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The Blogosphere Rumor Factory is heating up with reports that Don Berwick, the world’s most prominent advocate for healthcare quality and safety, will be the next administrator of the Centers for Medicare & Medicaid Services (CMS). (Take this with Read More...
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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 Read More...
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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 Read More...
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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 Read More...
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Dr. Sidney Wolfe, healthcare’s answer to Ralph Nader, spends most of his days unhappy with somebody. Pragmatic, see-both-sides types like me naturally recoil from Wolfe’s reflexive indictment of institutions ranging from the FDA to Medicare. But Wolfe’s Read More...
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A quick note to let you know about my 13th annual Hospital Medicine CME course, September 24-26 at the Fairmont Hotel in SF. The big news this year is the keynote speaker: Captain Chesley “Sully” Sullenberger, the pilot who landed US Airways Flight 1549 Read More...
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When a New York policeman commandeered a chopper after receiving a “plane down” distress call, he expected to find a Cessna or a Piper in the river. “I never, in a million years, expected to see US Airways in the Hudson,” said Sgt. Michael Hendrix when Read More...
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The Institute of Medicine just released its long-awaited report on trainee duty hours. It is well researched and balanced, and its recommendations appropriately reflect what we know vs. what we believe. Now the fun begins.Let’s start with a little background, Read More...
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August 11th was the 2nd anniversary of the epic implosion of George Allen's presidential campaign, the first defeat at the hands of YouTube. Two recent videos of unattended patients dying in ER waiting rooms leave me wondering whether healthcare has also Read More...
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Just returning from a work-acation, including a talk in Buenos Aires. Today I’ll briefly cover a few items: Medicare’s final “no pay” list; patient safety in Argentina; a great post on hospital finances; and one of the saddest things I’ve ever experienced. Read More...
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Yet another case of wrong-side surgery, this one at Boston’s Beth-Israel Deaconess Hospital. Though CEO Paul Levy does a nice job discussing the case on his blog, I’ll focus on two aspects Paul neglects: the role of production pressures in errors, and Read More...
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I gave a keynote yesterday to the first-ever meeting on “Diagnostic Error in Medicine.” I hope the confab helps put diagnostic errors on the safety map. But, as Ricky Ricardo would say, the experts and advocates in the audience have some ‘splainin’ to Read More...
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Fresh on the heels of my recent bar coding epiphany comes another “unintended consequences” article. It turns out that the whipsawing that accompanies the adoption of new technologies is completely foreseeable, the “why doesn’t this thing work right?” Read More...
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Last week, Time Magazine named the 100 most influential people in the world. Among the luminaries was Dr. Peter Pronovost of Johns Hopkins. I thought it was an inspired choice. The modern patient safety field has been blessed with a number of important Read More...
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This is one of the most commonly asked questions in IT World, and my answer has always been “CPOE first” – largely because that has always been David Bates’s (the world’s leading IT/safety researcher) answer. But I’ve changed my mind. Here’s why. Before Read More...
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