Between January 2013 through December 2014 the FDA has received reports of MDRs encompassing approximately 135 patients in the United States relating to possible microbial transmission from reprocessed duodenoscopes. Likely many other incidents have occurred that were not reported to the FDA. Review this Alert for more information and best practices for practitioners and patients.
Join the Center for Patient Safety on March 13th for our 9th Annual Patient Safety Conference. We just received confirmation of approval of 5.25 CE hours toward CPHQ recertification from the National Association for Healthcare Quality. Registration and more information.
The AHRQ-funded Multi-Center Medication Reconciliation Quality Improvement Study (MARQUIS) has produced a manual to help hospitals improve medication reconciliation practices to improve outcomes such as inpatient adverse drug events and readmission rates, which have significant patient safety and financial implications for hospitals. The manual describes a framework to assemble a team, adapt an implementation strategy and implement interventions aimed to improve med reconciliation.
Join us on March 13th for the Best Practices in Safe Care Panel – Sharing Successful Safety Programs
We hope you will join us for updates and strategies for success of key safety practices that the Center has been involved in over the past decade. Come listen to and participate in discussions with these panelists at the Center’s 9th Annual Conference, March 13th! Visit our website for more information including registration.
- Pat Posa will return for the Conference to share updates on successes of the CUSP program, challenges and potential for ongoing safety improvement
- Rachel Wells, CoxHealth, will share successes in using the HSOPS safety assessments and system-wide implementation of Just Culture
- Laura Hirshinger, MU Health Care will provide exciting updates on their Second Victim Program, including key learnings and growth into the future
- Leslie Porth, MHA will discuss the importance of transparency, its debate and importance moving into the future for health care quality and safety improvement
We are excited to host a Panel of former Patient Safety Commissioners at the Center’s March 13th Annual Conference! Each of the following panelists will share their perspective on the Commission’s work and safety over the past decade and needs for the future.
- Kat Nelson, MHA, Mercy, Commission Co-Chair
- Stephen Smith, MD , Anesthesiologist, Center for Patient Safety Board Member
- Lori Scheidt – State of Missouri Board of Nursing
- Pam Marshall, R.Ph, Walgreens and State of Missouri Board of Pharmacy Member
- Sue Kendig, JD, MSN, FAANP– Health Policy Advantage, Center for Patient Safety Board Member
Rules for abbreviation use generally focus on medication safety—identifying visual and textual ambiguities that may confuse other medical professionals. The ISMP List of Error-Prone Abbreviations, Symbols, and Dose Designations includes items like IU that could appear like IV or 10; and DPT, which could stand for Demerol-Phenergan-Thorazine or diphtheria-pertussis-tetanus. Read more Courtesy of CHPSO.
Share how your organization is celebrating Patient Safety Awareness Week, March 8-14! Tell us how you are raising awareness of your organization’s focus on safe care 24/7/365 at firstname.lastname@example.org and we’ll let others know about the great happening across the country!
George Heilmeier was, according to Wikipedia, a pioneering contributor to liquid crystal displays. Throughout his career, he researched and invented things for private industry and the government, eventually becoming the Chief Technology Officer for Texas Instruments. He developed a set of questions that anyone proposing a research project or product development effort should be able to answer. Known as “Heilmeier’s Catechism,” they should be helpful to anyone planning safety improvement projects, as well. Those familiar with the PDSA cycle will recognize this as a valuable expansion of the planning phase.
- What are you trying to do? Articulate your objectives using absolutely no jargon.
- How is it done today, and what are the limits of current practice?
- What’s new in your approach and why do you think it will be successful?
- Who cares?
- If you’re successful, what difference will it make?
- What are the risks and the payoffs?
- How much will it cost?
- How long will it take?
- What are the midterm and final “exams” to check for success?