Recognizing Fall Prevention Week

Fall Prevention Awareness Week started Saturday, September 22 and runs until Friday, September 28. Stopfalls.org has excellent resources and tools to support ongoing efforts including flyers, posters, fact sheets and videos. A fall can result in injury, trauma and even death. Sometimes the fall isn’t even the scariest part and it is the post-fall events of surgery, immobility and potentially pneumonia that result in death.

Like many baby-boomers, my mother is the caretaker for my grandmother. Now in her 90s, my grandmother is sharp as a tack, witty, and full of life, however, she is also very frail and purposeful in her movements. My mother lives in a two-story Cape-style home and serves dinner in her dining room, requiring my grandmother to venture down a flight of stairs from her bedroom. My mother’s husband has a coordinated drill with my grandmother that I always enjoy watching when I’m around. He takes her arm gently in his, stands beside her and they descend slowly and methodically down the stairs, one at a time, as if they were a single person. He matches his stride to hers, paying close attention to her hesitations, much like a dance partner. While he initially started doing the “stair dance” as a supportive function, he is actually preventing her from falling.

Not all older adults have a stair dancing partner, so it’s important to find another effective method of fall prevention. In a home with more than one floor, an electronic stair-lift may be appropriate if arrangements cannot be made for the individual to live fully on one floor. Recognizing trip hazards is also very important. My mother has three cats, so it’s necessary to ensure a cat is not underfoot when my grandmother moves about.

We are likely all familiar with an aging family member that is at risk of a fall. No matter how adamant they are about living on their own or continuing their daily routines without worry, any of us that work in healthcare recognize the serious risks. We want to protect our parents, our grandparents, or even our great-grandparents, but we must also respect their desires if they choose to age in their homes, even if they are doing so alone. Engage them in the conversation and review the checklists on stopfalls.org, watch videos together and let them know you care about their safety.

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

 

Patient Safety Awareness Week is March 11-17, 2018

Patient Safety Awareness Week (PSAW), an initiative from the National Patient Safety Foundation (NPSF) and the Institute for Healthcare Improvement, is designed to raise patient safety awareness among healthcare providers and consumers. This year, PSAW is March 11-17. It’s a great time to celebrate successes and re-focus on patient safety opportunities in your organization. The Center encourages providers and consumers to obtain information about patient safety issues. Below are highlights of Patient Safety Awareness Week activities.

Take advantage of the following resources and conferences to help launch a successful campaign! The Center’s highly anticipated Patient Safety Toolkit will be available for download by CPS Subscribers.

Join us on social media and check out these patient safety resources and tips we’re sharing during #PSAW2018!


Patient Safety Forum, March 14, 2018

Everyday across the country, healthcare is provided in many clinical settings and environments.  Likewise, the healthcare landscape is complicated as it evolves at an ever-quickening pace with new specialties, titles and tools.  Coupled with the growing demands placed on clinicians and healthcare leaders, how do we ensure the safety of our patients?  Join us for this collaborative opportunity to learn with other providers across the continuum of care how patient safety can be improved.
Added Bonus! All attendees of the forum will become a Subscriber to CPS’s online resource center, which provides toolkits, special previews to upcoming events, and a community forum. Find out more about becoming a subscriber!

Learn more about the Forum


Second Victim Experience, March 19, 2018

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.

Added Bonus! All attendees of the workshop will become a Subscriber to CPS’s online resource center, which provides toolkits, special previews to upcoming events, and a community forum. Find out more about becoming a subscriber!

Learn more about the Second Victim Workshop


The CPS Patient Safety Improvement Approach

The Center for Patient Safety believes every patient safety improvement journey includes an evaluation of your current culture. It’s important to use meaningful data to understand how staff perceive the organization’s approach to patient care. Our bundled approach gives you peace of mind that you’re working with the patient safety experts – and we want YOU to be successful!

Step 1: CPS administers a survey to your staff and provides a detailed interpretation of your results.
Step 2: We work closely with you to develop your action plans and next steps.
Step 3: Our work continues with you over the next six months to a year to provide education and training, workshops, resources and tools. We support you in reaching your goals!
Learn more about the CPS Patient Safety Approach through Culture Change

CPS Safety Watch/Alert: Elopement

TARGET AUDIENCE

  • Nursing, Medical & other Clinical Leaders
  • Clinical Educators
  • Patient Safety/Quality Improvement Leaders
  • Legal/Risk Management
  • And Leaders in:
    • Hospitals
    • EMS
    • LTC
    • Home Care

SAFETY WATCH: ELOPEMENT
Safety Watch v4-2 Elopement

Emergency Services are increasingly dealing with patients who elope prior to receiving care, many times due to lengthy wait times. Patient safety issues associated with these scenarios include increased risk of:

  • Adverse events
  • Misdiagnosis
  • Mental health exacerbation
  • Diversion which can lead to dangerous delays of care

ACTIONABLE ITEMS TO MITIGATE RISK

  • Review/establish an elopement policy
  • Review triage policy/process
  • Identify those at risk for elopement (such as those suffering with psychosis, dementia, drug or alcohol-related conditions)
  • Perform a gap analysis to address issues such as opportunities to reduce risk, assessing staffing, etc.

THE CULTURE CONNECTION

  • Open Communication: Interview staff to see if they have concerns regarding patient elopement
  • Teamwork: Develop a communication tool that will inform all ED staff of a high risk elopement patient.
  • Share: Openly share peer-reviewed best practices from the literature and processes that have been implemented at your facility or other facilities.

RESOURCES

NEXT STEPS

  • Share this watch with the target audience
  • Promote daily safety briefings
  • Continue to share incidents, near misses and unsafe conditions with the Center for Patient Safety

CPS PSO Watch/Alert: Fall Risk

The Center for Patient Safety issues this alert regarding falls based on our data analysis.

Falls are a difficult and long-standing challenge for providers. While the majority of events report no harm, falls continue to result in severe life-changing injury or even death.  The CPS recommends you re-evaluate your fall risk program, considering the following best practices:

  • Ensure the fall risk assessment tool correlates to the daily workflow and all nurses are trained in appropriate utilization of the tool
  • Include all staff (dietary, housekeeping, maintenance personnel also) and physicians in your falls prevention program
  • Utilize a standardized communication tool to communicate the patient’s fall risk potential to the entire team
  • Make certain the preventative measure match the patient’s risk factors
  • Individualize/tailor preventative measures to meet the patient’s needs (i.e. bed alarms are not effective for all patients)
  • Include consistent patient rounding as part of your preventative measures
  • Implement a quick post-fall huddle process to quickly identify contributing factors that require a system/program change
  • Routinely/daily review medications and their effect on each patient’s fall risk potential

This alert is provided to increase awareness regarding the complex considerations required for a successful falls prevention program.

 

Resources:

http://www.ahrq.gov/professionals/systems/hospital/fallpxtoolkit/index.html

http://www.patientsafety.va.gov/professionals/onthejob/falls.asp

http://www.ahrq.gov/professionals/systems/long-term-care/resources/injuries/fallspx/fallspxman1.html

http://centeronaging.med.miami.edu/documents/Evidence-BasedStrategiestoReduceFallRisk.pdf

http://www.champ-program.org/static/Falls_BPIP.FromHHQIWebsite.pdf

https://www.cdc.gov/steadi/

CPS Safety Watch/Alert: Home Health Medication Management

PSOalertA Home Health Care News article came out on 5/3/16 noting that medication mismanagement is an area in which home health agencies are woefully lacking. This article cited a Kaiser Health News Analysis of government records showed that inspectors identified 3,016 home health agencies (nearly a quarter of all agencies examined by Medicare) that inadequately reviewed or tracked medications for new patients. Medication mismanagement is seen as a major post-discharge complication as federal data shows that fewer than 50% of discharged patients are confident that they understand and can follow their discharge instructions.

Contributing factors to these medication errors include, lack of organization, lack of patient education and a lack of communication. Another factor which plays into the lack of communication is the fact that the government incentive to shift to electronic medical record was not set up to work across the continuum of care.  In effect, it contributes to setting up silos within the healthcare continuum as hospitals are not connected with home health care agencies outside of their own system and maybe not even within their own system depending on the software utilized by the hospital and the home health agency.

A review of data submitted to the Center for Patient Safety shows a similar trend in medication events.  Over a third of the medication events reported in the home health arena can be attributed to errors during med reconciliation and lack of communication during the transition from hospital to home health.

Suggested practices to reduce these errors include:

  1. Standardizing communication when a patient is being discharged from the hospital to home health. Include:
    1. Medication changes
    2. Completed and pending tests
    3. Follow up appointments
    4. DME needed by the patient
    5. Education provided to the patient
  2. Double-check medication
    1. Ensure important chronic medications were not stopped
    2. Make certain new medications are safe
    3. Double-check the interactions between medications
    4. Make certain patient hasn’t been prescribed two duplicate medications
  3. Transition the patient to home during the week
    1. Ensures that the patients primary care physician is available for medication questions
    2. Ensures that DME agencies are available to provide the patient with any equipment needed
  4. Patient Education
    1. Make certain the patient (and the family/primary caregiver) understand the diagnosis and medication prescribed
    2. Ensure they understand who they are to contact with any questions
    3. Is the patient/family aware of follow up appointments?
    4. Are they aware of lifestyle changes that may be required?
    5. If so have they been provided with information for support groups?

Patient safety is a major health issue which adversely affects patients in every health care setting.  Improving patient safety is a complex issue, which requires a total systems approach.  Implementing a patient safety culture in which leaders and front line staff put patient safety as a priority across the continuum of care is the foundation for preventing harm.  Reviewing processes and completing RCA’s of all events provides learning opportunities and also identifies areas of improvement.  But for the total systems process to work, an organization must have in place that strong patient safety culture where employees feel free to identify errors and unsafe conditions.

Resources:

http://homehealthcarenews.com/2016/05/spotty-medication-management-in-home-health-causes-dire-results/

https://www.washingtonpost.com/news/to-your-health/wp/2016/04/29/from-hospital-to-home-a-dangerous-transition-for-many-patients/

https://psnet.ahrq.gov/primers/primer/23

https://psnet.ahrq.gov/primers/primer/1

https://psnet.ahrq.gov/primers/primer/11

http://health.gov/hcq/ade-action-plan.asp

http://champ-program.org/static/MM_BPIP.FromHHQIWebSite..pdf

http://ahhqi.org/images/uploads/AHHQI_Care_Transitions_Tools_Kit_r011314.pdf

Free Webinar – PSOs: What you should know!

pso-whatyoushouldknowThe Center for Patient Safety is hosting a series of free upcoming webinars to share information and answer questions on how joining a Patient Safety Organization (PSO) can help you improve patient safety at your organization. Each webinar is available for providers in different healthcare settings, including medical offices, ASCs, LTC, EMS, and home care. A hospital-specific webinar was held in April but will be available again in the Fall. Contact the Center for more details.

Each webinar will help organizations and providers:

  1. learn the benefits of joining a PSO
  2. learn how joining a PSO can support your patient safety efforts
  3. learn how PSO protections can apply to your organization

Medical Clinics and Ambulatory Care
5/19/16 from 12-1pm Central     REGISTER

This webinar is open to healthcare professionals in medical offices, physician groups, and ASCs with a desire to improve patient safety and reduce patient risk, including professionals working in quality, risk, patient safety, quality improvement, and legal staff, executive leaders, and outside counsel and consultants for medical offices, ASCs or health systems.

Long Term Care
6/9/16 from 12-1pm Central     REGISTER

This webinar is open to healthcare professionals in LTC with a desire to improve patient safety and reduce patient risk, including professionals working in quality, risk, patient safety, quality improvement, and legal staff, executive leaders, and outside counsel and consultants for long term care or health systems.

Emergency Medical Services
6/16/16 from 12-1pm Central     REGISTER

This webinar is open to healthcare professionals in EMS with a desire to improve patient safety and reduce patient risk, including chiefs, managers, patient safety leaders, and legal staff, executive leaders, and outside counsel and consultants for EMS.

Home Care
9/8/16 from 12-1pm Central     REGISTER

This webinar is open to healthcare professionals in home care (home health, hospice, home and community-based services and private duty) with a desire to improve patient safety and reduce patient risk, including professionals working in quality, risk, patient safety, quality improvement, and legal staff, executive leaders, and outside counsel and consultants for home care.

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.