Continuing Education »

Justin’s HOPE Project has partnered with #IHI again this year in providing yearly scholarships to the Institute for Healthcare Improvement Forum in Dec. 2013 in Justin’s name. We will select 3 beneficiaries making the total of 19 since we began this project in 2008. The applications will be available soon on the enrollment tab of the IHI Forum site for you to share with your colleagues. This is my favorite patient safety and education project providing real time medical education to 3 more health caregivers who may not have been able to attend, otherwise. Many, many thanks to IHI President and CEO Maureen Bisognano and her team!

Stay tuned for more info….

Patient Safety Update: Get the Basics on Preventing Adverse Events after Hospital Discharge from AHRQ’s PSNet »

Get the Basics on Preventing Adverse Events after Hospital Discharge from AHRQ’s PSNet 

Adverse drug events are the most frequent complication that patients experience after they are discharged from the hospital, according to a patient safety primer available on AHRQ’s Patient Safety Network (PSNet).  The primer provides background and relevant, research-based information to help hospital staff reduce the incidence of adverse events that cause readmissions. It suggests that hospital staff follow a systematic approach, including implementing an effective medication reconciliation program; communicating information about the patient’s medication changes, pending tests, and follow-up needs with outpatient physicians; and educating patients and families about their diagnosis and follow-up needs.

To access the full patient safety primer, titled Adverse Events after Hospital Discharge go to:
http://psnet.ahrq.gov/primer.aspx?primerID=11

The 9th Annual Paediatric Patient Safety Symposium »

Please attend the Paediatric Patient Safety Symposium to hear experts speak about, and for, children and improving their care. I will be participating in the strategic planning meeting.

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Summary

As leaders in paediatric healthcare, our goal is to deliver the safest quality care possible. Now into our 9th year, the SickKids Annual Paediatric Patient Safety Symposium is a one-day conference that brings together national and international experts to share leading practices and applied science. As always, our aim is to achieve a thought-provoking, relevant and scientific meeting to advance the cause of paediatric patient safety locally, nationally and internationally. The day will include a combination of plenary and breakout sessions as well as a poster session. 

Who Should Attend:

  • Frontline healthcare providers
  • Healthcare leaders
  • Quality, safety and infection prevention specialists
  • Researchers
  • Educators
  • Families

Learning Objectives
  • Identify and define the multiple components of a safety culture (e.g. fair and just culture; resilient culture; data-driven culture; patient/family-centered culture)
  • Describe how each of these cultures influences/impacts patient safety
  • Recognize how leadership, partnership and infrastructure can successfully transform an organizations’ culture to improve safety and the quality of healthcare more broadly.
Is there Humanity in Medicine?   There was a message on our answering machine when my husband arrived home for lunch break. He looked at the caller ID and immediately called me at work. He said that it was from the involved hospital and he didn’t listen to the call as he wanted me to hear it first. I called my daughter and told a few close colleagues. I was going to live in the moment for awhile. Could it be that they were changing heart?   The thoughts came barreling back with hesitance and gusto. WHAT DID THEY WANT?  Were they going to sue me for telling Justin’s story (many families carry umbrella insurance policies for this reason) or were they going to finally come clean over 12 years later? Leaving someone in limbo after an adverse medical event should be criminal. They finally wanted to make amends, we thought. They were ashamed and they wanted to make things right.   I had just finished writing commentary for a healthcare leader’s new book explaining that I was still waiting for this moment of compassion.   Wonder if they wanted to know, after all of these years, what could possibly help us close a bit and continue on with a better feeling about humanity in medicine. Would I invite them to our home for coffee and cake? What should I serve them? Hmmm   Would I invite the kids to the meeting? What would my husband tell them? He was excited, too. He said that he would attend as long as the CEO, who we had dealt with in the past, had left, and he had.   I think that I would show them Justin’s bedroom, somewhat still in tact. Would I ask them to clean it? Would I explain how he received the shelf full of trophies for BMX racing, bowling and basketball? Would I show them the signed memorabilia from his favorite sports teams or would I just walk them in and say, it’s been too sad to go through the school papers and projects and simply walk out. That was personal. I will do it when and if I’m ready.   I wondered if they would name a playroom after Justin or a patient safety program focusing on my work. Do they even know what I’ve done? They would help me save children’s lives.   My friend had surgery at that hospital a few weeks prior and was afraid to tell me “where” she was having the procedure but finally did with tears in her eyes and her head down. She wrote a letter to the hospital when she returned home about my work and why she was hesitant to tell me where her surgeon was doing the surgery. I thought that this note to the CEO had inspired them to finally call with an intention to make amends….and apologize. If anyone could make them become human, she could.   As an attorney stated at a conference where we presented together recently, “They will NEVER contact you, Dale.”  I couldn’t speak for the rest of the talk as she had crushed my hope and told the room full of health caregivers that that’s the way it is. If you permit, you promote and she was promoting secrecy, and I wasn’t going to be a part of that. So, I thought, HA!! They did contact me and they really do care. You were wrong!   When I shared this new development with friends, they simply stated that they thought that the hospital wanted to forget that Justin or I ever existed. They are heartless and archaic in their views of patient and family centered care, was their take. What ignited their integrity, finally? It could be nothing, I told them.   As we have all learned, everyone is not nice.   Well, I returned home thinking about it all day and gently pushed the button on the answering machine. I closed my eyes and took a deep breath.   This could be a healing moment or another roller coaster ride of emotions. I had hope.   It was my husband’s friend thinking that he had had a heart attack……he didn’t. He just wanted to talk while he was waiting. He is a hospital frequent flyer and never thought that it would be upsetting to us to see the location of his call. He could have used his cell.   So, my bubble burst again. The attorney and my friends were right. False alarm…. no heart but a good lesson in preparedness. The old pain is alive and well buried deep inside and easily uncovered always still waiting for a cure.   Why do we still have forgiveness in our hearts that we want to convey to this hospital that “cared” for Justin when they finally tell us the truth? What keeps us humane and keeps them evil? Why do we still wait with a very slight glimmer of hope?   A hospital is merely a building with brick walls and there are some new people there that want to look forward and are not worried about what happened 12 years ago. They don’t want to learn from the past failures. It wasn’t their child.

Is there Humanity in Medicine?

 

There was a message on our answering machine when my husband arrived home for lunch break. He looked at the caller ID and immediately called me at work. He said that it was from the involved hospital and he didn’t listen to the call as he wanted me to hear it first. I called my daughter and told a few close colleagues. I was going to live in the moment for awhile. Could it be that they were changing heart?

 

The thoughts came barreling back with hesitance and gusto. WHAT DID THEY WANT?  Were they going to sue me for telling Justin’s story (many families carry umbrella insurance policies for this reason) or were they going to finally come clean over 12 years later? Leaving someone in limbo after an adverse medical event should be criminal. They finally wanted to make amends, we thought. They were ashamed and they wanted to make things right.

 

I had just finished writing commentary for a healthcare leader’s new book explaining that I was still waiting for this moment of compassion.

 

Wonder if they wanted to know, after all of these years, what could possibly help us close a bit and continue on with a better feeling about humanity in medicine. Would I invite them to our home for coffee and cake? What should I serve them? Hmmm

 

Would I invite the kids to the meeting? What would my husband tell them? He was excited, too. He said that he would attend as long as the CEO, who we had dealt with in the past, had left, and he had.

 

I think that I would show them Justin’s bedroom, somewhat still in tact. Would I ask them to clean it? Would I explain how he received the shelf full of trophies for BMX racing, bowling and basketball? Would I show them the signed memorabilia from his favorite sports teams or would I just walk them in and say, it’s been too sad to go through the school papers and projects and simply walk out. That was personal. I will do it when and if I’m ready.

 

I wondered if they would name a playroom after Justin or a patient safety program focusing on my work. Do they even know what I’ve done? They would help me save children’s lives.

 

My friend had surgery at that hospital a few weeks prior and was afraid to tell me “where” she was having the procedure but finally did with tears in her eyes and her head down. She wrote a letter to the hospital when she returned home about my work and why she was hesitant to tell me where her surgeon was doing the surgery. I thought that this note to the CEO had inspired them to finally call with an intention to make amends….and apologize. If anyone could make them become human, she could.

 

As an attorney stated at a conference where we presented together recently, “They will NEVER contact you, Dale.”  I couldn’t speak for the rest of the talk as she had crushed my hope and told the room full of health caregivers that that’s the way it is. If you permit, you promote and she was promoting secrecy, and I wasn’t going to be a part of that. So, I thought, HA!! They did contact me and they really do care. You were wrong!

 

When I shared this new development with friends, they simply stated that they thought that the hospital wanted to forget that Justin or I ever existed. They are heartless and archaic in their views of patient and family centered care, was their take. What ignited their integrity, finally? It could be nothing, I told them.

 

As we have all learned, everyone is not nice.

 

Well, I returned home thinking about it all day and gently pushed the button on the answering machine. I closed my eyes and took a deep breath.

 

This could be a healing moment or another roller coaster ride of emotions. I had hope.

 

It was my husband’s friend thinking that he had had a heart attack……he didn’t. He just wanted to talk while he was waiting. He is a hospital frequent flyer and never thought that it would be upsetting to us to see the location of his call. He could have used his cell.

 

So, my bubble burst again. The attorney and my friends were right. False alarm…. no heart but a good lesson in preparedness. The old pain is alive and well buried deep inside and easily uncovered always still waiting for a cure.

 

Why do we still have forgiveness in our hearts that we want to convey to this hospital that “cared” for Justin when they finally tell us the truth? What keeps us humane and keeps them evil? Why do we still wait with a very slight glimmer of hope?

 

A hospital is merely a building with brick walls and there are some new people there that want to look forward and are not worried about what happened 12 years ago. They don’t want to learn from the past failures. It wasn’t their child.

Happy National Nurses Week 2013! Special thanks to all of the nurses that I’ve had the pleasure to meet and work with over the past year: Northeast Hospitals IHI Open School Chapter, Endicott College, North Shore Community College and healthcare system,  Salem State University in Massachusetts, NJHA, NJ Council of Teaching/Children’s Hospitals Partnership for Patients Medication Safety HEN Conference, Saint Barnabas NJ Medical Center New Resident Orientation Grand Rounds, Daytona Halifax Health General Surgery Residency Program Grand Rounds,  Arkansas Children’s Hospital Grand Rounds, the Institute for Healthcare Improvement Forum, The Task Force for Global Health, the One & Only Safe Injection Practices Campaign NYS, MHAUS, The Beryl Institute, PIPSQC, Hearts in Healthcare, nursing bloggers, tweeters and journalists, and all of the others that I’ve met along the way this year and the thousands that I’ve worked with in the past. Your dedication to your patients and staff is phenomenal and truly appreciated. May you find a peaceful place to take a moment and rest and know that you are warmly honored by the families that you work with daily more than you could ever know. 

Happy National Nurses Week 2013!

Special thanks to all of the nurses that I’ve had the pleasure to meet and work with over the past year:

Northeast Hospitals IHI Open School Chapter, Endicott College, North Shore Community College and healthcare system,  Salem State University in Massachusetts, NJHA, NJ Council of Teaching/Children’s Hospitals Partnership for Patients Medication Safety HEN Conference, Saint Barnabas NJ Medical Center New Resident Orientation Grand Rounds, Daytona Halifax Health General Surgery Residency Program Grand Rounds,  Arkansas Children’s Hospital Grand Rounds, the Institute for Healthcare Improvement Forum, The Task Force for Global Health, the One & Only Safe Injection Practices Campaign NYS, MHAUS, The Beryl Institute, PIPSQC, Hearts in Healthcare, nursing bloggers, tweeters and journalists, and all of the others that I’ve met along the way this year and the thousands that I’ve worked with in the past.

Your dedication to your patients and staff is phenomenal and truly appreciated. May you find a peaceful place to take a moment and rest and know that you are warmly honored by the families that you work with daily more than you could ever know. 

Dear Mr. [Ms.] Hallmark for bereaved moms:

Dear Mr. Hallmark,

I am writing to you from heaven, and though it must appear A rather strange idea, I see everything from here. I just popped in to visit, your stores to find a card A card of love for my mother, as this day for her is hard.

There must be some mistake I thought, every card you could imagine Except I could not find a card, from a child who lives in heaven. She is still a mother too, no matter where I reside I had to leave, she understands, but oh the tears she’s cried.

I thought that if I wrote you, that you would come to know That though I live in heaven now, I still love my mother so. She talks with me, and dreams with me; we still share laughter too, Memories our way of speaking now, would you see what you could do?

My mother carries me in her heart, her tears she hides from sight. She writes poems to honor me, sometimes far into the night She plants flowers in my garden, there my living memory dwells She writes to other grieving parents, trying to ease their pain as well.

So you see Mr. Hallmark, though I no longer live on earth I must find a way, to remind her of her wondrous worth She needs to be honored, and remembered too Just as the children of earth will do.

Thank you Mr. Hallmark, I know you’ll do your best I have done all I can do; to you I’ll leave the rest. Find a way to tell her, how much she means to me Until I can do it for myself, when she joins me in eternity.

(via Compassionate Friends Chapter)

Patient Safety Tip of the Week Archive »

Plethora of Medication Safety Studies via The Truax Group April 2013

“For the past several months we had been collecting some recently published studies on medication safety to include in our What’s New in the Patient Safety World column. However, there have been so many of them that are clinically relevant that we thought we needed to include them in one of our Patient Safety Tips of the Week where we discuss them in more detail. Hence, today’s column….”

PIPSQC News this Month

This month, PIPSQC is pleased to bring you “Partnering With Parents to Save Children’s Lives” by Dale Ann Micalizzi, PIPSQC Ambassador Lead, Pediatric Patient Safety Advocate and Consultant, Founder/Director Justin’s HOPE at The Task Force for Global Health. All are invited to comment on the PIPSQC Blog and explore the resources available throughout the website.

Now into its 9th year, the SickKids Annual Paediatric Patient Safety Symposium (June 13, 2013) is a one-day conference that brings together national and international experts to share leading practices and applied science. The day will include a combination of plenary and breakout sessions as well as a poster session.

To submit an abstract, please visit the Call for Abstracts page. To register for the conference, please click here: SickKids 9th Annual Paediatric Patient Safety Symposium

Sincerely,

The PIPSQC Executive Team
E: contact.pipsqc@sickkids.ca 
W: http://www.pipsqc.org/

Making the Case for Continuous Learning from Routinely Collected Data - Institute of Medicine »

“In “Making the Case for Continuous Learning from Routinely Collected Data,” the authors suggest that in order to achieve better health, patients and clinicians will need to view every health care encounter as providing an opportunity to improve outcomes. The paper cites widely-reported examples of routinely collected digital health data being applied to improve services, inform patients, avoid harm, and speed research. Developed by individual participants from the IOM’s Clinical Effectiveness Research Innovation Collaborative, it asserts that patients and the public are the most effective advocates for resetting expectations that their data be used to advance knowledge and support continuous learning. Citing examples of efforts to engage patients and clinicians in continuous learning efforts, the authors see broader application of these approaches as critical to ensuring the success of a learning health system in achieving better care, lower costs and improved health.”