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!
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
AUGUST 2: Tomball, TX –Greater Houston area
AUGUST 23-24: DENVER, CO as part of the National EMS Safety Summit
OCTOBER 18: ST. LOUIS, MO
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.
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.
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:
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:
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.
Commit
ted 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:
Thursday, February 16 from 12-1 pm (Central)
To Register, Click Here.
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
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:
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!
The 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!
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:
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
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
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
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.