We all know that medical error can lead to significant patient harm. However, making meaningful decreases in such errors can be difficult, requiring fundamental system changes. Kaufman et al. (doi: 10.1542/peds.2011-2642), from Children's Hospital Colorado, demonstrate the opportunity, however, for decreasing errors by focusing on unplanned extubations. I was struck by the range of expertise among the authors of this study. The authors represented the Division of Cardiology and Epidemiology, and the Departments of Clinical Informatics, Quality and Patient Safety, Nursing, and Respiratory Therapy. I believe that without such collaborations, real system change will not occur. Fortunately, I have found that health care leaders, including Department Chairs and Hospital CEOs recognize the importance of such collaborations, which they now support (both morally and financially).
Tuesday, May 15, 2012
Posted by Dr. Lewis R. First at 12:01 AM