The Joint Commission is enhancing its focus on patient safety in hospitals, as evidenced by their October 20, 2014 announcement of a “first time event” – publishing a standards chapter on-line to ease access to key patient safety standards spread throughout their accreditation standards. Ana Pujols McKee, M.D., executive vice president and chief medical officer of the TJC states, “A solid foundation for patient safety is a safety culture. For leaders, our hope is they will study this chapter and use it as a tool to build or improve their safety culture program. Developing a culture of safety starts at the top of the chain of command, and then works its way through the layers of management and employees to build trust which is an essential ingredient for improvement. In order for improvement to take root and spread, leaders need to be engaged and know the current state of the culture in their organization.” The chapter is oriented toward leaders to establish a safety culture that leads to learning from patient safety events. Go to the Center’s website to learn more about the Center’s safety culture assessment and training services.
The latest newsletter from the Center for Patient Safety has been released. The Fall 2014 EMS PSONews contains information on the recently released PSO Safety Alert and EMS Safety Watch, articles on the legal environment to help maximize federal protections from the PSO, patient safety culture topics, and much more! Download the newsletter or view on Issuu.
All of us have the power to think and act in ways that keep patients safe. That means that everyone must use every tool at our disposal to avoid infection. That includes following CDC recommendations to get an annual flu vaccine. Our responsibility for patient safety means that we all must employ appropriate infection control procedures, not just when an infectious disease such as Ebola is in the headlines, but every single day. It means that hospital leaders must be vigilant in keeping clinical and nonclinical staff updated on policies, procedures and protocols relating to infectious diseases. And it means putting all of this into practice through training and exercises. Please check the AHA website for updated Ebola preparedness resources.
CPS has given the ISMP’s LTC AdviseERR shout outs in the past. We also talk a lot about distractions and interruptions as one of the most widespread causes of mistakes. ISMP takes on the distraction issue in its latest issue of its long-term care medication safety newsletter, available here. This issue speaks to the scope of the problem and has some great suggestions for controlling it. Subscribe to the newsletter.
Beginning in 2015, CMS will implement the following improvements to the Nursing Home Five-Star Quality Rating System:
• Beginning in January, focused survey inspections for a sample of nursing homes improve verification of staffing and quality measure information that is part of the Five-Star Quality Rating System.
• Implementing a quarterly electronic reporting system to audit payrolls to verify staffing information to improve accuracy and timeliness of data, and allow for the calculation of quality measures for staff turnover, retention, types of staffing, and staffing levels.
• Increasing the number and type of quality measures used in the Five-Star Quality Rating System.
• Strengthening requirements for states to maintain user-friendly websites and complete inspections of nursing homes in a timely and accurate manner.
• Improving the scoring methodology for calculation of facility quality measure ratings that are used for the Five-Star rating.
The Center gets many questions about TeamSTEPPS training. Nationally, Master Training Course information for 2015 is now available! Registration for TeamSTEPPS Master Training Course for Primary Care, adapting the core concepts of TeamSTEPPS for primary care office-based teams, is available at https://www.onlineregistrationcenter.com/primary-care. Additionally, general Master Training Course registration for classes January through May is expected to be available in early November at http://www.teamsteppsportal.org/.
The Center for Patient Safety has released a PSO alert regarding the potential for confusion when administering Midazolam or Morphine.
As a Patient Safety Organization (PSO), the Center for Patient Safety collects incident, near miss, and unsafe condition information on multiple types of healthcare related cases, including EMS medication events.
Recently, there has been a trend of medication errors pertaining to the administration of the incorrect medication involving Morphine and Midazolam. Specifically, confusing the two medications and administering the wrong medication.
Possible reasons for the error:
- Similar names of medication
- Similar packaging or container
- Similar route of delivery
- Medications were locked together
- No cross check process in place or time out taken before administration
Read the full alert and view recommendations and helpful resources.
October 2014 is recognized as “Talk About Your Medicines” month by the NCPIE in participation with the American Pharmacists Association Foundation. October brings awareness for patients and caregivers about benefits of documenting medications, sharing that with families and health care providers and talking with pharmacists to coordinate medication refills and compliance.