Groups   |   Careers   |   Sign In   |   Join Now
Search our Site
Patient Safety Blog
Blog Home All Blogs
The Patient Safety Blog has ceased publication but you can still read patient and workforce safety related posts on the IHI blog at Be sure to find us there. And thanks for visiting.


Search all posts for:   


Top tags: ASPPS Member Spotlight  2016 NPSF Congress  Voice of the Patient  ASPPS  burnout  culture  2017 Patient Safety Congress  Ask Me 3  communication  Leape  med errors  overtreatment  Stand Up for Patient Safety  transparency  workforce safety  health literacy  infection  leadership  opioids  patient advocate  patient safety research  RCA  undertreatment  2016  antibiotic resistance  apology  Boothman  Campbell  CDC  children's hospitals 

Leadership, Culture, and Patient Experience Take Center Stage

Posted By Administration, Thursday, September 24, 2015
Updated: Thursday, September 24, 2015


     Afternoon keynote speaker Dr. Skip Campbell
A video tribute to Dr. Lucian Leape
kicked off the evening program.

    Dr. Sands (left) with panel participants (from left): Dr. Richard Whyte;
Dr. Pat Folcarelli; Mary Fay, RN; Jeff Catalano, Esq.;
and Nancy Watson, JD.


The 8th Annual NPSF Lucian Leape Institute Forum & Keynote Dinner touched upon issues that are the keys to moving the patient safety agenda forward.

by Patricia McTiernan, MS


Would your hospital allow a news reporter to follow along as the leadership team conducted WalkRounds? What does your hospital do to provide support to clinicians involved in medical errors? Would you ever hesitate to recommend your physician or hospital to a friend or loved one?


These questions may not come up in day-to-day patient safety work, with its focus on numbers, data, protocols, and checklists. But they are among the thoughts provoked by the presentations at this year’s NPSF Lucian Leape Institute Forum & Keynote Dinner, held in Boston last week. Leadership, culture, patient experience, and workforce safety took center stage as the event’s presentations demonstrated the value of transparency in health care and the importance of leaders in influencing behavior within our health care organizations.


The Institute’s most recent report argues that greater transparency in health care – at all levels – can fuel better, safer care. With that report as the backdrop, Dr. Darrell “Skip” Campbell shared experiences from his work as a surgeon, researcher, and chief medical officer as well as from his current role as director of the Michigan Surgical Quality Collaborative.


Dr. Campbell pointed to research that showed that staff who had participated in Leadership WalkRounds were more likely than those who had never participated to say they would speak up when faced with a potential or actual medical error. During his time at University of Michigan Health System, Dr. Campbell was so confident in the promise of WalkRounds to drive improvement, he invited a news reporter to observe the ritual.


In his role as director of MSQC, Dr. Campbell works on a different level of transparency—between providers. MSQC is certified by the Agency for Healthcare Research and Quality as a patient safety organization and is made up of 73 member organizations across the state that agree to share data on surgical outcomes and not compete on safety.


MSQC works to identify top performers through the analysis of data; visits them, talk to them, and figures out what it is that they are doing to achieve the good results; and then distributes that information to the other members. One of their early successes has been a state-wide decrease in surgical site infections after colectomy.


Back to top

Breakout Knowledge

Dr. Gary Kaplan, chairman and CEO of Virginia Mason Health System and chair of the NPSF Lucian Leape Institute noted in his opening remarks that there are challenges and opportunities around the issue of transparency, as well as significant barriers. The Institute’s current focus is on translating its recommendations into action.


In breakout sessions, forum attendees discussed these issues. Rick Boothman, JD, chief risk officer at University of Michigan Health System and a member of the NPSF Board of Directors summarized the key points of consensus from the groups:

  • The single biggest area of concern is leadership’s role and the widespread failure to set expectations to create and support a safety culture.
  • Education is valuable, but it needs to be done correctly and embedded in the organization’s behavior.
  • Transparency can be powerful tool, but it needs to be used responsibly, with data that make sense and are delivered in useful ways.
  • There is a lack of appreciation for engagement by boards of directors in the issue of patient safety; board education on the issue is needed.
  • Provider-to-provider sharing of data and information is difficult to achieve, but is essential for progress.
  • Everyone in the organization needs to support the core mission of patient and workforce centricity – whether they are a housekeeper or a lawyer.
  • Information without action is not productive. It is the responsibility of the person reporting substandard care to be accurate, fair, and thorough, and the responsibility of the receiver to listen and understand the problem with the goal of fixing it if possible.

Where Does Apology Come In?

The afternoon concluded with an overview of the Massachusetts Alliance for Communication and Resolution following Medical Injury (MACRMI) and a panel discussion featuring staff of Beth Israel Deaconess Hospital in Boston, an organization that helped pioneer the MACRMI roadmap to respond to adverse events and suspected medical errors.


Dr. Alan Woodward was instrumental in starting MACRMI in 2005, when he was president of the Massachusetts Medical Society. “We were beating our heads against the wall with tort reform,” he said. “But we wanted to do something about patient safety.” He met with Rick Boothman at the University of Michigan, and eventually formed an alliance of hospitals in Massachusetts. Dr. Kenneth Sands, chief quality officer of Beth Israel Deaconess, served as principal investigator of MACRMI’s study, funded by the Agency for Healthcare Research and Quality, to identify the major impediments to apology and disclosure and strategies to overcome them. This work led to the MACRMI roadmap, known as CARe—communication, apology, and resolution following medical injury.


Dr. Woodward described CARe as a proactive process to review the case, advocate for the patient’s medical needsand if the injury was found to be avoidable, their financial needs—and to render appropriate apology, which he said, "is therapeutic for both clinicians and patients.”


Dr. Sands facilitated a panel discussion of a case that was handled through the CARe process. In the case presented, a communication breakdown led to a delayed cancer diagnosis. Speaking via a video, the patient explained that she found out she had cancer only after persisting in telling her doctor that something wasn’t right after her gallbladder surgery. “Patients shouldn’t have to figure this out for themselves,” she said.


In an important part of the process, the patient met with the vice chair of the department of surgery, who explained what happened and how, and what the organization was doing to prevent it from happening again.


Pat Folcarelli, RN, PhD, director of patient safety at BI Deaconess said that “physicians usually leave such a meeting feeling very positive. We prepare them beforehand, [telling them] that it is a critical meeting to communicate openly about what happened. Despite anxiety, most leave thinking they’ve been given a gift in terms of interaction with the patient and family that they hadn’t had before.”


Back to top

Making It Personal

Dr. Jonathan Perlin, the evening keynote speaker, began his talk, "To Care Is Human," by asking the question, “Would you ever hesitate to recommend your physician or hospital to a friend or loved one?” A former, long-time member of the NPSF Board of Directors, current chair of the American Hospital Association, and chief medical officer of Hospital Corporation of America, Dr. Perlin argued that patient safety and patient experience go hand-in-hand. He told four patient stories, each through the lens of the HCAHPS survey (Hospital Consumer Assessment of Healthcare Provider and Systems).


Would you ever hesitate
to recommend your physician or
hospital to a friend or loved one?

Two of the cases involved breaches of hand hygiene. In one case, the patient, a retired nurse, did not speak up to the anesthesiologist because she knew “for the next four hours, my life would be in his hands.” In another case, speaking up to a clinician about hand hygiene led to a rebuke about how “disruptive visitors can be asked to leave.”


Apart from noting that the most common mode of transmission of pathogens is via the hands, and that there are roughly 80,000 hospital acquired infections each year, Dr. Perlin also fixed on the patient’s perceptions: how would those patients respond to HCAHPS survey questions such as “Would you recommend this hospital?” and “How would you rate the nurses’ response to concerns or complaints?”


A noted expert in health information technology, Dr. Perlin suggested that better use of data could also help providers improve care and safety. “If each of us read two articles per night, we’d only be behind by 10,000 articles,” he said. “Care informs care.” More effective use of the digital records we are creating can be part of a learning health system.


Making it personal, Dr. Perlin concluded by saying that each patient he had discussed was a member of his own family. “Patient experience isn’t just about being nice,” he said. “Patient safety is inextricably linked to patient experience. It involves culture and leadership, with the patient at the center.”

Have you done work to improve the culture or the patient experience in your organization? Comment on this post below. Note: to post a comment you must be logged in. Register or log in.

About the Author: Patricia McTiernan, MS is assistant vice president for communications at the National Patient Safety Foundation and editor of the P.S. Blog. Contact her at

Back to top

Tags:  apology  Boothman  Campbell  communication  culture  Gandhi  Kaplan  leadership  Leape  Sands  transparency 

Share |
PermalinkComments (0)

Getting the Right Care, Every Time

Posted By Administration, Wednesday, September 2, 2015

Right Care Action Week Is October 18-24


Almost 20 years ago, the Institute of Medicine (IOM) targeted the overuse of health care services as a potential source of patient harm. An IOM consensus paper on health care quality attributed many problems in health care to overuse, underuse, and misuse of services, with overuse defined as “a health care service [that] is provided under circumstances in which its potential for harm exceeds the possible benefit.”


Since then, several efforts have been undertaken to raise awareness of unnecessary care—and the potential harm it affords. For example, the Choosing Wisely campaign, an initiative of the American Board of Internal Medicine Foundation, was started to promote conversations between patients and their health care providers about whether treatments and tests are truly necessary, not duplicative of other tests or treatments, and supported by evidence.


The Lown Institute, meanwhile, has taken on the issue of overtreatment and undertreatment as a major focus of its work and a priority issue. In a recent Health Affairs piece, the leaders of the institute highlighted how little research has been done into overtreatment in medicine.


Next month, the Lown Institute is leading Right Care Action Week, October 18-24, to raise awareness of the importance of the appropriateness of care for each individual patient.


The Lown Institute encourages organizations to develop programs and activities to fit their local community’s needs. To get involved in this effort, visit the website and commit to take action during that week to help result in better, safer, more appropriate care. For example:

  • Direct patients to the Ask Me 3 video on our website. Asking questions can help patients become more engaged in their care, more knowledgeable about their health conditions, and better able to follow treatment plans.
  • Report a case where overuse or underuse of services presented a safety issue. Currently, few safety reports are related to overuse and the risks of unnecessary care. As you become more aware, think about speaking up to prevent harm.
  • Visit the Right Care Action Week website to find out what others are doing or to share your own ideas.

NPSF is encouraging members of our community mark the week by taking action to help ensure the right care for everyone. We hope you’ll take part. 


Comment on this post below. Note: to post a comment you must be logged in. Register or log in.

Tags:  overtreatment  undertreatment 

Share |
PermalinkComments (0)

Burnout as a Safety Issue: How Physician Cognitive Workload Impacts Care

Posted By Administration, Monday, August 24, 2015
Updated: Monday, August 24, 2015

Chronically high levels of physician distress are creating a dangerous practice environment. Interventions to help reduce clinician burnout need to occur at multiple levels to make our health system safer. 

by Michael R. Privitera, MD, MS; Franziska Plessow, PhD; and Alan H. Rosenstein, MD, MBA


The stressors that cause burnout may vary from profession to profession, but the human condition that results is common to all. Burnout is defined by three factors:

  1. Physical and emotional exhaustion despite attempting to rest
  2. Depersonalization including dysfunctional coping mechanisms, cynicism, sarcasm, and compassion fatigue
  3. An objective and/or subjective lack of efficacy

Burnout is a frequent phenomenon across many health care professions, including nursing, medicine, pharmacy, social work, and other roles. Research on physician burnout shows lower levels of patient satisfaction, job satisfaction, and productivity; higher levels of medical errors, malpractice claims, leaving medicine, and early retirement; and higher personal levels of depression, heart disease, suicide, divorce, and substance abuse.


The average burnout rate among doctors in the US has been estimated to be 46%, while only 2% to 4% of physicians are disruptive in the workplace. In many cases of disruptive behavior, burnout from high chronic occupational stress has been found, suggesting a direct relationship between the two. The Joint Commission has issued a sentinel event alert warning that disruptive behavior can compromise patient safety and foster medical errors.


The biopsychosocial model was coined by George Engel to encourage consideration of biological, psychological, and social contributions to and consequences of clinical conditions. Applying this approach, we can see commonalities in cause and inter-relationships between physician burnout, altered safety of medical decision-making, and disruptive behaviors. Social components (health care reform environment, consequent occupational stress when unharmonized and uncoordinated) interact with psychological (rationality in decision-making, emotional control) and biological aspects (intrinsic biology of the physician and changed biology of their body from chronic high levels of stress), which then impacts the community that needs sufficient health care workforce to take care of patients.

back to top


Many national, state, government, insurance company, and regulatory agencies separately make mandates that affect the workflow of the physician. However, there is no central agency that oversees their coordination, let alone the harmonizing of these multiple mandates. While expected, it is not known whether full compliance with all mandates is possible.



Patient: 60-year-old male smoker, new patient to the practice with headache, fatigue, and disturbed sleep, comes in to see a hyper-stressed, burned out physician for a 20-30 minute slot. BP 148/92 Pulse = 96.


Physician behavior: The physician acts based on habit memory, i.e., reflex reactions, hyper-focuses on one symptom—sleep—instead of required cognitive flexible memory involved in pros and cons analysis. Regulatory demands require the physician to counsel on stopping smoking, make sure all Meaningful Use criteria are checked and reviewed, complete new patient history form, populate problem list, cover alcohol and drug use, immunization, preventive measures, and send for old record.


Resulting treatment: Sleep medication with refills, low sodium diet, return visit in 6 months for full physical.


What was missed: Major depressive episode. Insomnia was only one of the symptoms. Patient had suicidal ideation, intent, and plan to kill himself. As a result of poor functioning from his depression, he was about to lose his job. The physician missed the patient’s increased risk of stroke and heart disease from his major depressive episode especially in combination with smoking.


Lack of coordination to unify and simplify health care regulation and mandates draws the physician’s limited cognitive resource away from the intrinsic load being used to solve the clinical problem presented by the patient. The trouble is that no one would argue or attempt to push back when something gets labelled as a “quality” intervention due to the so-called halo effect. The halo effect is a cognitive/confirmation bias where positive feelings get generated toward something ambiguous or unproven. In this case, a quality initiative may lose closer scrutiny to potential impact just because it has the term “quality” attached to it (e.g., a person is wearing a halo, thus this person must be good).


   "We as a health care system
need to be concerned about
how much occupational stress
we are imposing on physicians
and other health care professionals
from extraneous cognitive load."

Chronically high levels of physician distress are creating a dangerous practice environment. The irony is that a portion of this distress comes from uncoordinated, unharmonized, and sometimes unproven “quality measures,” which by accumulation actually may be humanly impossible to attain and may even cause harm. Cognitive processes that occur because of excessive stress can lead to medical errors. This neurocognitive issue can be identified as a neurocognitive ergonomic (NCE, sometimes referred to as neurocognitive engineering) problem and is solvable by incorporating NCE principles with new initiative roll outs. Ergonomics is the applied science concerned with designing and arranging things people use so that the people and things interact more efficiently and safely (also called biotechnology, human engineering, human factors). Neurocognitive ergonomics applies ergonomic principles that use knowledge of brain function and thinking processes to lower cognitive strain and improve efficiencies.


We as a health care system need to be concerned about how much occupational stress we are imposing on physicians and other health care professionals from extraneous cognitive load. Our society has made the connection between cognitive workload and the safety of recipients of services in such professions as nuclear power workers, air traffic controllers, airline pilots, and others. It is becoming clear that physicians, nurse practitioners, physician assistants, and nurses need to be on this list for both their own and the patient’s safety.

back to top


Burnout is both preventable and reversible, which gives us an opportunity to provide support on two levels:

  1. The individual level, by promoting clinician’s physical and mental health
  2. The institutional level by decreasing sources of occupational stress through improved design, improving efficiencies of workflow, finding ways as an organization to reduce administrative burden on clinicians, and allowing bottom-up input in decisions that affect the practice environment

Urie Bronfenbrenner describes an ecosystem model that is relevant to conceptualizing the health care ecosystem. Various levels interact with each other and create feedback systems affecting the other levels:


a) Macro-level—national, state, insurance industry level decisions
b) Meso-level—health care system level decisions
c) Micro-level—individual physician and patient interaction in delivery of care
d) Exo-level—the interaction of physician with his or her family and with others in the community.


Interventions to help reduce burnout need to occur at all four levels to help more rapidly reduce the extent of burnout that exists.


In summary, there are certain things that we cannot take away from the cognitive workload of physicians that are intrinsic and germane to the practice of medicine. What we can change (by better design) is to be very careful and parsimonious about administrative, mandate, and regulatory demand. (See Table 1 below for suggestions for safer implementation of innovations in health care.) We can do a better job of being clearer and selective about what the essential and relevant quality issues are, what should be universally used, and what should be only indicated by the clinical situation, especially when implementing innovations in the health care system. We need to bear in mind the physical, emotional, time, and cognitive limitations that humans (who happened to be trained as physicians) have. In doing so we will be improving the safety of our health care workforce, which then is inextricably linked to the safety of our patients.

back to top


Table 1

Suggested Questions for Safer Implementation of Innovation in Health Care:

  1. Is there evidence that what we are suggesting as a new innovation in healthcare delivery—by itself—does not cause harm and in fact creates enough benefit to be worth the risk of imposing it on a currently time-challenged, overburdened, and burned-out healthcare workforce?
  2. Has the new innovation in delivery accounted for existing demands on the physician plus any new demands put upon them by other agency new innovation demands?
  3. Has there been sufficient collaboration between authoritative agencies with each other and the front-line providers of care, being respectful of each other’s concerns and intentions?
  4. Are there built in fail-safe mechanisms with the innovation to allow for mid-stream corrections in course? This requires the implementation of the suggestions in Question 3.


Conceptual Issues for Discussions:

  • Awareness of down-steam consequences that occur by accumulation of unharmonized duties
  • Efforts to assess and recognize potentially negative impact on delivery of physician services before policy decisions are agreed upon
  • Efforts for stakeholder agencies to better coordinate plans and logistics
  • Need for health care organizations to provide sufficient resource services (career/ business/ administrative/ clinical/ behavioral) to lower occupational stress and Burnout of physicians by assisting them with innovation rollout and ongoing operations
  • Are there ways in the meantime to have authoritative sources of mandates and regulations to attempt a collaborative effort? The goal would be to pare down the total cognitive load on the physicians to a safer level

Have you participated in any efforts or programs to reduce burnout among physicians and other health professionals? Comment on this post below. Note: to post a comment you must be logged in. Register or log in.

About the Authors:

Michael R. Privitera, MD, MS, is professor of psychiatry and director of the Medical Faculty and Clinician Wellness Program at University of Rochester Medical Center, Rochester, NY.

Franziska Plessow, PhD, is with the Berenson-Allen Center for Noninvasive Brain Stimulation, Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston MA.

Alan H. Rosenstein, MD, MBA, is an educator and consultant in health care management based in San Francisco, CA. Submit correspondence about this article to Dr. Privitera at

Tags:  burnout 

Share |
PermalinkComments (0)

NPSF Lucian Leape Institute 'Must Do' List

Posted By Administration, Friday, August 21, 2015

Writing for the NPSF Lucian Leape Institute, Dr. Bob Wachter authored an article on the Health Affairs blog calling for greater accountability among clinicians for certain practices that have been shown to increase the safety of care and improve outcomes.


Dr. Wachter and the Institute members believe, he wrote "it is time to require that clinicians follow certain well-established safety practices." Calling it the beginning of a "Must Do" list, Dr. Wachter cited hand hygiene and influenza vaccination of health care workers as "two evidence-based, relatively inexpensive, and highly effective practices."


The post acknowledges the importance of a Just Culture in health care and the -- usually -- appropriate emphasis on systems as a cause of error or adverse events. Yet willful disregard for established policies, the Institute members believe, can no longer be ignored.


Dr. Wachter specified the criteria to be considered for an action or practice to be added to the 'Must Do' list:

  1. The patient safety problem that is being addressed is important.
  2. The practice has been demonstrated by research or expert consensus to be effective in reducing harm.
  3. The impact of compliance with the practice is substantial, i.e., a significant number of patient harms would be prevented.
  4. Universal compliance with the practice, and auditing such compliance, is feasible for clinicians, health care organizations, and accreditors.
  5. The practice has been accepted as a standard by the National Quality Forum, relevant specialty societies, and by broad professional consensus.

Read the full article on the Health Affairs website.

What would you add to the 'Must Do' List? Comment on this post below. Note: to post a comment you must be logged in. Register or log in.

Tags:  Leape  med errors  Wachter 

Share |
PermalinkComments (0)

Environmental Factors That Contribute to Falls

Posted By Administration, Wednesday, August 5, 2015
Updated: Wednesday, August 5, 2015
An interview with Debajyoti Pati, PhD, recipient of an NPSF Research Grant for a study of extrinsic factors associated with fall risk, specifically design elements of hospital rooms and bathrooms.

According to a 2013 publication from the Agency for Healthcare Research and Quality, falls are the most frequently reported incident in adult inpatient hospital units, and 30% to 51% of falls result in some injury. Prior research into contributing factors has largely focused on intrinsic factors, such as patient-specific conditions, age, use of medications, and the presence of visual or other impairment.


Recent research funded in part by the NPSF Research Grants Program focused on one class of extrinsic factor—the physical design of the hospital room and bathroom. With help from Covenant Hospital (Lubbock, Texas) and HKS Architects, the researchers created mock physical space in a state-of-the-science lab at Texas Tech University and enlisted human subjects to test “worst-case scenarios” for potential falls.


Results of this study were recently presented at a meeting of the American Society of Mechanical Engineers. ASME honored the researchers with an award in recognition of the study’s innovative methods.


In this post, the study’s principal investigator, Debajyoti Pati, PhD, FIIA, IDEC, LEED®AP, answers some questions about the work. Dr. Pati is professor and Rockwell Endowment Chair, Department of Design, College of Human Sciences, Texas Tech University.


Q: What was the biggest challenge you faced in this study?

A: One of the biggest challenges was developing a bathroom configuration that would represent a typical inpatient bathroom. This involved surveying the design archives of HKS Architects, who have more than 70 years of experience in designing hospitals. Another challenge was developing a script that represents most scenarios of patient falls across all hospitals. This task was taken up by the Falls Committee of Covenant Hospital in Lubbock. The committee surveyed the industry to come up with representative scenarios.


Q: One part of your study identified the typical patient profile and fall details for worst case scenarios. Can you talk about this a bit?
A: The Covenant Hospital Falls Committee surveyed information from across the industry and their own experience to develop scenarios that represent all hospitals. These individual scenarios were subsequently collated by the investigators to generate a single script that includes the worst case scenarios, while not demanding too much time from the subjects. The final script was reviewed by the Covenant Falls Committee. We conducted several pilot runs in the presence of the Falls Committee members to ensure that the setting and the scenarios are realistic and representative.


Q: What can you tell us about your findings?
A: We are in the process of submitting manuscripts to two journals, but I can say that falls occur owing to intrinsic and extrinsic factors. We focused on one class of extrinsic factor (the physical design). During day-to-day activities people are forced to interact with elements of the physical environment. When they do, it involves several types of postural changes. Three postures were significantly correlated with falls – turning, pushing and pulling (not in any order). In the report, we have identified the specific physical elements in a patient room and bathroom that when combined with these postures result in potential falls. We have also made design recommendations to reduce fall events. We have a separate section in the report discussing the implications of the findings for patient room design.


Q: Does this research point to any immediate steps that hospitals or patients and families could take to reduce the risk of falls?
A: The best way to avoid falls is for patients to never venture to the bathroom alone. That needs operational and/or policy interventions. But patients do make trips to the bathroom alone – and in those situations, the physical design can be used to reduce the chances of a fall event. Our findings include those that involve room/bathroom configuration (very difficult – almost impossible - to change once a hospital is built), and those that involve individual elements (door, toilet bowl, IV pole, number and location of grab bars, etc.). None of these can be considered as minor fixes, although renovation is possible. With the right configuration at and around the toilet bowl, changing the grab bars is one minor fix I can think of. Hospitals can also take proactive measures in removing any obstacles around the bed and on the path to the bathroom. Physical objects that patients unnecessarily need to push or pull or navigate around are an important source of potential falls.


For patients, I’d advise never go to the bathroom alone. For families – if family accommodation is available in the patient room, stay close to the patient at all times and help. Some hospitals have increased the frequency of nurse rounding as an operational intervention to reduce unaided patient trips to the bathroom, and have shown considerable success.

Q: Although the study focused on a very specific setting and hospital room configuration, is it possible that that these findings have implications for reducing falls in other settings, such as for patients receiving care in their homes?
A: Yes. Many of the human–environment interactions identified in this study are also those one encounters at home or other long-term care settings.

Q: What surprised you the most, either about the way the study progressed or your final results?
A: I think we were most surprised by the role of the IV pole in potential falls. I had never thought about it before.

Q: What’s next for this area of research?
A: The design recommendations made in this study (implications for design practice) are essentially design hypotheses. The next step is to test those out through further studies to develop design guidelines.

Q: What can you tell us about the award your paper received from ASME?
A: The ASME award pertains specifically to the methodology of the study – a novel way of using motion-capture technology to detect potential falls. We are so glad that we had such innovative mechanical engineers in our team.


What aspects of your hospital's environment can be changed to reduce falls? Comment on this post below. Note: to post a comment you must be logged in. Register or log in.


Tags:  falls 

Share |
PermalinkComments (0)
Page 12 of 16
 |<   <<   <  7  |  8  |  9  |  10  |  11  |  12  |  13  |  14  |  15  |  16
Copyright ©2018 Institute for Healthcare Improvement. All Rights Reserved.

Membership Software  ::  Legal