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Finding someone usually a nurse to blame without looking at the underlying reasons an error was made. Failing to involve hospital leaders in fixing serious systemic problems. Changing a policy or educating staff without addressing necessary process changes.
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During an October 2003 survey conducted at Fort Lauderdale, FL-based Broward General Medical Center by The Joint Commission, surveyors recommended improvements with the organization's pediatric sedation process.
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The radiology lab at Newton-Wellesley Hospital in the Boston area has nearly cut the wait time for patients in half through the implementation of a Six Sigma process improvement initiative. What's more, the program has also saved the department more than $700,000 with increased efficiency.
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ThedaCare's Appleton (WI) Medical Center has cut its average length of stay by 20% and improved quality, safety, and patient satisfaction by transforming the way it provides care.
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Here are common mistakes made by organizations performing root cause analyses (RCA), with solutions offered by Claire Davis, vice president of quality at Norwalk (CT) Hospital:
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A woman pregnant with twins delivered her first baby without incident, but then experienced complications as she was in the process of delivering the second baby. The second baby was experiencing cord prolapse, and his heart rate plummeted. The physician continued to attempt to deliver the second baby vaginally for 10 minutes, but she eventually called for a cesarean. Fifteen minutes later, the baby was born and was diagnosed with cerebral palsy.
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The Government Accountability Office says that even though the Department of Health and Human Services (HHS) is undertaking a number of activities to pursue President Bush's goal for nationwide implementation of health information technology, it still has not developed a national strategy that defines plans, milestones, and performance measures for reaching the goal of interoperable electronic health records by 2014.
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The National Committee on Vital and Health Statistics (NCVHS) says the Department of Health and Human Services (HHS) should adopt a policy for the Nationwide Health Information Network (NHIN) to allow individuals to have limited control, in a uniform manner, over disclosure of certain sensitive health information for purposes of treatment.
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The State of Tennessee has expanded an existing contract with AT&T to provide the country's first statewide system to electronically exchange patient medical information.
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An 85% increase in the number of Internet hacker attacks on its health care clients has been reported by SecureWorks, a security-as-a-service provider. The company says attempted attacks have increased from an average of 11,146 per client per day in the first half of 2007 to an average of 20,630 per client per day in the last half of 2007 through January 2008.