Safety Culture Assessment Tool for Emergency Medical Services (EMS)

The Center is pleased to announce the availability of a culture assessment for EMS. The psychometric analysis was selected for publication in the Journal of Patient Safety in June 2018. The final tool consists of a set of 37 questions that cover 11 patient safety culture domains, aligning closely with the pre-existing domains in the Agency for Healthcare Research and Quality’s Surveys on Patient Safety™.

Developed in conjunction with the National Registry of EMTs, the safety culture assessment is designed specifically for EMS. The survey questions were tested extensively to ensure they are relevant and appropriate. The National Registry of EMTs surveyed its registrants and received more than 32,000 responses that contributed to the psychometric testing and validation.

CPS will host an informative webinar in August to discuss culture measurement and the value of the assessment. Free registration

Additional resources about the culture assessment and the value of culture measurement:

EMS Forward

EMSFORWARD is an ongoing campaign to drive awareness, conversation and action to improve patient safety. EMSFORWARD 360 is a supplemental campaign that amplifies the voices of the leaders and staff. The campaign is based on the 360 booklet which provides a deeper understanding and guide patient safety culture. Take a minute and download your free copy today. 

 

CPS PSO Annual Report

The Center for Patient Safety (CPS) is certified as a federally-designated Patient Safety Organization (PSO) in compliance with provisions of the federal Patient Safety and Quality Improvement Act of 2005 (PSQIA).  PSOs support the collection, analysis, sharing and learning about what medical error occur, why and how to prevent them.

PSO participation can support a safety culture that encourages and allows healthcare providers to safety report and share information about vulnerabilities within the healthcare system, PSOs are pivotal in the crusade to prevent medical errors and patient harm.  CPS provides several culture services that complement PSO services and support the development of a robust patient safety program.

CPS is positioned to assist new and current participants in gaining this invaluable learning and obtaining the federal protections that are available with the PSQIA – but, most importantly to reduce preventable harm.

Download Report Here

CPS Safety Watch/Alert – Violence Against Healthcare Workers

SAFETY ALERT: Violence Against Health Care Workers

Includes:

  • Verbal Threats
  • Hitting
  • Biting
  • Scratching
  • Kicking
  • Stalking
  • Harassment

ACTIONABLE ITEMS TO MITIGATE RISK

  • Review policies and education of staff pertaining to the recognition and de-escalation of hostile and aggressive behavior by patients.
  • Evaluate the need for security personnel and mental health professionals to assist with identification and de-escalation of aggressive behavior.
  • Assess physical work environment to limit/eliminate the possibility of staff working in isolation without escape route in the possibility a patient becomes physically aggressive.

THE CULTURE CONNECTION

  • Ask your staff if they feel comfortable reporting aggressive behavior
  • Encourage staff to use teamwork strategies such as ensuring a second staff member is readily available to assist with procedures where patients have increased risk of becoming aggressive
  • Leadership should evaluate the culture and consider implementing a support system for staff members who feel threatened/intimidated by patients

RESOURCES

Download Here

 

CENTER FOR PATIENT SAFETY RECOGNIZES LEE COUNTY EMS

Lee County EMS is awarded the EMS Patient Safety First Award

Left to Right – Field Training Officer Fred Jackson, EMS Chief, Ben Abes, Capt. Colin Johnson (Patient Safety Team Leader), Lt. Shane Rackliffe, Roger Desjarlais, Lee County Manager

Jefferson City, Mo. – The Center for Patient Safety is pleased to recognize Lee County EMS, which hosted the first EMS Patient Safety Boot Camp in March 2017, as the first recipient of the Center for Patient Safety’s EMS Patient Safety First Award. The award will be presented as part of EMS Week, May 20-26.

CPS Executive Director Alex Christgen said the award captures an organization’s “commitment and spirit to improve their safety culture and dedication for taking proactive steps in advancing the safety of their patients.”

She said Lee County EMS has taken numerous steps in this direction with several innovative approaches, including the development of a strategy and plan with specialized staff training and committee development, and as internal champions for patient safety.

Lee Varner, director of patient safety at CPS, noted, “EMS is a high-consequence industry and it requires an organization’s leadership to be actively involved in the development of a culture that is proactive and not reactive when it comes to safety.”

Varner said Lee County EMS uses methods learned in other high-risk environments, such as aviation and nuclear power, to address numerous risks in its daily work.

Approach to Safety

The Center for Patient Safety agrees with Dr. Tejal Gandhi’s advocacy for “a total systems approach to safety” — where safety is at the core of health care delivery across the continuum and a primary focus of any new initiative. Creating such approaches will require innovative thinking and contributions from all stakeholders.”  Dr. Gandhi’s blog can be followed here.  The Center For Patient Safety can help you advance your patient safety journey.

 

Joint Commission Sentinel Event Alert #59

The Joint Commission’s timely Sentinel Event Alert #59 relative to physical and verbal violence against health care workers reminds me of the #Me Too movement.  For too long providers have tolerated and ignored the inappropriate and sometimes harmful actions by patients, visitors and sometimes co-workers.  Everyone knows it’s often challenging to provide high quality, safe care in today’s health care environment; but having to withstand abuse that is overlooked makes it intolerable.  The Joint Commission provides a free poster providing information and increasing transparency.  Let’s all “stand up” to improve the culture for our health care providers.

CPS Safety Watch/Alert – Respiratory Compromise

BACKGROUND

Respiratory Compromise is a state in which there is a high likelihood of decompensation into respiratory insufficiency, respiratory failure or death, but in which specific interventions (enhanced monitoring and/or therapies) might prevent or mitigate decompensation.

Respiratory Compromise creates problems that are often serious and potentially life-threatening, but they are almost always preventable with the proper tools and approach.  Appropriate patient monitoring and therapeutic strategies are necessary for early recognition, intervention and treatment.

Common themes include:

  • Lack of appropriate monitoring and early identification of respiratory compromise
  • Distractions, complacency or failure to identify high risk patients at transitions of care
  • Not anticipating respiratory complications or lack of situation awareness
  • Complications and risks from procedural sedation

ACTIONS TO TAKE:

  • Understand the pathophysiology and clinical factors of respiratory compromise
  • Early identification of patients at risk
  • Appropriate and timely patient monitoring
  • Appropriate and prompt interventions and treatment

 

RESOURCES
*Respiratory Compromise Institute

Thanks to Dr. Brian Froelke, CPS

 

IHI offers free teleconference

Heads up!  The University of Chicago completed a survey of over 2500 adults regarding their experiences and perceptions of medical error.  Results:  1 in 5 Americans reported a medical error in their own care and one third reported an error involving those for whom they care.  The good news:  almost half of those who experienced a medical error spoke up about it.  IHI is offering a FREE teleconference on Monday, March 12 around the importance of speaking up from the perspective of clinicians, staff, patients and families.  Registration required.  Let’s work together to make care in America safer!

 

CPS Participates in Primaris Podcast to Launch PSAW 2018!

The podcast has just been released. Listen to the discussion on why Patient Safety Awareness Week is such a valuable time for patients and providers. Alex Christgen, Executive Director, and Lee Varner, Patient Safety Director, share their thoughts and provide tips to enhance the understanding of patient safety and why it is more important than ever to engage patients in their care.

Get Podcast Here

BLOG:

PSO Case Law: Ungurian v. Beyzman, et al., 2020 PA Super 105:

A recent Pennsylvania case shows how courts narrowly interpret the PSQIA, ignoring the D & A pathway and the clear language of the Final Rule. (Ungurian v. Beyzman, et al., 2020 PA Super 105). The cour

Joint Commission New Sentinel Event Alert 61: Managing the Risks of Direct Oral Anticoagulants:

The Center for Patient Safety wants to share this important harm-prevention advice from The Joint Commission and its Sentinel Event Alert: Managing the Risks of Direct Oral Anticoagulants. The Joint Commis

CPS Safety Watch/Alert – Culture Can Improve the Control of Multi-Drug Resistant Organisms:

Issue: A number of events reported co CPS’ Patient Safety Organization (PSO) demonstrate poor handoff communication about the patients’ infectious disease status Examples include: Patient with

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RESOURCES:

The Center for Patient Safety believes that collaboration and sharing are the best ways to drive improvement. We strive to provide the right solutions and resources to improve healthcare safety and quality.