Perspectives on Patient Safety Blog

The Perspectives on Patient Safety Blog features news and insight from Jim Parker, Senior Editor of The Joint Commission Perspectives on Patient Safety newsletter, and also provides readers with a free, online forum for readers to discuss all aspects of patient safety, including the National Patient Safety Goals, involving patients in their own care, health care provider communication, infection control, and other pressing patient safety issues.

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December Issue now available in print and online!

• 12/9/2011
• Author: Jim Parker
• 241 Views
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The December 2011 issue of Perspectives on Patient Safety is now available, containing the following articles: • Up to the Minute: Ensuring Timely Reporting of Critical Test Results • Sound the Alarm: Managing Physiologic Monitoring Systems • Effective Relationships: Key to Safety in a Complex Environment more >>

A New “Source” for Patient Safety Information from Joint Commission Resources

• 10/12/2011
• Author: Jim Parker
• 371 Views
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You, the readers, have told us that you’d like all the information you need on Joint Commission accreditation requirements, the accreditation process, performance measurement, and patient safety conveniently delivered, affordably priced, and in one place. To better meet your needs, JCR will introduce an improved, expanded version of The Source newsletter in January 2012.   The new Source... more >>

Come to the Home Care Executive Briefing

• 8/1/2011
• Author: Jim Parker
• 543 Views
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Every year Joint Commission Resources invites home care organization administrators, directors, and managers to this critical update on the home care accreditation. This year, this one-day event will take place October 13 at The Joint Commission headquarters, located just outside of Chicago in Oakbrook Terrace, IL. The event will focus on recent and forthcoming changes to the accredita... more >>

Come to the Hospital Executive Briefings

• 6/22/2011
• Author: Jim Parker
• 823 Views
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Hospital Executive Briefings Health care professionals who are interested and involved in improving patient safety at their organizations should attend one of JCR’s Hospital Executive Briefings The briefings are especially helpful for hospital executives, chief nursing officers, risk managers, quality improvement managers, accreditation managers, patient safety officers, chief medical of... more >>

Check Out These Upcoming Webinars!

• 6/17/2011
• Author: Jim Parker
• 690 Views
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Patient safety is at the heart of Joint Commission accreditation. The ultimate purpose of every standard is protecting patients, preventing harm, and improving quality. Joint Commission Reso... more >>

Reminder: Annual Conference Coming Up!

• 5/20/2011
• Author: Jim Parker
• 652 Views
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The Joint Commission and Joint Commission Resources Annual Conference on Quality and Patient Safety, June 8–10, in Chicago is right around the corner. Have you registered yet? This year’s conference includes the following expected keynote presenters: • James Reason, PhD, Professor Emeritus of Psychology University of Manchester, United Kingdom will speak present a retrospective and pr... more >>

New Global Data on HAIs

• 5/12/2011
• Author: Jim Parker
• 736 Views
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The World Health Organization (WHO) last week released a report, titled "World Health Organization Report on the Burden of Endemic Health Care–Associated Infection Worldwide." This report is a must-read for anyone interested in patient safety or infection prevention and control. According to the report, health care–associated infections (HAIs) are the most prevalent t... more >>

Reminding Staff About Hand Hygiene

• 4/21/2011
• Author: Jim Parker
• 910 Views
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Hand hygiene is a major patient safety priority in the United States and around the world. Many health care organizations continue to struggle with ensuring that staff comply with World Health Organization and Centers for Disease Control and Prevention guidelines, as well as Joint Commission National Patient Safety Goal Requirement NPSG.07.01.01. Recently I came across some amusing and i... more >>

See you at the Annual Conference!

• 4/7/2011
• Author: Jim Parker
• 781 Views
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I hope to meet some of you in person at the upcoming Joint Commission and Joint Commission Resources Annual Conference on Quality and Patient Safety, June 8–10, in Chicago. I plan to attend the conference and would relish the opportunity to meet and talk with you, the readers. You’ll likely find me at our on-site book store. This year’s conference has an intriguing line up, with th... more >>

Incident Underscores Importance of Patient Identification

• 2/15/2011
• Author: Jim Parker
• 1587 Views
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What are the odds, really, that a clinician might perform surgery on the wrong patient, or give the wrong blood product in a transfusion, or perhaps dispense the wrong medication? And really, how bad can it be? Perhaps we might ask a pregnant patient in Colorado whose retail pharmacist mistakenly gave her the drug methotrexate instead of the antibiotic she was prescribed, according to me... more >>

New CMS Rules Address Patient Safety/Rights Issues

• 2/1/2011
• Author: Jim Parker
• 2198 Views
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  Now is a good time for hospitals to evaluate their policies on who is allowed to visit patients. On Tuesday, January 18, 2011, new Centers for Medicare & Medicaid Services (CMS) regulations go into effect pertaining to patients’ rights to have visitors during hospital stays following a presiden... more >>

December Issue Links

• 1/7/2011
• Author: Jim Parker
• 1260 Views
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Happy New Year!  I hope all of you enjoyed a safe and restful holiday season. Shortly after December issue of Perspectives on Patient Safety went to press, The Joint Commission unveiled its new, upgraded Web site at http://www.jointcommission.org. As a result of this, a link to the Joint Commission’s report Improving America’s Hospitals:  The Joint Commission’s Report on Quality and Safe... more >>

2011 NPSGs Will Soon Become Effectve

• 12/21/2010
• Author: Jim Parker
• 1402 Views
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The year 2010 is coming to a close and in a couple of weeks the 2011 National Patient Safety Goals will become effective! Remember that if you have questions or concerns about how to interpret the goals, you can contact The Joint Commission’s Standards Interpretation Group (SIG) for help. Contact SIG at 630-792-5900, 8:30 a.m. - 5:00 p.m. (Central time). You can also contact SIG by using... more >>

Proposed NPSG Requirements in Field Review

• 12/7/2010
• Author: Jim Parker
• 1276 Views
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 The Joint Commission posted two proposed National Patient Safety Goal requirements designed to help hospitals, critical access hospitals, and long term care organizations prevent ventilator­-associated pneumonia (VAP) and catheter-associated urinary tract infections (CAUTI) on its Web site. These requirements may be integrated into existing Goal 7 to reduce the risk of health care–assoc... more >>

Tragic Incident Underscores Need to Prevent MDROs

• 11/18/2010
• Author: Jim Parker
• 1382 Views
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Earlier this week the tragic news broke that a newborn infant had died and 10 others were sickened during an outbreak of methicillin-resistant Staphylococcus aureas (MRSA) at a hospital in Richmond, Virginia. As a result of the outbreak, the hospital in question had to shut down its neonatal unit for five weeks. MRSA and other multidrug–resistant org... more >>

Tragic Event Reminds Us That Violence Is a Real Threat in Health Care

• 10/7/2010
• Author: Jim Parker
• 3193 Views
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Health care professionals often encounter human beings at the most intense moments of their lives—moments of pain and grief as well as moments of intense joy—such as when a  child is delivered or a loved one recovers from a serious illness.    In these moments, people are charged with emotion, often anxiety and sometimes anger. Unfortunately, faced with these extreme situations, so... more >>

Is Your Organization Patient-Centered?

• 9/11/2010
• Author: Jim Parker
• 4685 Views
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In an earlier post, I wrote about the importance of listening to patients and families during the course of providing care, treatment, and services. The theme of that earlier entry is summed up with this quote:  “The best practice is to consider the patient and family as full-fledged members of the care team. Family members (and the patients themselves) often have insights into a patient... more >>

Joint Commission Seeks Comment on 2010 Universal Protocol

• 8/26/2010
• Author: Jim Parker
• 6409 Views
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Accredited organizations now have the opportunity to tell The Joint Commission what they really think about the 2010 Universal Protocol. The Joint Commission is seeking public feedback on the 2010 Universal Protocol for Preventing Wrong-Site, Wrong-Procedure, and Wrong-Person Surgery™ for the Hospital, Critical Access Hospital, Ambulatory Care, and Office-based Surgery accreditation prog... more >>

H1N1 Pandemic Officially Ends

• 8/13/2010
• Author: Jim Parker
• 5942 Views
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The H1N1 influenza pandemic that created great anxiety among health care organizations and the public for two years has ended, according to a statement released by Margaret Chan, M.D., director-general of the World Health Organization. Perspectives on Patient Safety covered the pandemic from its first stirrings to the moment of its greatest prevalence.  In February 2010, we published a s... more >>

New Fall Prevention Resource

• 8/6/2010
• Author: Jim Parker
• 7746 Views
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  A fall for an elderly or severely ill or weakened patient can be deadly. Health care organizations have a responsibility to take steps to reduce the likelihood of falls in their facilities. This is the impetus behind The Joint Commission’s National Patient Safety Goal 9, requirement NPSG.09.02.01, which guides organizations’ fall prevention efforts.   Falls remain a serious patient safety... more >>

Working Together to Improve Health Literacy

• 7/26/2010
• Author: Jim Parker
• 6664 Views
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La mancata comunicazione sono molto frustrazinone.* Aren’t they? For some patients, including some well-educated patients, health care information can seem like a foreign language. The total number of people in the United States who have limited health literacy exceeds 89 million.1 These patients have a difficult time obtaining, processing, and understanding basic healt... more >>

See you at the conference!

• 6/18/2010
• Author: Jim Parker
• 8824 Views
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I hope to see some of you at The Joint Commission/JCR Annual Conference for Quality and Patient Safety June 23–25 in Chicago.   The conference has an exciting line up of presenters this year, including plenary sessions led by: ·         Joint Commission President Mark Chassin, M.D. ·         Author John J. Nance, J.D. ·         John  Ovretveit, BSc(hons), M.Phil., Ph.D., C. Psychol., C.S... more >>

New Sentinel Event Alert on Violence in Health Care

• 6/7/2010
• Author: Jim Parker
• 9578 Views
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Here’s a head’s up: The Joint Commission has issued Sentinel Event Alert, issue 45, “Preventing Violence in the Health Care Setting.”Violence and crime represent a serious hazard to both patients and staff, and security can be a challenge because many organizations, such as hospitals, must be open to the public 24-hours-a-day, 365-days-a-year.   The problem can take many shapes, one pati... more >>

JCR Selects 2010 Nurse Safety Scholar-in-Residence

• 5/28/2010
• Author: Jim Parker
• 9855 Views
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JCR and its partner Hill-Rom have selected a new Nurse Safety Scholar-in-Residence: certified wound, ostomy, and continence nurse Diane Whitworth, head of the Bon Secours St. Mary’s Hospital wound care team in Richmond, Virginia. Diane has more than three decades of clinical experience under her belt. She will taking over for the first Nurse Safety Scholar-in-residence, Nurse Practitione... more >>

Check Out JCR’s E-books

• 5/18/2010
• Author: Jim Parker
• 10081 Views
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Perhaps you’re a fan of JCR’s books; chances are that you have a few in your library.  Did you know that many of JCR’s titles are also available as e-books? E-books are PDF files that are identical to the hard copy versions, but without all the shipping and the paper consumption. The e-books are specially priced and available for immediate download.  E-books are also searchable, making i... more >>

Happy National Nurses Week

• 5/7/2010
• Author: Jim Parker
• 10943 Views
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This week is National Nurses Week! You are likely to see many signs, posters, and banners urging you to “Hug a Nurse Today.”  (While I certainly do not oppose this course of action, I would encourage readers to ask permission before pursuing it.) This is not only a good time to show gratitude for the incredible work nurses do, but a good time to consider their roles in the health care te... more >>

Organizations Still Struggle Against Health Care–Acquired Infections

• 4/27/2010
• Author: Jim Parker
• 11204 Views
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Combating health care–acquired infections (HAIs) continues to be a serious challenge for health care organizations.  Despite intensified focus on HAIs by The Joint Commission, the public, patient safety advocates the media, the health care industry, and federal, state, and local government agencies, very little progress is being made on this hot button issue that first hit the spotlight ... more >>

The Joint Commission Annual Conference on Quality and Patient Safety

• 4/20/2010
• Author: Jim Parker
• 12383 Views
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I hope to see some, if not all of you at The Joint Commission Annual Conference on Quality and Patient Safety, June 23-25 in Chicago. This is the 24th annual conference and this year brings an exciting line-up. The distinguished faculty for this event includes author, speaker, and veteran John J. Nance, J.D.; Joint Commission President Mark Chassin, M.D., M.P.P, M.P.H.; John  Ovretveit, ... more >>

Joint Commission Seeks Your Input for a New Monograph

• 4/8/2010
• Author: Jim Parker
• 12444 Views
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This blog (and the newsletter itself) has covered the importance of influenza vaccines for health care workers.  However, we have to remember that influenza is not the only communicable disease from which health care providers and their patients need protection. The Joint Commission is currently looking for health care organizations of all types that are willing to share their experience... more >>

Listen!

• 3/20/2010
• Author: Jim Parker
• 13582 Views
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My nephew Joshua struggles with cerebral palsy. For the time being, he requires a wheelchair and other equipment just to get through a typical day. He is unable to perform many simple tasks that most of us take for granted. It is inspiring to observe the grace with which he meets these challenges.   Joshua needs a lot of health care. He is sick often, and even when he doesn’t have strep throat... more >>

Patient Safety Awareness Week

• 3/10/2010
• Author: Jim Parker
• 14273 Views
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This is Patient Safety Awareness Week, an annual observance designed to raise awareness of patient safety issues in the United States. This year’s theme underscores the critical importance of communication in providing quality health care: “Let’s Talk: Healthy Conversations for Safer Health Care.” Without quality communication, even the most perfectly executed technical skills and most advance... more >>

Nomination Season Begins for 2010 Eisenberg Awards

• 3/3/2010
• Author: Jim Parker
• 13927 Views
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The Joint Commission is now accepting nominations for the 2010 John M. Eisenberg Patient Safety and Quality Awards. Award submissions will be due at The Joint Commission by close of business April 12, 2010. The Eisenberg Awards recognize major achievements of individuals and organizations in improving patient safety and health care quality. The Joint Commission a... more >>

Educate Patients about Dangerous Drug Interactions

• 2/11/2010
• Author: Jim Parker
• 15278 Views
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In late January the Associated Press and other media outlets reported that 13 hospitals in California were fined for patient safety violations by that state’s Department of Public Health. Each fine was in excess of $25,000. The most frequently occurring violations, nearly 30% of the total, involved medication errors.   Although not every adverse event will receive the media coverage garn... more >>

New Sentinel Event Alert

• 1/29/2010
• Author: Jim Parker
• 15357 Views
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Be sure to read the new Sentinel Event Alert on preventing death during or after pregnancy, released by The Joint Commission on January 26. Published for Joint Commission accredited organizations and interested health care professionals, Sentinel Event Alert identifies specific sentinel events, describes their common underlying causes, and suggests steps to prevent future occurrences. Th... more >>

Look for our Special Vaccination Issue!

• 1/19/2010
• Author: Jim Parker
• 15403 Views
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The February issue of Perspectives on Patient Safety is our Special Vaccination Issue.   The issue includes an article about JCR’s successful Flu Vaccination Challenge, which promotes influenza vaccination among health care workers. (See my previous blog  for more details.)   The issue also features a discussion with Kristin L. Nichol, M.D., M.P.H., M.B.A.,... more >>

Happy New Year, readers!

• 1/6/2010
• Author: Jim Parker
• 16049 Views
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This time of year is one of reflection and re-evaluation for many people. This reflection often culminates in a new year’s resolution.  Many of these resolutions deal with health: losing weight, eating healthier, quitting smoking, getting more exercise, getting regular medical and dental check-ups and so forth.     Health care providers also make resolutions, and being who you are, you a... more >>

Remember: National Patient Safety Goals Become Effective January 1!

• 12/17/2009
• Author: Jim Parker
• 17356 Views
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Year’s end is approaching and in a few short weeks the 2010 National Patient Safety Goals will become effective!  Remember that if you have questions or concerns about how to interpret the goals, you can contact The Joint Commission’s Standards Interpretation Group (SIG) for help. Contact SIG at 630-792-5900, 8:30 a.m. - 5:00 p.m. (Central time).    You can also contact SIG by using this... more >>

JCR’s 2009-2010 Flu Vaccination Challenge Gaining Momentum

• 12/10/2009
• Author: Jim Parker
• 17373 Views
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Flu season is now in full bloom and I hope all our readers are weathering the storm, both in their roles as health care providers and as potential patients!    Of course, the most effective way to ensure that you, your patients, and your families are safe from influenza is to be vaccinated. Joint Commission standards require accredited hospitals, critical access hospitals, and long term care o... more >>

Joint Commission Launches Center for Transforming Healthcare

• 9/10/2009
• Author: Jim Parker
• 23247 Views
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Most health care organizations have come to recognize that medical errors are most often the result of a breakdown in a system.  In many cases, several system failures contribute to a single incident of patient harm. Along the way in those cases, multiple opportunities are missed for someone to notice the breakdown and prevent the error.   To address patient safety problems at their root... more >>

Get Your Flu Shot!

• 8/25/2009
• Author: Jim Parker
• 23783 Views
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Autumn is approaching. While many in the United States are bracing themselves for chilly winds and leaf raking, some are bracing themselves for what many experts say will be a particularly nasty flu season.   Part of the concern over this year’s influenza season is related to 2008-2009 H1N1 virus. H1N1 wrecked havoc in some locales, leading to closings of schools and businesses. To date, more ... more >>

Speak Up!

• 8/6/2009
• Author: Jim Parker
• 25212 Views
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Greetings readers!   Let me suggest to you a new and interesting resource that The Joint Commission is offering to your patients through its Speak Up!™ program. The newest offering from the Speak Up! Campaign is designed to help parents made better decisions regarding their children’s health care.   The new brochure is available in both English and Spanish.   The new brochure offers parents... more >>

New MDRO Resource

• 7/8/2009
• Author: Jim Parker
• 25968 Views
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Joint Commission Resources is offering a new free resource to help combat a serious patient safety threat: multidrug–resistant organisms (MDROs).   The new toolkit What Every Health Care Executive Should Know: The Cost of Antibiotic Resistance, is available for free download here.   The Joint Commission’s National Patient Safety Goal 07.03.01 requires accredited organizations to implement best pra... more >>

Stop on by!

• 6/18/2009
• Author: Jim Parker
• 26491 Views
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I am interested in knowing which of our readers will be attending The Joint Commission Annual Conference in September. I plan to be there all three days, September 14–16, at the JCR Publications booth and in the sessions, and I hope to meet some of you face to face. The conference has an exciting line-up of speakers this year, including Joint Commission President Mark Chassin, M.D.; Robert... more >>

The Cost of Cutting Corners: A Pound of Flesh?

• 6/17/2009
• Author: Jim Parker
• 26078 Views
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In a past life I did a great deal of reporting on occupational safety and transportation safety. During that time it became apparent to me that many people viewed safety measures as an expense, draining money away from their personal or organizational bottom lines.   What the data revealed, time after time, was that investing in safety was actually a cost saving measure. The cost of injuries and i... more >>

Organizations Share Their Stories

• 6/3/2009
• Author: Jim Parker
• 26825 Views
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We are wrapping up the July issue of Joint Commission Perspectives on Patient Safety in the next few days. I am excited about this issue because it includes two case studies of exemplary organizations that have made great strides in improving the safety of their patients.    •   Baptist Health Home Health Network is a multisite home health and hospice agency that serves 800 patients in the state o... more >>

Celebrate National Nurses Week!

• 5/12/2009
• Author: Jim Parker
• 27793 Views
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This week represents the nation’s annual “shout out” to the backbone of our health care system:  Nurses.    National Nurses Week is celebrated each year from May 6 (National Nurses Day) to May 12 (Florence Nightingale’s birthday). Sponsored by the American Nurses Association, the theme for this year’s observance is “Nurses: Building a Healthy America.” The theme focuses on the issues of nation... more >>

Perspectives on Patient Safety Gets a New Look!

• 5/8/2009
• Author: Jim Parker
• 28492 Views
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“And now for something completely different.”   Your friendly neighborhood Perspectives on Patient Safety staff are pleased to unveil the newsletter’s new look. Designed by our trusty project manager, Bridget Chambers, we think the new design not only looks smashing, but also enhances readability. Check out the new design in your June issue, which is heading your ... more >>

So .. how can I help you?

• 4/9/2009
• Author: Jim Parker
• 29754 Views
• 2 Comments
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Every morning … the same ritual.   I wake up, brush my teeth, don my wizard’s cap and stroll to the deepest dungeon where I gaze into my Pool of Immortal Mystery, which shows me all pressing patient safety issues of the day.   OK, so it’s more like seven cups of coffee, a stack of media reports, checking in with the editorial advisory board, some tea, reading medical journals and press release... more >>

The Score on Med Rec.

• 3/25/2009
• Author: Jim Parker
• 31058 Views
• 1 Comments
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Greetings!   The word is on the street:  For the remainder of 2009, Joint Commission surveyors will not be scoring National Patient Safety Goal 8, which addresses medication reconciliation.   During 2009, The Joint Commission is reviewing the goal language with a fine-tooth comb to ensure maximum clarity; they are consulting health care organizations, physicians, pharmacists, nu... more >>

The Potato Incident: Lessons Learned

• 3/17/2009
• Author: Jim Parker
• 31705 Views
• 5 Comments
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Greetings!   A recent experience I had with a health care organization got me thinking about infection control, leadership, patient empowerment, and the importance of a collaborative work environment.   It all began with a potato.   The humble tuber’s time had come.  My family and I were going to eat it.   But this potato would not go gently into that good night.  In the a... more >>

Patient Safety Week Blogs: Day 5, Health Care Worker Fatigue

• 3/9/2009
• Author: Jim Parker
• 32530 Views
• 11 Comments
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Greetings! Happy National Patient Safety Awareness Week! I'll be writing a new blog every day of this week, discussing a different patient safety topic. The fifth topic in this series is "Health Care Worker Fatigue." Listen carefully, clinicians, because I am only going to say this once:  My job... more >>

Patient Safety Week Blogs: Day 4, Patient Involvement

• 3/9/2009
• Author: Jim Parker
• 33323 Views
• 2 Comments
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Greetings!Happy National Patient Safety Awareness Week! I’ll be writing a new blog every day of this week, discussing a different patient safety topic. The fourth topic in this series is “Involving Patients in Their Own Care.”As I pondered how I should approach the subject of patients’ involvement in their own care, I had a visitor. A curly-headed friend of mine popped in and announced... more >>

Patient Safety Week Blogs: Day 3, Handoff Communications

• 3/9/2009
• Author: Jim Parker
• 39683 Views
• 9 Comments
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Greetings! Happy National Patient Safety Awareness Week! I'll be writing a new blog every day of this week, discussing a different patient safety topic. The third topic in this series is "Handoff Communications."  Sometimes the best way for health care providers to ... more >>

Patient Safety Week Blogs: Day 2, Hand Hygiene

• 3/9/2009
• Author: Jim Parker
• 32130 Views
• 2 Comments
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Greetings! Happy National Patient Safety Awareness Week! I’ll be writing a new blog every day of this week, discussing a different patient safety topic. The second topic in this series is “Hand Hygiene.” Attack of the Helping Hand is a 1981 short film starring h... more >>

Patient Safety Week Blogs: Day 1, Safety Culture

• 3/6/2009
• Author: Jim Parker
• 32027 Views
• 3 Comments
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Greetings! Happy National Patient Safety Awareness Week! I’ll be writing a new blog every day of this week, discussing a different patient safety topic. The first topic in this series is “Building a Culture of Safety.” Webster’s Dictionary defines “cult... more >>

The Blog is Back!

• 3/5/2009
• Author: Jim Parker
• 31252 Views
• 2 Comments
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Greetings! It’s been while since this blog was updated, and for that I apologize. The blog was on a brief hiatus while some technical issues were worked out. Those being resolved, I am pleased to tell you that the blog is returning to active duty.  Next week, March 8–14, is National Patient Safety Awareness Week. To cel... more >>

Greetings!

• 12/11/2008
• Author: Jim Parker
• 38097 Views
• 8 Comments
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My name is Jim Parker. Since March 2006, it’s been my privilege to participate in the sharing of critical patient safety information with the health care community through The Joint Commission’s Perspectives on Patient Safety newsletter.My professional background is in magazine journalism. Prior to joining Joint Commission Resources, I spent seven years covering pre-hospital emergency heal... more >>