• Why are kids dying at the dentist?

    Is pediatric dental anesthesia safe? Right on the homepage of the ADSA is a big box: “getting sedated at the dentist: there’s nothing to worry about”. Recent news, however, seems to contradict that statement. In Texas alone, there are at least 85 reported deaths of patients who died following dental procedures between 2010 and 2015. In these cases, anesthesia was reportedly administered by dentists with anesthesia training. But what is a ‘dentist anesthesiologist’? In the FAQ section of the ADSA website, they state “Anesthesia is administered by a licensed anesthesiologist, who was trained in a formal anesthesia residency program.” No wonder people are confused…

    Keep Reading
  • Twitter has changed. Meet the new 140 character rules.

    Twitter has made some changes to the 140 character limit. Specifically, they have changed the structure to exclude “prefix” and “suffix” data. Here’s how the new changes will impact your twitter stream:

    Keep Reading
  • Why is everyone so upset about the VA APRN proposed rule?

    The best outcome of research in healthcare quality and safety would be to make the practice of medicine and healthcare systems so safe and so good that we essentially make ourselves obsolete. Are we there yet? Some think so. Within the VA system, a new rule has been proposed: “expanding the pool of qualified health care professionals who are authorized to provide health care… without the clinical supervision of physicians” and “to exercise Federal preemption of State nursing licensure laws…regardless of individual State restrictions that limit such full practice authority”. Let’s look at the details…

    Keep Reading
  • Medical error is #3 cause of death – what does this mean?

    Recently, a paper written by researchers at Johns Hopkins and published by the British Medical Journal estimated that medical error was the third leading cause of the death in the United States. This received – as you might imagine – considerable coverage in the media. The researchers proposed that death certificates should include a qualifier or indicator that medical error was linked to the death, if in fact it was, so that better statistics could be obtained. I certainly can’t argue with the fact that we do not have good data about how frequently medical error occurs, or how frequently such errors contribute to serious disability or death. However, the paper also offered a case illustration which did show how un-illuminating the death certificate is, but in my view, did not actually demonstrate a preventable error.

    Keep Reading
  • How do academic physicians find the path to success?

    Are we (the establishment of academic medicine) doing a good job of providing mentorship to the next generation? What is the “path” or “formula” – is there one? Can we improve faculty development for those who have dedicated their professional careers to academic pursuits – those who will make the big discoveries and leaps forward in patient safety and quality healthcare? If you are an academic, I hope you’ll…

    Keep Reading
  • Collaboration in Patient Safety: SPA and AAP lead by example

    While I’m sure that all physicians and other healthcare professionals want to collaborate in order to achieve the highest quality of medical care and enhanced patient safety, the Society for Pediatric Anesthesia and American Academy of Pediatrics are really leading by example. They hold a jointly sponsored academic meeting, and I had the privilege of speaking at one of the plenary sessions this year on quality and safety. This was a very special invitation, since I am not a pediatric specialist. The meeting was designed to focus on topics of pediatric anesthesia and sedation, as well as pain management and critical care services for infants and children.

    Keep Reading
  • Nudging toward safer healthcare

    A nudge is a form of social engineering to help people make the best decisions by also making the easiest, laziest choices – the defaults – the “right” choice. Example of success stories include helping people to save for retirement, increasing organ donation status for people who want to be organ donors, and healthier food choices by school kids in their cafeterias – even when the unhealthy choices were still readily available. The nudge represents an untapped source of innovation in patient safety efforts. How can we apply this concept to healthcare? First, let’s look at some serious nudge fails:

    Keep Reading

Google+