Serious safety events: Getting to Zero™

To advance the goal of Getting to Zero and eliminating preventable harm, ASHRM is providing guidance for defining, investigating, and measuring serious safety events. The first step in this process is the recommendation for a common and standardized definition. A common definition for a serious safety event facilitates timely detection, rapid action, and future prevention. This paper outlines that definition, provides a skill‐based model for investigation, and explains a clear plan for how to conduct the investigation. A measurement system is described to determine the frequency of SSEs and comparison methods to determine events prevented, potential lives saved, and methods to demonstrate financial loss control. These methods and approach are consistent with ASHRM's core values and mission, which is safe and trusted healthcare.     

ERM or ERM? That is the question!

I can answer the above question posed in the title of this issue's message with a resounding “Yes.” It is both ERM and ERM! Please allow me to translate this “Andyism.” ERM stands for both Enterprise Risk Management and “Everyone is a Risk Manager”—meaning risk crosses all boundaries throughout the healthcare enterprise; we all play an important role in keeping patients safe.     

Professional collaboration to achieve FASHRM and DFASHRM recognition

Members of the American Society for Healthcare Risk Management (ASHRM) are undeniably talented. They also share a spirit of volunteerism. Two ASHRM committees are fostering further member collaboration to provide individual growth, enhance educational offerings for members, and strengthen the organization's journal. Though 26% of ASHRM members have attained the CPHRM credential, only 2.5% of ASHRM members have attained a fellow designation. Primary barriers to attaining a fellow designation are the requirements for continuing education and contributions to the risk management field. The organization's Journal Editorial Review Board, in concert with its Annual Conference & Exhibition Committee, encourages members to explore opportunities to write for the Journal, speak at the annual conference, and attain one of the organization's professional designations. In addition, the Barton Certificate Program in Healthcare Risk Management promotes professional development with sessions taught on this topic for new and experienced risk managers.     

From To Err Is Human to Improving Diagnosis in Health Care: The risk management perspective

The publication of To Err Is Human in 2000, followed by Crossing the Quality Chasm in 2001, marked a watershed in patient safety. The Institute of Medicine (IOM) reports intensified the focus on patient safety and demanded a redesign of the healthcare system to improve quality and safety. Since publication of these reports, the focus has been on improving processes—those methods of healthcare delivery prone to failure and errors. Recently, there has been a concerted and sustained drive to add cognitive (diagnostic) errors to the focus. The recent publication of the IOM's Improving Diagnosis in Health Care has expanded the focus on patient safety and quality improvement. A new focus on diagnostic errors augments rather than replaces the previous focus. In this article, the authors offer a brief review of To Err Is Human and Crossing the Quality Chasm to lay a historical foundation. They then discuss a transition into the focus on diagnostic errors and summarize the latest recommendations from Improving Diagnosis in Health Care. This collated synthesis of 3 powerful IOM reports should guide risk managers and other healthcare personnel as they strive to improve every aspect of healthcare delivery.     

Perspectives on healthcare reform: A year later,what more do we know?

PPACA or the Affordable Care Act(1) was signed into law on March 23, 2010.(2) To many, the Affordable Care Act offers the promise of far greater access to high‐quality, affordable care. But to others, PPACA risks unsustainable cost increases, diminished freedoms, and irreparable harm to the world's finest healthcare delivery system. Which characterization will ultimately be proved correct? Or might the actual reforms surprise both proponents and skeptics? With a year of experience under our belts, it seems appropriate to ask: What more do we know about the new law, now?