Patient Safety

Falls Prevention Awareness Day is Sept 23, 2014

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From the Center for Healthy Aging, National Council on Aging (NCOA):

Strong Today, Falls Free® Tomorrow

Falls Free Coalition Logo

Date: September 23, 2014

The 7th annual Falls Prevention Awareness Day will be observed on September 23, 2014—the first day of fall. This year’s theme, Strong Today, Falls Free® Tomorrow, seeks to raise awareness about how to prevent fall-related injuries among older adults.

The Falls Free® Initiative is a national effort led by NCOA to address the growing public health issue of falls and fall-related injuries and deaths in older adults.

Norway uses smaller ambulances with big focus on safety

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ambulance design3Ever wondered what an ambulance from another country might look like?  Ronald Rolfsen from Oslo University Hospital recently spoke about Ambulance Safety and Design at the Kansas EMS Conference.  In Norway, there is a tradition to use smaller ambulances compared to USA. The ambulances are designed with a focus on automobile safety, occupant safety, ergonomics, and user friendliness. At the head of the stretcher is a seat where the airway of the patient would be managed. If you look closely you will see that equipment and necessary tools are within reach. Rolfsen says it’s important to set design standards so crews can take care of the patient and remain secure with seat-belts. The pictures are from Oslo ambulance services new intensive care ambulance.  Thank you for the great presentation at KEMSA, Ronald Rolfsen!

Click “Read More” to see interior photos of a Norway ambulance. Read More

PSOs Are Watching New Florida Decison about PSWP

    Posted in Patient Safety, Patient Safety Act, PSES, PSO, PSO case law, PSWP    |    Comments Off

A Florida trial court order regarding the discovery of hospital incident reports is circulating in PSO circles.  (Charles v. Southern Baptist Hosp. et al., Duyal County, Case No. 15-2012-CA-002677.)  The order expresses a very restrictive view of PSWP (more below) and the hospital has expressed an intention to appeal the order.  As a trial court order in Florida, it has no value as precedent in any other jurisdiction, even within Florida.  However, the order will be part of the ongoing discussion about PSO protections, so CPS wants its stakeholders to understand it. The key facts:

  • Florida has very specific requirements for hospital risk management, including staff licensure and submission of certain incident reports to the state.  The statute also requires the hospital to gather information via incident reports that may not be reported to the state, but which is necessary to carry out the mandated activities.
  • The discovery request specifically asked for reports prepared pursuant to parts of the statute.
  • The court recognized the applicability of the Patient Safety Act and accepted that the hospital had a PSES and that the information was utilized appropriately in that context, and therefore would be protected PSWP except for the state risk management and reporting requirements.
  • The court found that the need to gather the information under state law and to report some of it precluded it from being protected PSWP. Read More

CPS issues Safety Watch on EMS Stretchers

    Posted in EMS, EMS PSO, Events, Patient Safety    |    Comments Off

Safety WatchMultiple stretcher-related incidents have been reported to the Center’s Patient Safety Organization.  The areas of concern are from real events.  Read the full Safety Watch on EMS Stretchers.

Released 08.11.2014.

EMS Hand Washing Study

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EMT Hand-Washing Habits Need Improvement
Have you read this interesting and surprising study about EMS and hand sanitizing?  As an industry we might want to study and discuss it further as well as support each other for better compliance?  Does it raise a deeper question?  What about the equipment we touch while taking care of our patients?  When we are gloved are we risking cross contamination to ourselves and our next patient? Furthermore, think about the cab of our ambulances with the many things we touch and have contact with.  Is there any risk there?  Most services are vigilante and proactive with their disinfection process, however, we are prone to slips and drift from best practices.

What are your thoughts, do you wash your hands?

New ISMP Long-Term Care AdvisERR newsletter

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The Institute for Safe Medication Practices (ISMP) has issued the July edition of its newsletter, Long-Term Care AdvisERR.  The newsletter includes tips on safe administration of U-500 Insulin, safe use of new oral dispensers for morphine sulfate, as well as addressing how to set up your MAR to avoid confusion.  Here is a link to subscribe to this free resource that offers advice on frequently reported medication safety events and access past issues.

AHRQ and The Joint Commission e-learning module for LTC

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The Agency for Healthcare Research and Quality (AHRQ) and The Joint Commission released an e-learning module last week aimed at reducing healthcare-associated infections (HAIs) in assisted living and nursing homes.  The tool is available to all long-term care facilities and includes resources and quizzes in an online format.   The objective of the tool is to provide principles to “prevent infections and achieve high safety performance over extended periods of time”.

Opportunity for Long Term Care Facilities!

    Posted in LTC, Patient Safety    |    Comments Off

National Collaborative to Reduce Infections, Focus on CAUTI!  SIGN UP BY AUGUST 29th!

The Center for Patient Safety and Missouri Hospital Association are partnering to bring national faculty and resources to Missouri nursing homes to work collaboratively on reducing infections with a focus on eliminating CAUTI!  Sign-up for this opportunity is only available until August 29th!  There is no cost for participating in this collaborative!

Read additional information about the project, including an overview of the project, team leaders responsibilities.

If you are interested in signing up to participate, complete the AHRQ Safety Program for Long-Term Care: CAUTI Online Registration Form.

If you have any questions, please contact Kathy Wire at the Center for Patient Safety at kwire@mocps.org or Jessica Rowden at the Missouri Hospital Association at jrowden@mail.mhanet.com.

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