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 suspect TB transferred to floor without making staff aware.
    • Patient transferred to ICU from the ED without sharing information that patient was positive for MRSA.
    • Patient directly admitted without informing receiving personnel that swab testing for influenza had come back positive.

Actionable Items to Mitigate Risk

  • Standardize communication during handoffs.
  • Include in the standardized handoffs a summary of the patient’s infectious disease status, including need for precautions.
  • Identify any outstanding testing during handoff.

The Culture Connection

  • Effective handoffs and clear communication among staff members, within and between units, are important components of a strong safety culture.
  • In addition to investigating the clinical components of these events, the organizations should examine any culture factors that impede full and appropriate communication at handoffs.

Resources

CPS Releases PSO Report: #CultureForward

The Center for Patient Safety, a Patient Safety Organization (CPS PSO), is pleased to present this report summarizing some of the information we are learning from the collaborative participation of healthcare providers across the country.

Please note throughout this report, each contracted provider with the CPS PSO participates voluntarily. Each participating organization may elect to report different types of patient safety events, or they may elect to only submit information about the least or most severe cases, therefore, analysis of PSO data is always conducted with this understanding. Benchmarks and rates are unattainable without having a complete data set, so the information in this report is intended to offer a snapshot of the trends and findings from the thousands of events we have collected from hospitals, long-term care organizations, health systems, home health, emergency medical services, and medical offices.

We hope you find value in the information we have provided in this report. If you are not yet participating with a PSO, please contact CPS and we would be happy to help you with your selection process. All PSOs are different and it is important that you find the one that best meets your needs. As a reminder, organizations can participate with more than one PSO. We would encourage you to do so if there are beneficial offerings to your organization. Some PSOs are specific to, for example, children’s hospitals, while others may be specific to Pharmacies. CPS works across the continuum of care and is positioned to help you achieve your greatness.

I encourage you to review this report and compare the findings to patient safety concerns at your own organization. Contact me or any member of the team for information about how we can support your organization as an extension of your quality or safety department. We want you to be successful!

Download the Report

Patient Safety Boot Camp Now Available for EMS

Patient Safety Boot Camp Now Available for EMS

There’s lots of talk in the EMS world about patient safety and patient culture, but few resources to assist agencies in improving their culture and moving forward.

The Center for Patient Safety (CPS) has taken action. Based on similar work done in the acute setting several years ago, we have developed a day-long Patient Safety Bootcamp for EMS professionals.

Attendees will learn the basics of the science of patient safety, human factors, error reduction, process improvement and measurement. Presentations are in TED talk style, with “work-out” discussion sessions after each topic for attendees to analyze how their agency is fairing relative to the presented topic. Tools such as fishbone, root cause analysis, prioritization matrices and action plans are used throughout the day.

The goal is for each participant to leave the boot camp with either the start or refinement of a patient safety plan. Presenters are safety specialists with many years of experience in patient safety and quality improvement.

I encourage EMS personnel to consider this unique opportunity to dive in to patient safety!

LOCATIONS

JULY 25:  , BRANSON, MO Preconference workshop- MISSOURI EMS EXPO

  • Special guest speaker: TBA
  • REGISTER HERE for the Branson EMS EXPO BOOT CAMP

AUGUST 2: Tomball, TX –Greater Houston area

  • Hosted by- Northwest Community Health
  • Special guest speaker: TBA
  • REGISTRATION for EMS BOOT CAMP Tomball TX, COMING SOON

AUGUST 23-24: DENVER, CO as part of the National EMS Safety Summit

OCTOBER 18: ST. LOUIS, MO

  • Special guest speaker: TBA
  • REGISTER HERE for PATIENT SAFETY BOOT CAMP

Diagnostic Errors are a Problem!

Diagnostic errors are problematic!  About a decade ago hospital-acquired infections (HAIs) were in the same position, seeming like an impossible health care issue.  But hospitals across the nation have made great progress in reducing HAIs, although there definitely is room for more improvement.  Diagnostic errors are our next challenge.  Read more from Dr. Peter Pronovost, Director of the Armstrong Institute for Patient Safety and Quality at Johns Hopkins and Senior VP for Patient Safety and Quality.

LEARN MORE! Center for Patient Safety and Verge Health is hosting a FREE WEBINAR tomorrow!

Physician Engagement: Reducing Diagnostic Errors to Improve Patient Safety
March 15, 2017 1:00pm -2:00pm CDT

Diagnostic errors impact our patients, our providers, and, of course, our finances. We have a responsibility to address the concern. Join this webinar to learn the impact of diagnostic errors and what steps can be taken to help reduce the occurrence of these costly events.

SPEAKER: Michael Handler, MD, is the Center for Patient Safety’s Medical Director. Dr. Handler will address the 2015 IOM Update’s recommendations and the existing physician engagement opportunities that can benefit patient safety at your organization.

It’s Patient Safety Awareness Week – #PSAW2017

The Center for Patient Safety encourages providers to use the week as a great way to remind the staff and community of their commitment to safety.
It should be a time of celebration of successes, but also a time of reflection.

In recognition of the week, and the efforts that continue every day throughout the year, the Center for Patient Safety is offering a 20% discount on the already affordable safety culture survey services. Download a proposal with sample feedback reports and an online sample survey link. We encourage the use of the survey as a diagnostic tool to assess your culture. Get started today and take advantage of the offering!

Several available toolkits can support your improvement efforts. It’s easy to start with tools that have already been developed and proven successful:  10 Patient Safety Tips for Hospitals

We also want to remind you that consumer involvement is important to ensure a successful patient safety program. The Agency for Healthcare Research and Quality provides several flyers and videos that can complement your events and programs during Patient Safety Awareness Week:

Patient Safety Awareness Week Approaches, March 12-18th

The Center for Patient Safety (CPS) encourages all healthcare organizations to use Patient Safety Awareness Week, March 12-18th, as a way to remind staff and community of your commitment to safety. It should be a time of celebration of successes, but also a time of reflection.

Free Toolkit for Patient Safety Awareness Week 2017

CPS reminds you to plan in advance for Patient Safety Awareness Week. Plans don’t have to be time consuming or extravagant, but a little planning can go a long way. We recommend hosting an event or several events to recognize patient safety efforts at your organization.

For example:

  • Recognize staff and committees that work every day to provide safe care
  • Launch a patient safety culture assessment during the week (mention this blog and receive 10% off your survey services through CPS!)
  • Have leadership, patient safety/risk/quality department and/or safety committees host events in the cafeteria with snacks or dessert or something special to celebrate safety at their organization
  • Ask departments to develop poster presentations of their successful safety efforts. Display in hallways.
  • Hang a safety awareness week poster in the foyer of the organization with signatures from all staff
  • Hold safety-focused training during Patient Safety Awareness Week
  • Publish safety-focused articles for the organization’s internal newsletter, professional newsletters, local newspapers, local consumer groups
  • Contact a local radio station to host a spokesperson to share patient safety tips and highlights
  • Launch a new safety awareness effort – a “good catch” program, implement a new “CUSP Team”, announce an upcoming “Safety Culture Survey”, etc.

Several available toolkits can support improvement efforts. It’s easy to start with tools that have already been developed and proven successful:  10 Patient Safety Tips for Hospitals

We also suggest you consider consumer involvement to ensure a successful week. The Agency for Healthcare Research and Quality provides several flyers and videos that can complement events and programs during Patient Safety Awareness Week:

Visit www.unitedforpatientsafety.org for more information and resources about #PSAW2017.

CPS FREE WEBINAR: Leadership, Louder than Words: C-Suite Ambassadors of Patient Safety

Committed c-suite leadership to inspire a shared vision is the most critical element in a successful patient safety program. This non-delegable responsibility sets the example by supporting an open and transparent environment, fostering a patient safety culture among all caregivers.

Learn how senior leaders use these steps to provide and support a safer care venue for all patients:

  • Assessing the Culture
  • Integrating patient safety into your strategic plan
  • Supporting your patient safety plan
  • Improving your care processes
  • Sustaining the gains with redesign and high reliability

Thursday, February 16 from 12-1 pm (Central)

To Register, Click Here.

The Second Victim Experience – Train-the-Trainer Workshop

Most health care providers adjust well to the multitude of demands encountered during an unexpected or traumatic clinical event. Providers often have strong emotional defenses that carry them through and let them “get the job done.” Yet sometimes the emotional aftershock (or stress reaction) can be difficult. Signs and symptoms of this emotional aftershock may last a few days, a few weeks, a few months, or longer.

Program Objectives

  1. Describe the ‘second victim’ phenomenon and high risk clinical events.
  2. Describe the six stages of second victim recovery.
  3. Utilize components of the Scott Three tier model of support to design a plan for your organization.
  4. Develop a plan to deploy peer support team training.

(more…)

Free Webinar For Hospitals on Survey on Patient Safety

Culture impacts everything we do.  And it’s no different in health care organizations.  The strongest cultures support employee engagement, promote open communication and the sharing of mistakes to foster improvement.

Learn about how the Center’s survey administrative survey can save you time and money and why measuring your culture is so important to improve patient safety.

Friday, September 9th from 12-1pm (Central) – REGISTER

The Center for Patient Safety is hosting a webinar to share information and answer questions on how taking the Survey on Patient Safety can help you improve patient safety:

Benefits of CPS Safety Culture Survey Services:

  • Deepest feedback reports in the industry!
  • Comprehensive reports at the organization and department-level!

SAVE TIME & MONEY! Save 30+ hours of administrative time.  You’ll need about 2 hours for the entire process and we’ll take care of the rest!

  • ACCESSIBLE – online, anonymous survey with access via computer, smart-phone, tablet, etc
  • DATA ANALYSIS – data is analyzed for you
  • SUPPORT – we’ll talk with you about your results and guide you to your next steps

Learn More about SOPS

CPS Newsletter, Summer Edition Released!

NewsImageThe latest newsletter from the Center for Patient Safety has been released. You won’t want to miss the best practices and patient safety resources in this issue!

View this newsletter

A NEED FOR SPEED
Improving Event Investigation through the Development of SPRINT: Serious Patient Safety Event Rapid Investigation Teams. 4

THE ORANGE DOOR
Facing use of street drugs and alcohol, and decreased availability of medical care and facilities for individuals suffering mental or behavioral illnesses, Liberty Hospital has been able to stem the tide using a multi-disciplinary approach to helping create a safer care environment for staff and patients alike. 6

A UNITED FRONT TO IMPROVE CARE
What the AHRQ guidance means for providers and their patients. 11

PSO LEGAL UPDATE:
Cases involving the Patient Safety and Quality Improvement Act continue to work their way through state and federal courts. 15

EMS UPDATE:
New CPS report seeks to raise awareness of safety concerns in the EMS community. 16

ALSO IN THIS ISSUE:

  • Call to Action: Change the Statistic
  • Safety Insider
  • Watch Your Step, a Falls Analysis
  • New CPS Report Seeks to Raise EMS Awareness: EMSForward
  • CPS Unveils New Website
  • Put the Focus on Safer Care in EMS Community
  • PSO Update: For PSO Participants

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

Read More

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.