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<br /> September/October 2013 Volume 10, Issue 5<br /> PREVENTING<br /> PATIENT VIOLENCE<br /> Root Cause Analysis<br /> Plan Ahead to Prevent<br /> Slips, Trips and Falls<br /> Readmissions, Nursing Homes<br /> and Primary Care<br /> Special Section: Incident Reporting<br /> <br /> CONTENTS<br /> September/October 2013 Volume 10, Issue 5<br /> Features<br /> 26 Lessons from the Frontline: Compassionate Approaches to<br /> Preventing Patient Violence<br /> By Ruth Ison, MDiv, STM<br /> 32 Improving Reliability with Root Cause Analysis<br /> By Robert J. Latino<br /> 38 Usability Testing of a U-500 Insulin Syringe:<br /> A Human Factors Approach<br /> By Kelly Abraham, MPH; Bryanne Patail, BS, MLS, FACCE; and<br /> Danielle Wurth, MSE<br /> 44 Plan Ahead t<a title="PSQH September/October 2013 page 1" href="http://viewer.zmags.com/publication/e1c0f66a?page=1"> September/October 2013 </a> <a title="PSQH September/October 2013 page 2" href="http://viewer.zmags.com/publication/e1c0f66a?page=2"> </a> <a title="PSQH September/October 2013 page 3" href="http://viewer.zmags.com/publication/e1c0f66a?page=3"> </a> <a title="PSQH September/October 2013 page 4" href="http://viewer.zmags.com/publication/e1c0f66a?page=4">CONTENTS September/October 2013 Volume 10, Issu</a> <a title="PSQH September/October 2013 page 5" href="http://viewer.zmags.com/publication/e1c0f66a?page=5"> </a> <a title="PSQH September/October 2013 page 6" href="http://viewer.zmags.com/publication/e1c0f66a?page=6"> </a> <a title="PSQH September/October 2013 page 7" href="http://viewer.zmags.com/publication/e1c0f66a?page=7"> </a> <a title="PSQH September/October 2013 page 8" href="http://viewer.zmags.com/publication/e1c0f66a?page=8"> SPONSORING ORGANIZATIONS Amer</a> <a title="PSQH September/October 2013 page 9" href="http://viewer.zmags.com/publication/e1c0f66a?page=9"> </a> <a title="PSQH September/October 2013 page 10" href="http://viewer.zmags.com/publication/e1c0f66a?page=10"> </a> <a title="PSQH September/October 2013 page 11" href="http://viewer.zmags.com/publication/e1c0f66a?page=11"> </a> <a title="PSQH September/October 2013 page 12" href="http://viewer.zmags.com/publication/e1c0f66a?page=12"> NEWS ANA Issues Standards for Safe Patient Hand</a> <a title="PSQH September/October 2013 page 13" href="http://viewer.zmags.com/publication/e1c0f66a?page=13"> HIE to Transform Clinical and Financial Outcomes </a> <a title="PSQH September/October 2013 page 14" href="http://viewer.zmags.com/publication/e1c0f66a?page=14"> PATIENT- AND FAMILY-CENTERED CARE Partnering wit</a> <a title="PSQH September/October 2013 page 15" href="http://viewer.zmags.com/publication/e1c0f66a?page=15"> leadership. An accurate assessment of the curr</a> <a title="PSQH September/October 2013 page 16" href="http://viewer.zmags.com/publication/e1c0f66a?page=16"> ANALYTICS Predictive Analytics Drives Patient E</a> <a title="PSQH September/October 2013 page 17" href="http://viewer.zmags.com/publication/e1c0f66a?page=17"> It smacks of Big Brother and the deper- sonalized</a> <a title="PSQH September/October 2013 page 18" href="http://viewer.zmags.com/publication/e1c0f66a?page=18"> it won’t be good enough to analyze past performan</a> <a title="PSQH September/October 2013 page 19" href="http://viewer.zmags.com/publication/e1c0f66a?page=19"> ADVERTISEMENT</a> <a title="PSQH September/October 2013 page 20" href="http://viewer.zmags.com/publication/e1c0f66a?page=20"> READMISSIONS Nursing Home Tackles Readmissions </a> <a title="PSQH September/October 2013 page 21" href="http://viewer.zmags.com/publication/e1c0f66a?page=21"> we deal with ongoing patient issues. We can circu</a> <a title="PSQH September/October 2013 page 22" href="http://viewer.zmags.com/publication/e1c0f66a?page=22"> HEALTH IT & QUALITY Evolving to Health 3.0 By </a> <a title="PSQH September/October 2013 page 23" href="http://viewer.zmags.com/publication/e1c0f66a?page=23"> from various clinical transactional sys- tems and</a> <a title="PSQH September/October 2013 page 24" href="http://viewer.zmags.com/publication/e1c0f66a?page=24"> ISMP FentaNYL Patch Fatalities Linked to ‘Bysta</a> <a title="PSQH September/October 2013 page 25" href="http://viewer.zmags.com/publication/e1c0f66a?page=25"> ministration (FDA) evaluated 26 cases of pediatri</a> <a title="PSQH September/October 2013 page 26" href="http://viewer.zmags.com/publication/e1c0f66a?page=26"> 2001). Studies have shown that people are less li</a> <a title="PSQH September/October 2013 page 27" href="http://viewer.zmags.com/publication/e1c0f66a?page=27"> </a> <a title="PSQH September/October 2013 page 28" href="http://viewer.zmags.com/publication/e1c0f66a?page=28"> LESSONS FROM THE FRONTLINE: Compassionate Ap</a> <a title="PSQH September/October 2013 page 29" href="http://viewer.zmags.com/publication/e1c0f66a?page=29"> vent and manage patient violence. Because actual </a> <a title="PSQH September/October 2013 page 30" href="http://viewer.zmags.com/publication/e1c0f66a?page=30"> PREVENTING PATIENT VIOLENCE common are confront</a> <a title="PSQH September/October 2013 page 31" href="http://viewer.zmags.com/publication/e1c0f66a?page=31"> Boarding of acutely ill patients in the ED wi</a> <a title="PSQH September/October 2013 page 32" href="http://viewer.zmags.com/publication/e1c0f66a?page=32"> PREVENTING PATIENT VIOLENCE and other professio</a> <a title="PSQH September/October 2013 page 33" href="http://viewer.zmags.com/publication/e1c0f66a?page=33"> </a> <a title="PSQH September/October 2013 page 34" href="http://viewer.zmags.com/publication/e1c0f66a?page=34"> Improving Reliability with Root Cause Analysi</a> <a title="PSQH September/October 2013 page 35" href="http://viewer.zmags.com/publication/e1c0f66a?page=35"> In 1972, Allied Chemical Corporation pioneer</a> <a title="PSQH September/October 2013 page 36" href="http://viewer.zmags.com/publication/e1c0f66a?page=36"> ROOT CAUSE ANALYSIS Figure </a> <a title="PSQH September/October 2013 page 37" href="http://viewer.zmags.com/publication/e1c0f66a?page=37"> </a> <a title="PSQH September/October 2013 page 38" href="http://viewer.zmags.com/publication/e1c0f66a?page=38"> ROOT CAUSE ANALYSIS Figure</a> <a title="PSQH September/October 2013 page 39" href="http://viewer.zmags.com/publication/e1c0f66a?page=39"> Root Cause Analysis In this approach, the fo</a> <a title="PSQH September/October 2013 page 40" href="http://viewer.zmags.com/publication/e1c0f66a?page=40"> USABILITY TESTING OF A U-500 INSULIN SYRINGE: A H</a> <a title="PSQH September/October 2013 page 41" href="http://viewer.zmags.com/publication/e1c0f66a?page=41"> sponding dose; applicable volume; ease of use; le</a> <a title="PSQH September/October 2013 page 42" href="http://viewer.zmags.com/publication/e1c0f66a?page=42"> USABILITY TESTING Table 1. Demographic distrib</a> <a title="PSQH September/October 2013 page 43" href="http://viewer.zmags.com/publication/e1c0f66a?page=43"> </a> <a title="PSQH September/October 2013 page 44" href="http://viewer.zmags.com/publication/e1c0f66a?page=44"> USABILITY TESTING Table 2. Distribution of part</a> <a title="PSQH September/October 2013 page 45" href="http://viewer.zmags.com/publication/e1c0f66a?page=45"> For example: in order to deliver 0.75 mL of </a> <a title="PSQH September/October 2013 page 46" href="http://viewer.zmags.com/publication/e1c0f66a?page=46"> Plan Ahead to Prevent Slips, Trips,</a> <a title="PSQH September/October 2013 page 47" href="http://viewer.zmags.com/publication/e1c0f66a?page=47"> Before (left): Blankets on wet operating room floo</a> <a title="PSQH September/October 2013 page 48" href="http://viewer.zmags.com/publication/e1c0f66a?page=48"> SLIPS, TRIPS, AND FALLS It may take some effort</a> <a title="PSQH September/October 2013 page 49" href="http://viewer.zmags.com/publication/e1c0f66a?page=49"> </a> <a title="PSQH September/October 2013 page 50" href="http://viewer.zmags.com/publication/e1c0f66a?page=50"> </a> <a title="PSQH September/October 2013 page 51" href="http://viewer.zmags.com/publication/e1c0f66a?page=51"> SPECIAL ADVERTISING SECTION Incident Reporting</a> <a title="PSQH September/October 2013 page 52" href="http://viewer.zmags.com/publication/e1c0f66a?page=52"> SPECIAL ADVERTISING SECTION “The system is ac</a> <a title="PSQH September/October 2013 page 53" href="http://viewer.zmags.com/publication/e1c0f66a?page=53"> </a> <a title="PSQH September/October 2013 page 54" href="http://viewer.zmags.com/publication/e1c0f66a?page=54"> SPECIAL ADVERTISING SECTION AHRQ has deve</a> <a title="PSQH September/October 2013 page 55" href="http://viewer.zmags.com/publication/e1c0f66a?page=55"> SPECIAL ADVERTISING SECTION changes and the </a> <a title="PSQH September/October 2013 page 56" href="http://viewer.zmags.com/publication/e1c0f66a?page=56"> SPECIAL ADVERTISING SECTION Once trust is est</a> <a title="PSQH September/October 2013 page 57" href="http://viewer.zmags.com/publication/e1c0f66a?page=57"> </a> <a title="PSQH September/October 2013 page 58" href="http://viewer.zmags.com/publication/e1c0f66a?page=58"> SPECIAL ADVERTISING SECTION Looking Toward t</a> <a title="PSQH September/October 2013 page 59" href="http://viewer.zmags.com/publication/e1c0f66a?page=59"> </a> <a title="PSQH September/October 2013 page 60" href="http://viewer.zmags.com/publication/e1c0f66a?page=60"> SPECIAL ADVERTISING SECTION Next year, 50-bed</a> <a title="PSQH September/October 2013 page 61" href="http://viewer.zmags.com/publication/e1c0f66a?page=61"> </a> <a title="PSQH September/October 2013 page 62" href="http://viewer.zmags.com/publication/e1c0f66a?page=62"> SPECIAL ADVERTISING SECTION as needed. We ac</a> <a title="PSQH September/October 2013 page 63" href="http://viewer.zmags.com/publication/e1c0f66a?page=63"> </a> <a title="PSQH September/October 2013 page 64" href="http://viewer.zmags.com/publication/e1c0f66a?page=64"> NEWS Quality Conundrums Lynn Helmer, MD, MBA, CH</a> <a title="PSQH September/October 2013 page 65" href="http://viewer.zmags.com/publication/e1c0f66a?page=65"> American Board of Quality Assurance and Utilizati</a> <a title="PSQH September/October 2013 page 66" href="http://viewer.zmags.com/publication/e1c0f66a?page=66"> Patient Safety and Quality Healthcare (PSQH) welc</a> <a title="PSQH September/October 2013 page 67" href="http://viewer.zmags.com/publication/e1c0f66a?page=67"> </a> <a title="PSQH September/October 2013 page 68" href="http://viewer.zmags.com/publication/e1c0f66a?page=68"> </a>