Preventing medication errors often means using checklists and leveraging technology. But implementing these seemingly simple tools requires interdisciplinary teamwork, learning, and a commitment to ongoing verification that the process is working. Clinical operations nursing director Joy Lombardi describes how Huntsman Cancer Institute made chemotherapy highly reliable.
Changing practice is personal. It doesn’t happen through edict or mandate. Changing practice requires ongoing respectful dialogue. It requires clear vision, data-driven analysis and the support of a dedicated team. Changing practice takes longer that you think it will. In this example, we recognize the power of a partnership in this challenging and important work.
General Surgery resident Josh Bleicher spent a year exploring opioid prescribing patterns in patients discharged after elective surgery. What did he find? We need a more patient-centered approach to opioid prescribing.
A missed diagnosis can delay treatment or result in inappropriate treatment, causing unnecessary pain, suffering, and often financial hardship for our patients. Internist and hospitalist Peter Yarbrough helps explain why diagnostic errors happen with strategies to prevent them.
When health care is designed around patient needs, it doesn't just benefit the patient — it can also help providers find fulfillment in their work. But what does that look like in practice? Physician Joy English opened the Orthopaedic Injury Clinic, an innovative service that delivers better value to patients. Her success is a case study in how to achieve both provider and patient happiness.
Medical errors often occur due to system failure, not human failure. Hospitalist Kencee Graves helps explain why we need to evaluate medical error from a system standpoint.
Biometric identification is a national best practice — but adapting that to a local environment isn’t easy. Although it’s rare, confusing an identity can have scary consequences (like getting a prescription for a drug you’re allergic to.) So Doug Ostler and his team worked to implement palm scanners and make patients feel safer.
Utah's value engineers turn any real-world event into a cause for improvement. Recently, senior value engineer Will McNett and a friend were swept up in an avalanche, traveling 50 yards down the southeast face of Albright Peak in Grand Teton National Park. What many would consider terrifying, Will considered a cause for observation, investigation, analysis, and improvement.
Is zero possible? In the case of central line infections, the answer was once no. A CLABSI (central line associated blood stream infection) was once considered a car crash, or an expected inevitability of care. When University of Utah’s Burn Trauma Intensive Care Unit started treating CLABSIs like a plane crash, or a tragedy demanding in-depth investigation and cultural change, zero became possible.
Delivering a great health care experience is only possible with one crucial component: reliable scheduling. It’s such an essential part of efficient operations, in fact, that the University of Utah Health created an access optimization team to help providers across the system.
Engineer Cindy Spangler compares canyoneering and surgery and identifies a common thread: the need for high-reliability processes. She describes how surgical time-out, a quick huddle to debrief before surgery, can serve as a useful model for reducing the risk of harm in canyoneering.
Using improvement methodology to solve one piece of America’s opioid epidemic. Dr. Sean Stokes and team used the practice of scoping to focus on one population and one procedure to achieve manageable, measurable improvement.
