati
Patient Safety and Quality Healthcare (PSQH) welc