Patient Safety

New issue of WebM&M available

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The Agency for Healthcare Research and Quality (AHRQ) has released their latest issue of  WebM&M (“morbidity & mortality rounds on the web”).  AHRQ case topics include:

A Lot of Pain (Medications) - Hospitalized for foot amputation, a man with COPD and chronic pain on long-acting morphine experienced post-operative pain and severe muscle spasms. After being given hydromorphone, morphine, and diazepam, the patient became minimally responsive and a code blue was called.  Read the full case and commentary

Too Much, Too Fast – A patient with ALS was hospitalized with presumed pneumonia and sepsis. Although he was treated with broad-spectrum antibiotics and fluid resuscitation, additional potassium was administered due to his potassium level remaining low. The patient went into cardiac arrest and resuscitation attempts were unsuccessful. Read the full case and commentary

No BP During NIBP – A man with atrial fibrillation underwent ablation in the catheterization laboratory under general endotracheal anesthesia. The patient was extremely stable during the 7-hour procedure with vital signs hardly changing over time. Inadvertently, the noninvasive blood pressure measurement stopped recording for 1 hour but went unnoticed. After the error was discovered, the case continued without any problems and the patient was discharged home the next day as planned. Read the full case and commentary

CPS attends Air Medical Transport Conference in Nashville

    Posted in Culture of Safety, EMS PSO, Just Culture, Patient Safety, PSO    |    Comments Off

The Center for Patient Safety (CPS) recently exhibited at the Air Medical Transport Conference (AMTC) in Nashville, Tennessee.  This exciting opportunity allowed us to meet with industry leaders, experts, and providers in air medical services. The conference brought a wide group of these attendees to the exhibit hall with new and innovative equipment and technology. CPS enjoyed sharing information about our services with air and ground EMS during breaks.

Many people were not familiar with the services available from a Patient Safety Organization (PSO), like the Center for Patient Safety.  Many states do not have peer review protection for their quality and safety work, but, by participating with a PSO, federal protection is available for safety and quality work. A PSO offers a safe way to share adverse events, near misses, and unsafe conditions. We all learn in different ways, but we can agree learning by our mistakes can be costly. Working with a PSO offers the opportunity to report errors in a safe way so we can learn from each other to help prevent future events.

Many of the programs and sessions at the conference addressed culture issues. Just Culture reshapes our understanding of accountability, the role of the system, and the role of human behavior. This allows us to distinguish human behaviors and develop a consistent way to establish a safe environment by managing the system and behavior. As we shift the way we think, act, and react, we are beginning to change the culture in EMS.  Just Culture is not a one day event; it’s the starting point for an organization’s journey as they shape their future course.

If you would like more information please contact us.

Fist bump – save lives?

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Research is showing that greeting people with a fist bump vs. a handshake greatly decreases the chance of spreading diseases.  Of course that will require a culture change, but some hospitals are taking on that challenge.  Study results are in the August edition of the American Journal of Infection Control.

EMS PSO Data Entry Webinar a Success

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The Center recently hosted an EMS data entry webinar to assist new participants in entering events.  Established and new participants were able to use this webinar  to focus on how to use special features of the Verge platform, as well as how to enter events into ShareSuite.  We hope it gave insight on how to enter some of the events that new participants might need help with.  Alex Christgen describes the Verge platform as “a robust tool that offers many opportunities above and beyond adverse reporting”.   One of the many features is that ShareSuite participants can run reports and start to understand trends or explore areas for quality improvement.  Recent updates on the reporting fields have shortened the time necessary to enter an event.

Did you know the Center supports reporting on the following?

  • Medication Errors
  • Airway Management issues
  • Equipment/Device/Supply issues
  • Ambulance Crash
  • Other Miscellaneous Events
  • STEMI/Stroke Quality Indicators

Center releases Summer edition of PSO Newsletter

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The latest PSONews-Summer Edition includes:

  • PSO data summary
  • EMS PSO & LTC PSO Updates
  • Legal Environment Updates
  • Good Catch
  • And much more!

EMS Telemedicine is coming, are you interested?

    Posted in EMS, Patient Safety    |    Comments Off

Telemedicine is not new, in fact many hospitals have been using it for years to monitor or support other health facilities.  With the introduction of new technology as well as the mobility to support it, EMS Telemedicine is starting to grow.  Read more about the Alleghany pilot program.

Falls Prevention Awareness Day is Sept 23, 2014

    Posted in Falls, Patient Safety, Resident Safety, Toolkit    |    Comments Off

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

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

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

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