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.

 

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.

 

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!

Patient Safety Resources

Are you frustrated because others in your organization don’t seem to have the same passion or urgency to improve patient safety?  Limited resources and increasing financial pressures are driving the focus on patient safety down on the list of priorities.  It’s difficult to build a business case to support the importance of constantly improving patient safety.  Now there’s help!  The Institute for Healthcare Improvement and National Patient Safety Foundation recently published a resource to assist you – and it’s free!  Remember that improving patient safety is a journey, not an initiative.  Never give up!

Zero Harm

Zero Harm – that’s the goal for every health care provider!  The only way to achieve this is for patient safety to be embedded into your culture.  That means  organizational leaders make it a priority by “walking the walk and talking the talk”. The culture must change the providers’ thinking from “it’s a known complication” or “it sometimes happens” to “not on my shift!”  Recently the American College of Healthcare Executive and the National Patient Safety Foundation released a whitepaper which provides guidance and tools to advance your organization’s culture of safety.   Whether you are just beginning your journey or are attempting to sustain levels of improvement, click here to downlad the guide which will be useful in directing your efforts and evaluating your success along your journey to zero harm. 

 

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.

 

 

“EMSForward” Campaign Focuses on Culture to Increase Patient Safety Awareness in EMS

The new campaign from the Center for Patient Safety (CPS) highlights the ten safety topics that will move “EMS Forward” in 2017. The emergency medical services (EMS) safety campaign was launched January 23, in conjunction with the annual National Association of EMS Physicians conference in New Orleans.

New laws and a changing healthcare system mean EMS professionals are being called upon to change their processes. To meet these new expectations, the advancement of safety in EMS must be a focal point for EMS leadership across the nation.

“Patient safety rests with the attitudes, beliefs and perceptions of everyone across the healthcare continuum”, said Lee Varner, CPS Patient Safety Director. “This year’s campaign is about making the culture connection and identifying the importance of organizational culture when it comes to safety.”

The ten patient and provider safety topics are projected to be of greatest concern in EMS in 2017 and include areas such as bariatrics, pediatrics, and airway management.  The campaign is not an all-inclusive list of safety concerns, but rather a mechanism to drive awareness, support open dialogue, and promote improvement activities.

Each topic is delivered in a real-life scenario and concludes with a question to encourage deeper reflection on the reader’s own organizational culture. As the campaign unfolds throughout the year, CPS will provide support and resources about the topics.

“The EMS community is largely committed to improving safety, and CPS is positioned to support them,” said Alex Christgen, CPS Executive Director. “The EMS Forward campaign is one way to focus our combined efforts. Together, we’ll make an impact in a new and profound way.”

For more than 11 years, CPS has worked to improve safety for both patients and providers by providing creative culture solutions, including Patient Safety Organization (PSO) services, culture assessment services, ongoing education and consultation.

In collaboration with its EMS PSO participants, CPS developed a data system specifically for capturing the details of medical errors that occur in EMS care environments. The data from the PSO provides supporting evidence for the topic selections in this report.   

Join the EMS Forward campaign and download a free copy of the report at www.emsforward.org.

Download the full press release here.

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

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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.