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

A Need for Speed

By: Lynnette Torres, Quality Improvement Manager for Memorial Hospital of Carbondale

Sepsis – a dreaded word for patients, families and health care providers alike. Sepsis is an infection caused by microorganisms or germs (usually bacteria) invading the body. It can be limited to a particular body region or be widespread in the bloodstream.

Addressing the Challenge
In addition to outcomes, the Agency for Healthcare Research and Quality lists sepsis as the most expensive condition treated in U.S. hospitals, costing more than $24 billion in 2013 increasing on average annually by 11.9%. It has been estimated that if the U.S. as a whole achieved earlier sepsis identification and evidenced based treatment, there would be 92,000 fewer deaths annually, 1.25 million fewer hospital days annually, and reductions in hospital expenditures of over $1.5 billion.2 Research has shown that mortality from sepsis increases 7% every hour that treatment is delayed. As many as 80% of sepsis deaths could be prevented with rapid diagnosis and treatment.3 Understanding this severity, Memorial Hospital of Carbondale, Illinois, began addressing the sepsis
challenge several years before it became a focus for the Centers for Medicare Services (CMS). A multi-disciplinary improvement team began studying sepsis, and realized how much more difficult and unique it is to meet all the requirements than the previously required core measures from CMS.

Making it Easier
The team began working on revising all order sets that are used for patients who may be septic, including the required measures of the Sepsis Bundle: blood cultures, lactic acid, antibiotics, fluid resuscitation, and vasopressors. A Kaizen project focused on the work flow for septic patients as well as components of the evidenced-based sepsis care bundle. Revised sepsis order sets for patients in triage, the ED and inpatient nursing units now include the required measures. These changes make it easier to ensure the proper care is provided in a timely manner. All nursing staff, hospitalists and ED physicians were educated on the sepsis requirements and new order sets. One-on-one education was provided when necessary. “Cheat sheets” and guides for sepsis care were created for physicians and nursing staff. The sepsis care path was laminated and placed on computers as a visual reminder. A checklist was created for nurses and physicians in the ED; these checklists double as a hand-off tool to communicate the continuum of care between providers.

Memorial has concurrent and retrospective nurse abstractors in the Quality Department. The concurrent abstractor reviews the patients who meet sepsis criteria daily, along with tracking use of the sepsis order sets.  Order set compliance data is shared with the providers.

“There are approximately 750,000 new sepsis cases each year in the US, with at least 210,000 fatalities. As medicine becomes more aggressive, with invasive procedures and immunosuppression, the incidence of sepsis is likely to increase even more. Reducing mortality due to severe sepsis requires an organized process that guarantees the early recognition of sepsis along with the uniform and consistent application of evidence-based practices.”

Moving Forward
The team continues to meet and seek ways to simplify the order sets to increase compliance. One of the challenges is missing the required lactic acid timeframe for admitted patients who have the first blood drawn in the ED but are not in their inpatient room when the Lab phlebotomists go to draw for the second order. The phlebotomists now place a sign above the bed indicating that they have been there, asking nurses to please contact the Lab so the second draw may be done in a timely manner.

The Results
Since the sepsis core measure is “all or nothing” for compliance, it is a challenge. However, the results at Memorial Hospital are consistently improving. Use of the revised sepsis order sets started in the low teens and has increased to about 65%. Total compliance with the Sepsis Bundle has increased to the mid-50’s. The team continues to meet every other week and gather input from the ED physicians and hospitalists to address the challenges, one of which is early recognition of sepsis so the timeframes can be met.

For More Information
Lynnette Torres is the Quality Improvement Manager for Memorial Hospital of Carbondale. For more information, including the tools used by Memorial Hospital of Carbondale, contact Lynette at 618-549-0721 Ext. 65472 or 618-684-3156 Ext. 55610. Memorial Hospital of Carbondale is a 140-bed tertiary care hospital, serving as the flagship hospital for Southern Illinois Healthcare and regional center for the 16-county southern Illinois region.

Great Read – IHI Reliability Article

IHI recently shared good advice on how to improve care to lessen the likelihood of human error.  Systems and processes can be made more reliable by standardizing, simplifying, reducing autonomy and highlighting deviation from practice.  Read article.

 

 

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.

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/

Are Critical Thinking Skills Becoming Extinct?

As an RN for nearly 30 years, I’ve seen many changes in the healthcare arena since I started as a Student Nurse Assistant in 1986. I recently had a discussion with other healthcare providers regarding the identification of patients with sepsis. The topic of young healthcare providers lacking critical thinking skills came up. This is a conversation that I’ve had with multiple healthcare providers over the past few years, but this time it just really frustrated me. The conversation brought up many potential contributing factors, such as patients entering the hospital more acute than they have been historically; shorter duration of hospital stays; and the emergence of technology.  After the conversation I began thinking that maybe today’s generation of healthcare providers is disadvantaged in that documentation is electronic and mainly checkboxes, placing a reliance on technology.  My theory is that maybe there is an association between actual writing, and learning the relationships and associations that are the foundation for critical thinking skills.

I began thinking of my own career as a Neonatal ICU nurse and remember how the first institution I worked at required an environmental assessment ….gasp…handwritten (actually EVERYTHING was handwritten, I even had a color coded pen, one color for day shift, another for evening and another for night) at the beginning of every shift. So, I had to start off my shift writing:  “Received infant in “name of warmer bed brand/isolette brand” set on “manual mode/servo mode” set at “__”. Infant on “type & brand of ventilator” settings at “list the settings” with “self-inflating bag or anesthesia bag at bedside.”  Infant attached to “brand of monitor” with heart rate alarms set at “…”, respiratory rate alarms set at “…”, B/P alarms set at “…” and O2 sat alarms set at “…”.”  Anyway, I think you get the idea.  But the point is that writing this assessment set into motion relations between what I was writing/observing and the condition of the infant.  It started the foundation for that “critical thinking process.”  I remember learning through writing my observations/assessment on a premature infant the association between hypothermia and hyperglycemia…that it usually meant the infant was stressed and we (the healthcare team) needed to be assessing possible causes. So going back to my theory of recognizing relationships/associations through writing what you’re observing had me going to Google (yes, I confess to absurd love of Google for all my questions!). What I found was a multitude of articles supporting my theory that writing notes does help your brain develop relationships and associations.  Now granted a Google search is definitely NOT scientific research of any kind, but it does provide a starting point.

That leads me to wondering how we can help the upcoming generation of healthcare providers develop these critical thinking skills. Technology is here to stay and to be honest I think it’s a good thing! But, I can see where the above mentioned factors can put up a barrier into the development of critical thinking skills.  Patients are more acute, they usually have a multitude of diagnosis, not just one.  The stay in the hospital is also shorter, which actually means that healthcare providers need to have those critical thinking skills as the opportunity to observe/assess your patient is shorter. So my question to other healthcare providers is threefold:

  • What do you think? Are critical thinking skills becoming extinct?
  • If so, what are some potential solutions to help develop critical thinking skills?
  • How can we leverage technology to assist with the development of critical thinking skills?

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.