Register Now – Limited Space! Second Victim Train-the-Trainer Workshop

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Thursday, September 24, 2015,
730am – 3pm
Mid-America Transplant Services
1110 Highlands Plaza Drive East
Suite 100
St. Louis, MO 63110

Hosted by:

CPS Logo

Registration fee $399, second from same organization $350.  Space is limited, so register early.  Please note cancellations will not be accepted after August 1, although replacement for registered attendees is allowed by contacting the Center.


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New ISMP LTC AdvisERR Issue Describes New Enteral Connectors

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Twenty-five years ago, I was involved in the investigation and response to a patient’s death that occurred because a really good nurse accidentally administered tube feeding into the patient’s IV.  At the time, we looked in vain for a foolproof connector system to prevent any future similar mistakes.
Recently, new standards have been driving the development of connectors  for enteral (tube feeding) systems that are incompatible with other connectors.  The latest edition of LTC AdvisERR from the Institute for Safe Medical Practices (available here) has an extensive description of one of these systems, with comprehensive information on its benefit.  In safety science we look at establishing barriers that keep our caregivers from making inevitable human errors.  This design and the recommendations behind this represent a true step forward for the science of safety.

US Supreme Court asked to review Kentucky Supreme Court decision about Patient Safety Act

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On March 20, 2015, the American Hospital Association and Federation of American Hospitals filed a friend-of-the-court brief urging the Supreme Court to review a Kentucky Supreme Court decision that could compromise Congress’ intent that the Patient Safety and Quality Improvement Act of 2005 protect health care providers’ reports to patient safety organizations from discovery in litigation. The brief explains that patient safety organizations “can aggregate data from members; provide evidence-based analysis of the root causes of medical errors and near-misses; and propose systems-focused solutions to prevent future mistakes.” Recognizing that these objectives can be achieved only through broad-based participation by providers who can honestly assess their mistakes without fear of repercussions, Congress established federal confidentiality for reports to a PSO. The brief indicates the Act’s privilege is “a critical tool for improving patient safety,” and said the Kentucky decision “is particularly unwarranted” because medical records and traditional tools of discovery are available to plaintiffs to find out the facts underlying an incident.

Reduce Medication Errors in EMS

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Nobody wants a medication error but often we don’t have a new strategy or method for prevention.  Experts suggest that most errors are linked to a flaw in a system design or an unfortunate behavioral choice.  Regardless, working towards prevention requires better processes as well as improving our safety behaviors.  To learn more, check out this article by Kim D. McKenna MEd, RN, EMT-P, recently posted at

AHRQ Releases WebM&M

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The Agency for Healthcare Research and Quality has released the April WebM&M, morbidity & mortality rounds on the web.  Spotlighted case is “Dissecting the Presentation“, with additional cases: “Transition to Nowhere” and “Fire in the Hole! – An OR Fire“.

Surgical checklists are also addressed this month with an interview with Lucian Leape,MD, Adjunct Professor of Health Policy at the Harvard School of Public Health, and an interview with David Urbach, MD, MSc, Professor of Surgery and Health Policy, Management and Evaluation at the University of Toronto.

Safety Alert Issued: High Alert Medications

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PSOAlert!The Center for Patient Safety is issuing a Safety Alert based on industry data and recent findings from event data being submitted to the PSO.  The following areas of concern have been reported to the PSO:

  • A pediatric patient receives a higher than standard dose of Propofol and requires resuscitation.
  • A battery fails on an insulin IV pump and goes unnoticed.
  • Approximately one in every five reported PSO medication events involves a high alert medication such as anticoagulants (warfarin, heparin, Lovenox), Propofol, insulin, hypoglycemic agents, opioids and so forth. Events relate to prescribing, dispensing, administering and monitoring errors.

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Safety Watch Issued: Endotracheal Intubation in EMS

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Safety WatchThe Center for Patient Safety is issuing a Safety Watch based on industry data and recent findings from event data being submitted to the PSO.  The following areas of concern have been reported to the PSO:

  • Tube dislodgement during patient movement
  • Patient aspiration
  • Rapid Sequence Intubation

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Just Culture, Routine Activities, and the Severity Bias

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In Just CultureSM, we address two factors that often interact to undermine our efforts to provide safe and effective care.  The first is severity bias.  If an organization reacts to a harmful outcome by punishing the person involved, yet ignores the same behavior when the outcomes are good, that is severity bias.  The article at the end of this link has a perfect example.  Night nurses at a state group home frequently slept through their shifts.  This was generally known.  Yet, when a resident died because his nurse missed the two-hour check on his oxygen, the facility fired her.  While her choice to sleep was a poor one, it was poor every night.  And it was a poor choice for all the other staff members who did it.  But only the one who got “caught” was punished.

When an organization tolerates these choices, it creates a culture that says the choices are OK—just don’t get caught.  In the article, it seems that the home was able to fill hard shifts and pay staff less by allowing (or quietly ignoring) their choice to rest on shift.  It normalizes deviance.

What message does your organization send to staff members by looking past (normalizing) choices that deviate from policy?  And what further message does it send if it punishes only those individuals who are closest to a bad outcome?

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