The Joint Commission just released its 2009 National Patient Safety Goals, and – no surprise – they focus on infection prevention. While this seems natural today, it wasn’t always so. In fact, the conflation of infection control and patient safety is one of the most surprising twists of the patient safety revolution. The inclusion – make that ...

This is one of the most commonly asked questions in IT World, and my answer has always been “CPOE first” – largely because that has always been David Bates’s (the world’s leading IT/safety researcher) answer. But I’ve changed my mind. Here’s why.Before I start, I promised that I’d let you know if I ever blogged on a topic in which I have a ...

Should doctors and nurses be subject to different penalties for precisely the same infraction? Of course not. Are they? Sure. Just ask Britney Spears.Britney was hospitalized at UCLA at least twice in the past few years – once when she gave birth to her first son in 2005, and again in early 2008 for psychiatric care. Both times, dozens of UCLA ...

In this month’s issue of the Joint Commission Journal of Quality and Patient Safety, I (with UCSF’s Adams Dudley and the American Hospital Association's Nancy Foster) tackle this provocative question. The answer may surprise you: yes (probably). The devil will be in the details.I hope you’ll have a chance to read the full article (the Joint ...

My friend Mark Smith, who runs the California HealthCare Foundation, once wryly observed, “Have you ever noticed that the doctors who talk about how much fun primary care is only practice it one afternoon a week?” I may have become the hospitalist version of Mark’s Ivory Tower internists, but I’ll take my chances.I just finished a two-week stint ...

Great quote by USC cardiologist Leslie Saxon (a reporter reached her on her cell phone as Leslie was shopping) on this week’s NEJM study on delayed defibrillation: “You’re better off having your arrest [here] at Nordstrom [than in a hospital]… because there are 15 people around me.”You’ve probably seen the study, a detailed analysis of ...

Let's make this short and sweet. In this week's New Yorker, Atul Gawande describes Peter Pronovost's crusade to improve the safety of intensive care through the use of checklists. If it sounds dull, it's not. In fact, it is thrilling and inspiring. Gawande glides effortlessly from microscopic detail to panoramic view and back again to help us ...

I had mixed emotions this morning when I heard that radio shock-jock Don Imus had returned to the airwaves. My 2004 interview with Imus was perhaps the wackiest experience of my life. It also made Internal Bleeding into a bestseller. Here’s the story:When Internal Bleeding came out, the book’s publicist, a lovely South African woman named Jeanine ...

Last year, I (with Peter Pronovost) wrote the toughest paper of my life – one that critiqued the Institute for Healthcare Improvement’s 100,000 Lives Campaign. This is the healthcare equivalent of criticizing both Mother Teresa and your local food bank in a single sitting (you can also read Don Berwick and his team’s response here). Although some ...

The first commandment of the modern patient safety movement was “Thou Shalt Not Blame.” Old-Think: errors are screw-ups by “bad apples,” and can only be prevented by some combination of shaming and suing the doctor or nurse holding the smoking gun. New-Think: errors represent “system problems;” any attempt to assess blame will drive providers ...