Lessons Learned

How Effective is Your Causal Analysis Process?

Although performing a root cause analysis (RCA) after an adverse event has become standard practice in many health care organizations, there is little evidence to support that this process has improved patient safety.1 Organizational culture plays a large part in the success of an RCA; there are fundamental issues in the structure of the RCA process to address as well.


Annie’s Story: How a System’s Approach Can Change Safety Culture

In an era dependent on technology to make our lives easier, patients continue to suffer from severe complications with medical devices. While the FDA monitors problems associated with medical devices, some devices require thoughtful design and sufficient research before the devices are rushed to market. As part of the research, such devices require a close look at how they work within a system. Some devices receive the proper research1 after it is made publicly available, when end users unintentionally go through a trial-and-error phase.


Small Bore Connectors June 2014 Update

International standards are currently in development for:

  • 80369-7 “Luer” connectors: IV and hypodermic applications
  • 80369-3 “Enfit” connectors: enteral applications (e.g., feedings)
  • 80369-6 connectors: neuraxial applications
  • 80369-2 connectors: breathing and driving gas applications
  • 80369-5 connectors: limb-cuff inflation systems

The January 2016 California deadline applies to IV applications, enteral feeding, and epidural uses. The first three of the above standards are relevant to this deadline.

The Luer connector standards will tighten current specifications, so that fewer connector problems (e.g., leaking junctions) will be encountered in IV applications. Otherwise, the Luer standard has not significantly changed, and end-users should not notice any differences.


Requirements for High Reliability
From QA to QI

In my last column, I discussed the critical role of leaders in shaping organizational culture.  Here we take the next step and look at the requirements for achieving high reliability. Given high rates of adverse events, process failures and patient harm, the idea of achieving high reliability in healthcare may seem absurd. Even so, many well-respected healthcare leaders have sounded the clarion call to make this the primary goal.