Chasing Zero - Utilizing HIT to eliminate medical errors

[rninformatics, DNP, RN]

I know this is preaching to the choir but this is an excellent series presentation.

Chasing Zero

View a commentary aired recently on Discovery Health. DiscoveryChannelCME :: Continuing Medical Education

As you know, Dennis Quaid nearly lost his twins to a medication error. Through his experience and with several key individuals (Dr. Donald Berwick-IHI, Dr. Charles Denham-TMIT, Janet Corrigan, Phd-NQF, Carolyn Clancy, MD AHRQ, Lucian Leape, MD, Peter Pronovost, MD, Don Wright, MD, MPH, and political leaders) this broadcast was created.

It is a 4 part series that is dedicated to "Chasing Zero" by telling stories of the victims (both the families and health care providers) involved in serious medical errors. Many of these I am sure you have already heard of. Besides several patient stories and Dennis Quaid's story, stories from indicted health care providers Julie Thao, RN and Eric Cropp, Pharmacist are reviewed.

It highlights the weapons that enforce Chasing Zero and the "sweet spot of high performance and safe hospitals" as:

Leadership: Engaged leaders willing to boldly make changes

Safe Practices: Practices that work

Technology: Implement safe practices with great technologies that make it easier to be safe

This series confirms what many of us have been concerned about for quite some time. Besides leadership being tasked with boldy embracing a Patient Safety Focused Culture, we really need to embrace practices that are safe--no longer can we afford to wait many years to implement evidence-based practice. (Some of these proven safe practices are as simple as check lists.)

Not only that, it is even more important than ever to make sure that everything that nurses are doing is aimed at creating a safer environment for patients. Do nurses have the time to review evidence based practices? Do nurses have the time to exercise critical thinking? Do nurses have the time to provide the psychosocial support that is needed in order to foster patient and family trust and then give effective education that we know impacts patient satisfaction and participation in their own health care, length of stay and readmission rates?

When implementing new safety technologies (BCMA, CPOE, etc), is there a focus on workflow re-engineering to make sure that the technologies are used safely? It is well known that without close attention to workflow that work-arounds (many completely circumventing the safety of the technology) will be employed.

Excellent series. As Informatics Professionals lets all get a new sense of urgency to "Chase Zero"!!