Latest AHRQ Newsletter Notes Improved Patient Safety with Medical Team Training

The November AHRQ newsletter has two examples about the positive influence of team training on medical workers and its effect on patient safety.     Dr. Robert Wachter, Editor of AHRQ WebM&M, spoke with Dr. Eduardo Salas, a professor of Psychology at the University of Central Florida who served in the Navy for 15 years, about applying lessons learned from military team work training to medical teams.   “Those who know about teamwork do better.” Read the  interview and listen to a perspective piece online.

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Surgical Fire Prevention Toolkit from the FDA

The Food and Drug Administration has launched the Preventing Surgical Fires Initiative.   Resources that are part of the initiative include a toolkit for organizations to use to reduce the risk of surgical fires including a fire safety video from the Anesthesia Patient Safety Foundation.   As part of the initiative, the Association of PeriOperative Registered Nurses is making the Fire Safety Toolkit available for download free of charge through November 13.  

20 Tips to Help Prevent Medical Errors – Patient Fact Sheet

Medical errors can occur anywhere in the health care system: In hospitals, clinics, surgery centers, doctors’ offices, nursing homes, pharmacies, and patients’ homes. Errors can involve medicines, surgery, diagnosis, equipment, or lab reports. These tips tell what you can do to get safer care.

 

20 Tips to Help Prevent Medical Errors

Patient Fact Sheet


Medical errors can occur anywhere in the health care system: In hospitals, clinics, surgery centers, doctors’ offices, nursing homes, pharmacies, and patients’ homes. Errors can involve medicines, surgery, diagnosis, equipment, or lab reports. These tips tell what you can do to get safer care.

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One in seven Medicare patients in hospitals experience a medical error. But medical errors can occur anywhere in the health care system: In hospitals, clinics, surgery centers, doctors’ offices, nursing homes, pharmacies, and patients’ homes. Errors can involve medicines, surgery, diagnosis, equipment, or lab reports. They can happen during even the most routine tasks, such as when a hospital patient on a salt-free diet is given a high-salt meal.

Most errors result from problems created by today’s complex health care system. But errors also happen when doctors* and patients have problems communicating. These tips tell what you can do to get safer care.

What You Can Do to Stay Safe

The best way you can help to prevent errors is to be an active member of your health care team. That means taking part in every decision about your health care. Research shows that patients who are more involved with their care tend to get better results.

Falls are Leading Cause of Injury Deaths for 65+ Population

Friday, September 23rd is the nationwide Falls Prevention Awareness Day. The Missouri Center for Patient Safety encourages everyone to consider the falling risks our loved ones may face, participate in local Falls Awareness Day activities, and take action.   The Missouri Department of Health and Senior Services website offers a listing of Falls Day activities throughout Missouri, as well as numerous resources to identify and reduce the risk of falling for elderly loved ones. (more…)

Pharmacists Reduce Medication Discrepancies for the Elderly at Discharge

Research reveals a decrease in medication discrepancies may be possible if a pharmacist is included in the patient discharge planning with the internal medicine team.

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Australia Developing Strategy to Address Violent Patients

Australia is proposing methods to address violent patients in their hospital EDs. One suggestion is a card system, similar to the one in place in the United Kingdom, that could help to reduce the number of violent acts towards Emergency Department staff and other patients.
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AHRQ Issues Healthcare Associated Infections Research Protocol

“Closing the Gap:   Prevention of Health Care-Associated Infections” updates a 2007 AHRQ report, recognizing the “volume and range of activity” in reducing HAIs.   The report expands to healthcare settings other than hospitals, including ambulatory surgery centers; focuses on infections relating to surgical sites, and the use of central lines, catheters, and ventilators; discussing the link between quality improvement strategies and reduction of HAIs.

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“Closing the Gap: Prevention of Health Care-Associated Infections” updates a 2007 AHRQ report, recognizing the “volume and range of activity” in reducing HAIs. The report expands to healthcare settings other than hospitals, including ambulatory surgery centers; focuses on infections relating to surgical sites, and the use of central lines, catheters, and ventilators; discussing the link between quality improvement strategies and reduction of HAIs.

The National Quality Forum Releases 2011 Serious Reportable Event (SRE) Update

The NQF has released “Serious Reportable Events in Healthcare – 2011 Update: A Consensus Report”, including updates to 25 SREs, and adding four new SREs.

New SREs are events resulting in death or serious injury related to the loss of biological specimens, failure to communicate test results, neonates associated with labor or delivery in a low risk pregnancy, and metallic objects in MRI areas. Updates also address SREs in settings other than hospitals, including outpatient/office-based surgery centers, skilled facilities and office-based practices.

Missouri Center for Patient Safety Announces New Website

Patient safety web site delivers a new level of communication, awareness and learning for MOCPS participants and the public.

Jefferson City, MO (PRWEB) June 09, 2011

The Missouri Center for Patient Safety (MOCPS) has introduced a new web site at https://www.centerforpatientsafety.org for use by health care providers and the general public to enable a greater focus on important patient safety related issues and services.

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TJC Announces National Patient Safety Goal Addressing CAUTI

The Joint Commission has approved a new National Patient Safety Goal for 2012 related to catheter-associated urinary tract infection (CAUTI) prevention in hospitals.   The goal requires implementation of evidence-based practices to prevent CAUTIs, which account for up to 80 percent of all healthcare acquired infections (HAIs).

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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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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.