Archive | 2009
Tunnel View, Yosemite

Rainy Day Interviews, Oscar Winners’ Mortality, and a Randomized Trial of Niceness in the ER: The Extraordinary Mind of Don Redelmeier

One of the great joys of a life in academic medicine is the opportunity to work with lots of very smart people. But one regret is that there is something about academia that tends to homogenize – faculty learn that, when it comes to competing for the next grant or promotion, it pays to be […]

Read full story Comments { 12 } 165 views

A Q&A With Me in Today’s New York Times

The interview, by Pauline Chen, the surgeon and NY Times author who writes the terrific “Doctor and Patient” column on-line, is here — it mostly focuses on my thoughts about patient safety 10 years into the movement. The story and topic were also picked up by Tara Parker-Pope in her “Well” blog, and the comments […]

Read full story Comments { 5 } 15 views

How UCSF’s Root Cause Analysis Process Became Our Most Useful Patient Safety Activity

Hospitals face so many urgent tasks in safety – computerize, promote teamwork, implement evidence-based safety practices, discover unsafe conditions – that it’s hard to know where to start. If you’re struggling, I recommend that you put your Root Cause Analysis enterprise on steroids. This is what we did at UCSF Medical Center, and it was […]

Read full story Comments { 18 } 1,174 views

December 1, 2009: The Patient Safety Field Turns Ten

On December 1, 1999, the Institute of Medicine released a report entitled To Err is Human: Building a Safer Health System. Although its authors hoped to spark a national movement, they had little cause for optimism. After all, early efforts by advocates like Berwick and Leape and organizations like the National Patient Safety Foundation had […]

Read full story Comments { 4 } 231 views

Jail Time for a Medical Error, Redux: The Case of Eric Cropp

Two years ago, I wrote about the case of Julie Thao, the Wisconsin nurse sent to prison for a medication error. I argued then that – although Julie bypassed some safety rules – she most certainly did not deserve jail time. Along comes another case involving jail time for a medical mistake, this one featuring […]

Read full story Comments { 27 } 12,539 views

Singapore: Pragmatism, Noah’s Ark and the Relentless Search for Best Practices

From Tokyo, I flew on to Singapore, where I had the honor of being visiting professor at the massive (1500-bed) Singapore General Hospital, a guest of Dr. Kheng Hock Lee. Kheng Hock, one of Singapore’s leading family physicians, has been charged with developing Singapore’s hospitalist program. Having last been to Singapore 20 years ago, many […]

Read full story Comments { 2 } 1,883 views

A Week in Asia: Today, Japan; Tomorrow, Singapore

A couple of weeks ago, I had the chance to visit Tokyo and Singapore – the former to speak at a conference on “Training of the Generalist Physician,” and the latter as visiting professor at Singapore General Hospital. Today: some observations on the medical scene in Japan; tomorrow, the same viz Singapore. The Tokyo conference […]

Read full story Comments { 3 } 98 views

NY Times Magazine on Brent James’ Quest to Transform Healthcare Quality

Just a quick heads up on an article in next weekend’s New York Times Sunday Magazine by my friend David Leonhardt. David profiles Intermountain Healthcare’s Brent James, capturing Brent’s (and Intermountain’s) unique and increasingly influential philosophy of using performance data to catalyze physician practice change. 

 The piece, which deftly highlights the tension between “cookbook […]

Read full story Comments { 4 } 392 views

Is Healthcare IT Ready for its Big Coming Out Party?

In 2001, when my colleagues and I ranked nearly 100 patient safety practices on the strength of their supporting evidence (for an AHRQ report), healthcare IT didn’t make the top 25. We took a lot of heat for, as one prominent patient safety advocate chided me, “slowing down the momentum.” Some called us Luddites. Although […]

Read full story Comments { 7 } 141 views

"This American Life" on Why the Healthcare System is Out of Control

If you can spare 2 hours, do yourself a favor by listening to the two-part healthcare series on NPR’s extraordinary show, This American Life. By using examples that are memorable for their simplicity and lack of hyperbole, the series (the episodes are here and here) does a superb job illustrating how we got into the […]

Read full story Comments { 2 } 260 views