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

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Free Teleconference

The Center for Patient Safety’s mission is to help health care providers improve their culture.  Along those lines, IHI is offering a free teleconference on Thursday, March 8 at 1:00 pm Central Time, when two leading experts will address the importance of mindfulness as it relates to patient safety.  No cost, but registration is required.  The presenters also recently shared a free white paper:   10 Mindfulness Exercises for the Health Care Workplace.

 

AHRQ Posts Medical Office Toolkit for Tests

Some of the best-known safety speedbumps for physician practices lie in the patient testing area.  Orders have to be developed and communicated, results communicated from the lab to the office and then to the patient or other providers.  The provider who ordered the test has to see the results and react appropriately.  Documentation of this process needs to be complete and accurate.   AHRQ has developed a toolkit to address this issues in collaboration with the University of Colorado.  It is available here.  [link:  https://www.ahrq.gov/professionals/quality-patient-safety/hais/tools/ambulatory-care/labtesting-toolkit.html?utm_source=ahrq&utm_medium=en&utm_term=&utm_content=1&utm_campaign=ahrq_iltp_2018]  And remember that in support of that work, the Center for Patient Safety offers the AHRQ Safety Culture Survey for Medical Offices, along with follow-up support to improve the culture behind the work.

 

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

Patient Access to Care Notes

Heads up!  Copying and pasting in your electronic health record (EHR) might make your documentation process easier, but it can result in big issues downstream as other care providers take action based on inaccurate information.  AHRQ recently published an article by Dr. Shannon Dean from the University of Wisconsin School of Medicine which outlines the concerns and some potential “fixes”.  I like the following:  “The OpenNotes initiative—which allows patients to read their clinicians’ notes—represents another real opportunity for heightening provider awareness of the need for documentation accuracy, as patients will now also be able to hold us accountable for quality documentation.”  What do you think – would allowing patients access to the care notes lead to more accurate documentation?

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/

CPS Safety Watch/Alert – Medication Shortages

Medication Shortages:

  • Adversely affect drug therapy
  • Can cause complications in medical procedures
  • Contribute to medication errors
  • Create frustration for providers & patients

ACTIONABLE ITEMS TO MITIGATE RISK

  • Validate details of shortage & check with suppliers
  • Determine stock on hand
  • Determine purchase history & true use
  • Estimate time until shortage impacts agency & length of shortage
  • Identify alternative drug and sources

THE CULTURE CONNECTION

  • Communicate with staff details regarding shortage:
    • Specific drug & effective date/length of shortage
    • Alternative drugs/concentrations
    • Temporary guidelines & processes
  • Utilize teamwork to identify susceptible patient population
  • Review the 5 “R’s” of medication administration (Right medication, Right dosage, Right route, Right patient, Right time)
  • Implement 2-person medication read-back or cross-check policy

RESOURCES

 

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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

Administering a Culture Survey

IF IT’S EASY, YOUR PROBABLY NOT DOING IT RIGHT.

Why assess your culture?

You can improve what you measure. Without measuring, you have no way to know if you are improving.

These statements are especially true when it comes to assessing your culture. It may be easy to take a quick poll of staff and infer their perceptions to that of the rest of your organization’s employees, but there’s no certainty in your results. Using a standardized survey tool can provide measurable and meaningful feedback.

Another reason to assess your culture is because many regulatory and certifying bodies now require or recommend measurement of an organization’s patient safety culture. This is because they, too, recognize the clear connection between strong cultures with open communication and the effective implementation and sustainability of patient safety and quality improvement programs.

  • The Joint Commission
  • Leap Frog
  • CMS Merit-based Incentive Payment
    System (MIPS)
  • CMS Quality Assurance and Performance Improvement (QAPI)

The Center for Patient Safety has been administering culture assessments since 2010, and we understand the most successful organizations have a fine-tuned process for administering the survey and analyzing their results. In this article, we’ll discuss some of the most pertinent planning details when preparing to launch a survey. Subsequent articles will include diagnostic tips for evaluating your survey data.

While standard online survey templates may ease the burden of survey administration, there are four key areas that, if addressed upfront, can save time, resources, and frustration in the long run.

1. Which Tool.
The Center has always supported the Agency for Healthcare Research and Quality’s (AHRQ) Survey on Patient Safety (SOPS) tools though there are many other surveys that can provide a similar analysis. The SOPS tools have been developed for a multitude of healthcare provider types with specific, relevant questions asked, based on varying care settings, such as nursing homes, hospitals, ambulatory surgery centers, pharmacies and medical offices. These surveys have also been psychometrically tested and validated and are available in more than 40 languages.

2. Which Medium.
How do you normally administer surveys to your staff? Are they at ease with an online version, or are they most comfortable with a paper survey? While this seems like an insignificant question, it is quite important. If staff are fearful, they will hesitate to write unfavorable feedback on a paper survey because they think their handwriting will be recognized. However, they may also think the organization will track their online response back to them for purposes of punishment. Using a third party vendor often works best and creates a neutral environment for staff to respond. Consider offering a combination of online and paper surveys. Allow staff to take the survey in a confidential environment with varying options for submitting them. Providing options other than submitting them to their manager increases anonymity, resulting in truer results.

3. Custom Questions.
We often get question-happy when it comes to surveys. It’s efficiency at its finest: “While we have our staff’s attention, let’s just go ahead and ask a few more questions, like what they thought about the EHR implementation, their employee engagement for the year and what sport the organization should have at the next company picnic.” This is a big no-no. If you’re using a standardized survey, keep the list of questions short and relevant. The AHRQ SOPS ask about 45-50 questions and can take up to 15 minutes to complete. Limit additional questions to no more than five and keep it related to culture. More than five questions on an unrelated topic will cause confusion and create survey fatigue.

4. Promotion.
Staff won’t do something if they don’t know they need to do it. Put a little effort into marketing the survey and you’ll get a very valuable return. The more staff that take your survey, the more accurately your results will reflect the culture of your organization. This in turn gives you better data to analyze. Plan with your marketing department, do a search on Google, or harness your creativity to develop posters and email templates. Ask your CEO or President to write a brief memo about the value and importance of all staff taking the assessment and their desire to see honest feedback. Put a link to the survey on your Intranet; distribute surveys at a monthly staff meeting; offer a certificate for a free drink for turning in a completed survey; or host a pizza party if you reach your target response goal. These are small tokens of appreciation that can have a big impact on getting valuable insight.

In Summary 

Your time will be most efficiently spent analyzing the results and preparing action plans post-survey, so addressing these four areas upfront will remove many of the headaches that can go along with planning and administering a survey. If a third-party option is a better choice for you, please contact the Center for Patient Safety to discuss our custom options. We’ll even help in the analysis of your survey results. Find out more information about our survey services.

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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.