Near miss to significant event.


I was trying to distill Nance to a few quick sentences and came up with:

Expect failure to achieve success

If you want peace, prepare for war

This is achieved via teams, not individuals

Attitude / culture and environment are paramount


Here are a few “open to anyone ideas” for QI / safety from the session 6/7

Rn activated protocols that allow them to dose OTC medications via a flow sheet for common issues such as pain, fever, sleep, allergic symptoms

Safety net system should have the capacity to analyze trends in the marco-data to identify themes / repeat event.

PCP initiative to increased number of advanced directives on file for their panel based on CAM scores to decrease uncertainty about wishes at end-of-life.

Video informed consents that present a visual, standardized model for the patients / family to improve understanding, evidence-based approaches and also allow them to generate question by watching numerous times. I think this may actually save providers time, not generate more work. I am considering trialing one for blood transfusions for my QI commitment.

Large hospital systems should generate a “second-opinion” network that is easily accessible to the public.


Will keep you all posted with more ideas from today’s session.