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Ironically, the fifth wrong-site surgery occurred at Rhode Island Hospital as it continues working with The Joint Commission's Center for Transforming Healthcare on improving surgical protocols. The hospital volunteered for the project to improve the safeguards to prevent patients from undergoing wrong-site, wrong-side, and wrong-patient surgical procedures.
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When the same "never event" happens five times in two years at the same hospital, something is terribly wrong. Risk managers and patient safety experts are aghast at the reports coming from Rhode Island's largest hospital and wondering what it means about the culture of that institution and the state of patient safety efforts across the country
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The economy may be struggling, but Healthcare Risk Management's Salary Survey indicates that income for health care risk managers is generally on the upswing.
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With so much focus on health care these days reform, malpractice, and never events on everyone's mind risk managers are uniquely situated to influence the debate and display their value to employers.
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News: A man with a history of suicidal ideation was involuntarily admitted to the hospital. The next day, the man was transferred to an acute care psychiatric facility and placed on 15-minute observation status by the on-call physician.
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Lean management is a big trend in the business world these days, including the health care arena, but risk managers may assume that the "lean" is all about budget cutting and belt tightening. Not at all, say the experts in this strategy and the health care providers who are using it.
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The string of wrong-site errors at Rhode Island hospital may be attention-getting, but the hospital is not the only one experiencing this never event. An identification error led to a pregnant woman undergoing a CT scan intended for another patient at Banner Thunderbird Medical Center in Glendale, AZ, which is now prompting litigation.
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"We're all glad it's pretty much over," Margaret VanAmringe, MHS, The Joint Commission's vice president for public policy and government relations, says with a laugh.
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With the ever-growing focus on transparency, hospitals are demanding more from quality improvement professionals. When Paul L. Green, RN, MS, CPHQ, started his career in health care, QI professionals ran data and filed them away.
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Replacing the core measure set for pregnancy and related conditions, which comprised three measures, The Joint Commission has introduced a core measure set on perinatal care, with data collection beginning with April 1 discharges.