Patient Safety

Managing Disappointed Employees with CPS tools

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CPS offers Just Culture Training and Survey of Resident/Patient Safety Culture (SOPS) as they are effective tools to manage employee learning and organizational performance.  A recent study (available here and discussed for LTC here)  has demonstrated the adverse impact on organizational health of workers who feel slighted—who believe that their employer has not met the employee’s expectations.  SOPS culture survey can help healthcare providers identify areas where staff believes they are not supported, allowing facility management to address those issues proactively.  Just Culture provides many pathways to explore the expectations and understandings of employees, and encourages intervention where employee understanding is inconsistent with the organization’s goals.
Sign up for either one or get more information at

St. Louis AHRQ SHARE Approach Workshop

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The U.S. Department of Health and Human Services (HHS) and Agency for Healthcare Research and Quality (AHRQ) is offering a free train-the-trainer workshop on shared decision making on January 23, 2015 in St. Louis, MO.

Using the SHARE Approach, a five-step process for shared decision making, these free workshops provide health care professionals with patient decision aids, conversation starters,  tips to communicate with patients, an implementation guide for clinical teams, and other tools that support shared decision making in clinical practice settings.

Clinicians who participate will learn how to implement the SHARE Approach and train peers in shared decision making. Participants can earn up to seven hours of continuing medical education credits (CME)/continuing education units (CEUs).  A learning network and webinar series will also be available to support ongoing implementation.

The January 23 workshop will take place at the Robert A. Young (RAY) Federal Building, 1222 Spruce Street, St. Louis, MO 63103 from 8:30 a.m. to 4:30 p.m. Click here to register. To learn more about the SHARE Approach please visit the AHRQ website.

Thoughts from David Maxfield of Vital Smarts on Change – Applicable to Culture Change in Healthcare

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Check out this recent article on changing culture, “When you’re trying to influence people who need motivation, but not information, don’t offer more information. Instead, use questions to create a safe environment where they can explore motivations they already have.” Read more.

Looking for a great gift idea that keeps giving?

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Your tax-deductable donation to the Center for Patient Safety supports ongoing patient safety education and resources to thousands of healthcare providers across the country. Make a donation and support safer care today!

The Center for Patient Safety values partnerships with organizations and individuals who want to support improvement in healthcare quality and patient safety. Because the Center is a not-for-profit organization, donations are tax-deductible.

There are three ways to join the effort to spread safety culture throughout the healthcare community: individual donation, organizational sponsorship levels, and/or supporters can sponsor an event or initiative.

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Insulin Pens: Are your patients safe?

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A success story from CoxHealth, Springfield, Missouri

Insulin pens were designed for convenience to permit a single person to administer multiple self-injections, using a new needle each time. Many hospitals began using the pens because of their convenience and accuracy. However, reports from several hospitals indicated that the pens were being reused, placing thousands of patients at risk. An alert from the Center for Disease Control in 2009 warned that the pens should be used on a single patient only and are not to be shared between patients. Despite this alert, inappropriate use in hospitals continues, indicating that some healthcare personnel do not adhere to safe practices and may be unaware of the risks to patients.
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About Patient Safety Organizations (PSOs): Did You Know?

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Now that Patient Safety Organizations (PSOs) have been in existence for more than five years, the federal Patient Safety and Quality Improvement Act (PSQIA) is better understood, and knowledge about the Act has increased. Still, there are a number of questions we commonly receive at the Center for Patient Safety.  Here are the top 10 questions, answered by the Center’s Patient Safety Specialist, Eunice Halverson at

Why should a health care provider join a PSO?
PSOs are independent, external experts who can collect, analyze and aggregate patient safety work product to develop insights into the underlying causes of patient safety events. Communications with PSOs are protected to allay fears of increased liability or fear of sanctions. With this federal protection, healthcare providers can share information with other participants, via the PSO, and learn from each other to ultimately improve patient care. More information is available from the AHRQ on working with a PSO.

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Taking the Bite Out of Flu for LTC

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Flu is upon us early, and even though the vaccine is not completely effective, fifty percent protection beats none. Not only can the flu vaccine protect residents, but it can also reduce the disruption from staff sick days.  Long Term Living magazine talks about how unfortunately, long-term care staff are far less likely to be vaccinated than staff in other healthcare situations.
The CDC has developed a toolkit specifically for LTC employers to help encourage the vaccination of their workforce.  It is available on the CDC website.

TeamSTEPPS Training Curriculum Now Available Online – Offered at no-cost!

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TeamSTEPPS Online Communication and Teamwork Course

AHRQ’s TeamSTEPPS® training curriculum is now available online as an accredited continuing education program, allowing health care providers to become certified as Master TeamSTEPPS Trainers through a web-based course.

TeamSTEPPS is an evidence-based teamwork approach to improve communication and teamwork skills among health care professionals. The TeamSTEPPS Online Master Trainer Course consists of 11 modules, 8 of which offer continuing education (CE) credits. Sample topics include Communication, Situation Monitoring and Mutual Support.

The training curriculum is engaging and includes videos, instructor guides, and slide presentations to further demonstrate the concepts presented in the course.

Learners in a cohort or noncohort group completing the full course of all 11 modules and a coaching session with a TeamSTEPPS Master Trainer not only receive CE credits but can also receive certification as a Master Trainer. Learners can also choose to complete individual modules for CE credits only.

Interested participants can begin the process by completing the TeamSTEPPS readiness assessment. The class is offered at no cost to participants on a first come, first serve basis. The course can be viewed at: .

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