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Author Archives: Daniel Cohen
Patient-Centeredness: What does this mean in Patient Safety?
In 2001 the Institute of Medicine, in its seminal publication Crossing the Quality Chasm, provided a practical definition of patient-centeredness; that being, “providing care that is respectful of and responsive to individual patient preferences, n
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Pitfalls in the Informed Consent Process – Candid Discussions of Risk
Accessing quality healthcare and exercising individual options for care are basic human rights. Information sharing, honesty and openness are elements of the informed consent process that facilitate the provision of safe care and serve to decrease l
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Causal Contributing Factors Grandparents… Parents… Children…
The usefulness of classifying patient safety incidents, the insufficient or failed processes that result in harm, lies in the identification and analysis of contributing or causal factors and the resultant learning, prevention of incidents and improv
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“Primum non nocere” – first do no harm
What we see....., Mr. Holmes observes!
When most of us think about patient safety incidents we tend to focus on harm related to specific acts of omission or system inefficiencies that result in harm to individual patients. We generally focus on ho
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Patient Safety Incidents – Clarity in Definitions Matters!
There is a conundrum in patient safety incident classification that arises because of conflicting opinions regarding just what is or is not an incident! The primary reason for adverse event reporting is to identify learning opportunities and preve
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“Never Leave Your Wingman” – Mentoring for Safety
Healthcare education is about mentoring and generally this means that more experienced clinicians provide top-down mentoring necessary to mould young men and women into the professionals our patients deserve. This mentoring model has been sustained f
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Systems Thinking – We are not planes nor pilots
Healthcare safety monitoring and improvement strategies have often been compared to other industries and found to be lacking. Our profession is often compared to the airline and nuclear energy industries and even with the automotive industry. In many
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Talking to Patients about Adverse Events
Caring for patients is fraught with danger. Every time we stand at the bedside we bring benefits but also risks. Problems with our systems of care and personal lapses from a range of human factors often result in harm, preventable harm. Healthcare
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The Human Connection – What’s hand-washing got to do with it?
I have always washed my hands in front of patients, always; and I’ll tell you why. Part of the reason is to prevent infection, but mostly it has to do with humility and the deeply human connection I want to convey to patients. I want to be safe,
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The Communication Conundrum and Patient Safety
Communication inefficiencies have been identified as common causes of patient safety incidents and harm. Simple solutions exist to address communication failure but are not consistently utilized in healthcare settings. Why this is may have more to do
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