CPS Safety Alert/Watch – LIFEPAK 15 Monitor/Defibrillators

BACKGROUND:

  • Stryker Launches Voluntary Field Action for Specific Units of the LIFEPAK 15 Monitor/Defibrillator.
  • Stryker has become aware that certain LIFEPAK 15 Monitor/Defibrillators were reported to experience a lock-up condition after a defibrillation shock was delivered.  This condition is defined as a blank monitor display with LED lights on, indicating power to the device, but no response in the keypad and device functions.
  • The company is contacting customers with impacted devices to schedule the correction of their device(s), which will include an update to the firmware for a component on the System Printed Circuit Board Assembly.

ACTIONS TO TAKE DURING AN EMERGENCY:

  • If a device exhibits the lockup condition during patient use, the steps from the General Troubleshooting Section (page 10-18) of the LIFEPAK 15 Monitor/Defibrillator Operating Instructions should be immediately followed:
    • Press and hold ON until the LED turns off (~5 seconds) Then press ON to turn the device back on
    • If the device does not turn off, remove both batteries and disconnect the device from the power adapter, if applicable.  Then reinsert batteries and/or, reconnect the power adapter, and press ON to turn the device back on.

ADDITIONAL RESOURCES:

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.

 

Press Release: Center Promotes Patient Safety Awareness Week March 11 -17th

The Center for Patient Safety (CPS) acknowledges the continuous focus on safe care across the continuum of healthcare. To support year-round efforts of healthcare providers, professionals and consumers, CPS will set aside time to highlight important patient safety issues, spread awareness and provide resources, during Patient Safety Awareness Week (PSAW).

“From March 11 to 17, we are emphasizing that safety in the delivery of healthcare is the highest priority all the time,” said Alex Christgen, Executive Director of CPS. “Safe care is the most important aspect of care regardless of where that care takes place, from EMS, to hospitals, physician offices, ambulatory settings, pharmacies, home or long-term care settings.”

CPS has several key initiatives planned for Patient Safety Awareness Week and beyond:

Patient Safety Forum, March 14, 2018 – CPS is highlighting PSAW by partnering with Medtronic to offer all caregivers a Forum in St. Louis MO focused on learning to identify and care for patients with respiratory compromise. 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? This forum is a collaborative opportunity to learn with other providers across the continuum of care how patient safety can be improved.

Patient Safety Awareness Week Tips and Toolkit – Healthcare professionals are encouraged to take advantage of the PSAW Tips page or download the PSAW2018 Toolkit, which is free to CPS Subscribers. The toolkit includes a downloadable poster, flyer, stickers, table tent, desktop wallpaper, and social media image. Also included is a Toolkit Guide to help you celebrate throughout the week and the rest of the year. Engage other providers in your community and across the care continuum, encouraging patients and family members to ask, “How do you provide safe care?”

About CPS: The Center for Patient Safety is a private, not-for-profit corporation dedicated to fostering change throughout the nation’s healthcare delivery systems and across the continuum of care. The Center’s vision is a healthcare environment safe for all patients and healthcare providers, in all processes, all the time. Find the Center on Facebook and Twitter @PtSafetyExpert and @PtSafetyEMS

Download Press Release

National Fire Prevention Week perfect time to learn ways to stop surgical fires

The Center for Patient Safety joins The Joint Commission in recognizing National Fire Prevention Week. Unfortunately, surgical fires continue to occur.  Recent reports to the Center’s PSO include:

  • 4×4 held by the surgeon caught on fire from a cautery during eye surgery
  • Electrical fire in the fluoro base of a cysto table
  • Flash fire during removal of a mole
  • Patient’s beard started on fire during removal of lesions with cautery

 

It’s never too late to remind staff and physicians about the factors that contribute to surgical fires and  lace to reduce the risk of surgical fires. Together, we can make a safer environment!

Emergency Medical Services Agenda 2050. How do see the future of EMS?

The EMS Agenda 2050 “Envision the Future” Straw Man document has been released to the public for comments to guide the future direction of EMS.  The document is a comprehensive and robust body of work with a wide range of topics, all of which are important to the EMS profession.

The Center for Patient Safety (CPS) was founded in 2005 and shortly thereafter began working with EMS.  Over the years we have worked to raise awareness and offer creative solutions around patient safety.

Since our work at CPS is a specialized area of healthcare we are excited to see that the Technical Expert Panel has included a section on patient safety in the Straw Man document.  The document doesn’t merely mention the importance of patient safety but includes 9 areas that focus on the topic of patient safety and developing a culture of safety.  In addition, the areas listed offer innovative and actionable steps for EMS leaders to implement for the reduction of preventable harm.

Today, we see an opportunity to create action and change in the EMS profession regarding patient safety.  Please join us in reading the Straw Man document and then comment on it to let your voice be heard.  CPS will be advocating for the steps listed in the document and welcome your insights on this valuable document-with your input we can effectively address the issues surrounding patient safety.

To learn more about EMS Agenda 2050 and read the Straw Man document use this link.

http://emsagenda2050.org/

Using Culture in Your Organization

This article is an excellent read!  Patient safety culture and patient safety are the buzzwords these days, but what are some actions to help you improve your patient safety culture?

  • First, understand the culture of your organization. This is truly the foundation for prioritizing patient safety.
  • Involve your patients and their family members as active participants in their care. This helps increase their health literacy, which contributes to improved patient outcomes.
  • Reinforce that reporting events is necessary so you can continually evaluate and improve systems—-not to provide fuel to blame the healthcare providers. Providing a user-friendly reporting system that is integrated into your organization’s daily processes will increase the number of reported events and unsafe conditions.

To sum it up:  “In the long run, patient and workforce safety will not only be a moral imperative but will likely be critical to sustainability and essential to delivering on value.”   (Gary Kaplan, MD)

View Article

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 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

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.

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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.