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

The Second Victim Experience – Train-the-Trainer Workshop

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.

Program Objectives

  1. Describe the ‘second victim’ phenomenon and high risk clinical events.
  2. Describe the six stages of second victim recovery.
  3. Utilize components of the Scott Three tier model of support to design a plan for your organization.
  4. Develop a plan to deploy peer support team training.

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Second Victim Train-the-Trainer Workshop Underway Today!

fullsizer1Today the Center for Patient Safety partnered with the University of Missouri Hospital to teaching how to implement a Second Victim program.  Great support program for health care professionals who are involved in an unanticipated patient event causing harm.  Participants are from across the country.

CPS Newsletter, Summer Edition Released!

NewsImageThe latest newsletter from the Center for Patient Safety has been released. You won’t want to miss the best practices and patient safety resources in this issue!

View this newsletter

A NEED FOR SPEED
Improving Event Investigation through the Development of SPRINT: Serious Patient Safety Event Rapid Investigation Teams. 4

THE ORANGE DOOR
Facing use of street drugs and alcohol, and decreased availability of medical care and facilities for individuals suffering mental or behavioral illnesses, Liberty Hospital has been able to stem the tide using a multi-disciplinary approach to helping create a safer care environment for staff and patients alike. 6

A UNITED FRONT TO IMPROVE CARE
What the AHRQ guidance means for providers and their patients. 11

PSO LEGAL UPDATE:
Cases involving the Patient Safety and Quality Improvement Act continue to work their way through state and federal courts. 15

EMS UPDATE:
New CPS report seeks to raise awareness of safety concerns in the EMS community. 16

ALSO IN THIS ISSUE:

  • Call to Action: Change the Statistic
  • Safety Insider
  • Watch Your Step, a Falls Analysis
  • New CPS Report Seeks to Raise EMS Awareness: EMSForward
  • CPS Unveils New Website
  • Put the Focus on Safer Care in EMS Community
  • PSO Update: For PSO Participants

Second Victim Study: Research Volunteers Needed!

Are you a clinician who has been part of an adverse clinical event? Did it lead to a career transition into a new role or position? If you answered yes, your insight is needed!  Researchers at University of Missouri Health Care and University of Massachusetts‐Boston are seeking clinicians to participate in a short online survey about the impact of adverse clinical events on career transitions. The survey takes about 10 minutes. Responses are anonymous and confidential. You can take the survey by clicking this link.

CPS White Paper Released:  The Intersection of Safety Culture, Second Victim Intervention Programs and PSOs

 

On September 24, 2015 the Center for Patient Safety, in collaboration with MU Health Care and the North Carolina Quality and Patient Safety Center PSO, released a white paper discussing the integration of Second Victims Intervention Programs within health care settings. The paper highlights the importance of high reliability concepts and a safety culture to encourage and support event reporting, learning and prevention, support for caregivers and advantages of working with a PSO to further support a safety culture. Details about development and results of the MU Health Second Victim Intervention Program and integration of a Second Victim Program at the University of North Carolina are also included.  Read the White Paper here. 

Caring for our Caregivers

There is growing and significant interest in EMS provider mental health.  This has been attributed to the increasing number of stories about provider mental health issues.  EMS leaders from around the country are taking notice and looking for ways to improve as well as implement the best support for our men and women on the frontlines of healthcare.  The Center for Patient Safety has likewise been concerned about this distressing and often not discussed topic.  There are likely many causal factors for these cases, regardless; each one is tragic as many providers have no place to turn.

Being a provider can bring unique challenges that are often only understood by another provider.  One unique program that is available is the Second Victim Program.  This program has been developed by health care professionals that understand those unique challenges.  Please join the Center for Patient Safety on September 3rd for a free webinar to learn more about the Second Victim Phenomenon and how this program might help make a difference. To register or read more.

Second Victims in EMS

Being an EMS health professional often requires putting emotions aside for the sake of patients. But despite the emotional resilience that allows EMS healthcare providers to care for patients under stressful, high-stakes circumstances, sometimes an unexpected clinical event or outcome can have a heavy emotional impact.

Earlier this year, a paramedic took her life following a 25 year career in EMS:

“Really, EMS sees it all. It’s the accumulation of that exposure to trauma that gets really wearing,” Kim Gorgens said, a former paramedic and now clinical associate professor at Denver University. Gorgens said the industry must do better to recognize, and treat those who are suffering.  Read the full article.

Second victims are “Healthcare team members involved in an unanticipated patient event, a medical error and/or a patient related injury and become victimized in the sense that they are traumatized by the event.  Frequently, these individuals feel personally responsible for the patient outcome.  Many feel as though they have failed the patient, second guessing their clinical skills and knowledge base.”

Second victims may exhibit a wide variety of physical and psychosocial symptoms. Signs and symptoms of this emotional aftershock may last days, a few weeks, a few months or even longer. Many second victims feel quite vulnerable by the wide ranging symptoms and frequently express that they have never experienced such an intense emotional response in their lives.

Despite the increased understanding of the second victim phenomenon, many of today’s EMS organizations are unaware of how to act on that knowledge to support their health professionals. Therefore, many healthcare providers still suffer alone after an unanticipated clinical event. Through proper social support and guidance, EMS organizations can prevent excellent healthcare providers from experiencing long-term consequences such as prematurely leaving their chosen profession or experience prolonged professional and personal suffering.

If you are interested in learning more about implementing a second victim support framework within your health care setting, there are several resources available.

In collaboration with the University of Missouri Health System Second Victim Program, the Center for Patient Safety is pleased to host the following workshops:

SECOND VICTIM: TRAIN-THE-TRAINER WORKSHOP
September 24, 2015 from 7:30-3pm
FIND OUT MORE

SECOND VICTIM: CARING FOR THE CAREGIVER
September 3, 2015 12:00-1:00
FIND OUT MORE

New Patient Safety Primer from AHRQ on Second Victims

New Patient Safety Primer from AHRQ on Second Victims

A health professional is often required to put emotions aside for the sake of their patients. But despite the emotional resilience that allows healthcare providers to care for their patients under stressful, high-stakes circumstances, an unexpected clinical event or outcome can have a heavy emotional impact.  Named Second Victims’ by Albert Wu, these health care professionals often struggle alone.

Second Victims are healthcare team members involved in an unanticipated patient event, a medical error and/or a patient related injury and become victimized in the sense that they are traumatized by the event.  Frequently, these individuals feel personally responsible for the patient outcome.  Many feel as though they have failed the patient, second guessing their clinical skills and knowledge base.

If a healthcare employer lacks a structured coping method, the second victim response can result in career-altering experiences for even the most engaged professionals.  Learn more about the Second Victim Experience.

In collaboration with the University of Missouri Health System Second Victim Program, the Center for Patient Safety is pleased to host the following workshops:

  • Train-the-Trainer Workshop in Saint Louis, Missouri. Registration is limited!  Read more.
  • Free Second Victim webinar for EMS providers – “Second Victim: Caring for the Caregiver”.  Read more.

Read the Agency for Healthcare Research & Quality’s Patient Safety Primer:  Support for Clinicians Involved in Errors and Adverse Events (Second Victims).

Babies Switched in Hospital – Nurse Fired!

Doug Wojcieszak of Sorry Works! shares an interesting blog regarding a mistake made at a hospital in Texas where babies were given to the wrong mothers.   DNA testing assured the parents had their correct babies, but the nurse was fired. We don’t know the details, but consider the harm done to the nurse as well as the hospital.  Do you think their employees are willing to report future errors or near misses?  Read more

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.