On My Oath.

Most osteopathic medical students will take an oath adopted in 1954 by the American Osteopathic Association. We examine this oath to explore its ethical content by focusing on two specific lines. We conclude that the oath would benefit from scrupulous revision to promote patient-centered care.

Roles of Environmental Services Workers' Wages and Status in Patient Safety.

Environmental services is a mission-critical function of any health care organization, contributing in key ways to patients' health, well-being, and overall care experiences. This article offers context from a risk management standpoint on the importance of recognizing, valuing, and protecting environmental services professionals' contributions to health care organizations' capacity to be fulfilling, safe places to be a patient and to care for patients.

How Should Gene Editing Be Managed by Risk Managers?

Gene editing, because it is a new technology, presents challenges to health care organizations' risk managers. At this time, little claims data exists upon which to make informed decisions about loss control and to draw upon when developing risk mitigation strategies. This article explores gene editing through the eyes of risk managers and underwriters and concludes that traditional risk management tools must be used to reduce risk until more is known about the frequency and severity of claims.

Safer health care environments by design.

Health care environments can and are being designed to prevent injury, minimize human error, and actually promote improved health and safety. This article shows risk managers how evidence-based design is reducing medication error, staff injury, infection rates, patient falls, and more. Research knowledge can contribute to effective design solutions by simply clarifying a safety problem so solutions can be sought; it can inform the design process with potential solutions; or it can be part of a structured process where new research knowledge is created. This article shares specific examples of the types of research that can inform designing for a safer physical environment. A case study shows how one project in two phases benefited from engaging initially in a general way and later, in a highly structured process, to integrate the evidence to improve design for safety.

Where should patient safety be installed?

The structure of an organization is important, and structure has a profound influence on the way people work and what gets done. Where work units and individuals in an organization are placed, to whom they report, and with whom they are grouped signals power, prestige, and privilege. It also divides workers into groups with common interests and motivations. The question is, where should patient safety be placed in a health care organization? Such a question can be answered only within a framework of understanding that gives a clear definition to patient safety. We define safety, as do safety professionals from other industries, as the reduction of risk. This definition is also in concert with the risk management model that identifies claims management, risk financing, and loss control as its foundational triad.

Effective followership: A standardized algorithm to resolve clinical conflicts and improve teamwork.

In healthcare, the sustained presence of hierarchy between team members has been cited as a common contributor to communication breakdowns. Hierarchy serves to accentuate either actual or perceived chains of command, which may result in team members failing to challenge decisions made by leaders, despite concerns about adverse patient outcomes. While other tools suggest improved communication, none focus specifically on communication skills for team followers, nor do they provide techniques to immediately challenge authority and escalate assertiveness at a given moment in real time. This article presents data that show one such strategy, called the Effective Followership Algorithm, offering statistically significant improvements in team communication across the professional continuum from students and residents to experienced clinicians.

Institutional disclosure: promise and problems.

This study explores rationale for and barriers to the prompt and honest disclosure by healthcare organizations of care-related un-intended harm to patients. Although fear of legal action is frequently put forward as the reason that disclosure programs have been slow to be adopted by the medical community, social and nonjurisprudential explanations also pose challenges. This study identifies multiple facilitators and obstacles that transcend concerns about litigation and limit disclosure of adverse events that result in serious injury or death.

The case for training Veterans Administration frontline nurses in crew resource management.

Using cultural analysis, the authors present a rationale for a nursing-focused crew resource management (CRM) program in the Veterans Health Administration. Although the value of CRM in aviation is well documented and CRM has been successfully applied in healthcare settings to improve communication and teamwork, there is little evidence outlining the implementation of CRM on nursing units with nursing as the primary focus. This article describes the preproject data supporting a nursing-focused CRM program called nursing CRM. This is the first in a series of 2 articles highlighting this program.

Ethics, risk, and patient-centered care: how collaboration between clinical ethicists and risk management leads to respectful patient care.

Patient-centered care is driven in part by the ethical principle of autonomy and considers patients' cultural traditions, personal preferences, values, family situations, and lifestyles. Patient decision-making capacity, surrogate decision making with or in the absence of a patient's advance directive, and the right to refuse treatment are three patient-care issues that are central to the work done by both the risk manager and the clinical ethicist that have strong relevance to patient-centered care. This article discusses these three issues briefly and offers two challenging case studies involving patient-centered care that illustrate how a clinical ethics consultation may help to avert the escalation that can lead to a tort claim.

The architecture of madness and the good of paternalism.

From the era of the asylum to the present day, the architectural design of inpatient facilities has long been considered a contributing factor in the treatment of patients with mental and substance use disorders. The author examines the ethical basis for decisions about the design of psychiatric hospitals--architectural paternalism. The ethic of paternalism in the design of asylums and in contemporary thinking about psychiatric hospital design is described. The author argues that limitation of patients' autonomy and rights by the purpose-built architectural environment is legitimate and ethical.

A qualitative analysis of the central values of professional paramedics.

Biomedical ethics decisions are often made after reflection, deliberation, and after a process of communication, reveal the values and interests of the patient or the patient's family. However, acute and rapid changes in the patient, the very public view of the care provided, and a need for rapid decision making by paramedics in a prehospital setting make protracted deliberation and reflection a practical impossibility. As paramedics provide care for patients, they regularly make value-laden choices that affect the type of care, how care is provided, and to whom care is provided. These choices transcend the technical judgment and professional skills necessary for provision of emergency care in prehospital settings. This article identifies, describes, and organizes a number of central values of professional paramedics and discusses how values may be considered by paramedics when resolving conflicting values.

Termination of life support after severe child abuse: the role of a guardian ad litem.

Discontinuation of life-sustaining interventions often raises ethical concerns. In cases of severe child abuse with poor prognosis for recovery, accused parents may have a conflict of interest regarding medical decision-making for their child, because the outcome of such decisions may impact legal charges filed against them. The recently issued American Academy of Pediatrics guidelines for addressing such cases recommended the appointment of a guardian ad litem for medical decision-making. We present the case of an 8-month-old infant who was abused severely by her father, resulting in a persistent vegetative state. We describe our experience with appointing a guardian ad litem and the ethical issues involved.