AHRQ Web M&M Released

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The Agency for Healthcare Research and Quality (AHRQ) has released their latest issue of the Web Morbity & Mortality cases and commentaries.  For more information, visit AHRQs website using the links found in the case summaries:

Spotlight Case: Monitoring Fetal Health
A woman who had an uncomplicated pregnancy and normal labor with no apparent signs of distress delivered a cyanotic, flaccid infant requiring extensive resuscitation. Although fetal heart rate tracings had shown signs of moderate-to-severe fetal distress for 90 minutes prior to delivery, clinicians did not notice the abnormalities on the remote centralized monitor, which displayed 16 windows, each for a different patient. The commentary by Mark W. Scerbo, PhD, of Old Dominion University, and Alfred Z. Abuhamad, MD, of Eastern Virginia Medical School, provides an overview of fetal heart rate monitoring, the risks and benefits of this complex process, and factors that influence its safety such as staff training and safety culture. (CME/CEU credit available.)

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Managing Disappointed Employees with CPS tools

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CPS offers Just Culture Training and Survey of Resident/Patient Safety Culture (SOPS) as they are effective tools to manage employee learning and organizational performance.  A recent study (available here and discussed for LTC here)  has demonstrated the adverse impact on organizational health of workers who feel slighted—who believe that their employer has not met the employee’s expectations.  SOPS culture survey can help healthcare providers identify areas where staff believes they are not supported, allowing facility management to address those issues proactively.  Just Culture provides many pathways to explore the expectations and understandings of employees, and encourages intervention where employee understanding is inconsistent with the organization’s goals.
Sign up for either one or get more information at www.centerforpatientsafety.org.

A Message from the CPS Executive Director

    Posted in Becky Miller, Center Info, Events    |    Comments Off
Becky Miller, Executive Director

Becky Miller, MHA, CPHQ, FACHE, CPPS
Executive Director
Center for Patient Safety

We are excited about the Center for Patient Safety’s 10th year as a part of the solution to address the multitude of issues surrounding patient safety.  Safety culture is the KEY!  Medical error prevention and reduced patient harm occurs in organizations with a strong safety culture, supporting and encouraging the reporting of adverse events, near misses and unsafe conditions; reporting that leads to learning what and why errors occur and to sharing of solutions.

We hope you will join us as the celebration continues throughout 2015, including our March patient safety conference and available resources during Patient Safety Awareness Week!

Find out more about Patient Safety Awareness Week.

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PSO 101: Introduction to PSOs

    Posted in Events, PSES, PSO, PSO case law, PSQIA, PSWP    |    Comments Off

January 21 @ 11 Central  – Free webinar

Questions and Answers signpostConfused about Patient Safety Organizations (PSOs)?  You’re not alone!

Join the experts at the Center for Patient Safety as they describe the basics of the Patient Safety and Quality Improvement Act (PSQIA) and provide an introduction to the terminology and concepts of PSO participation.  Applications to EMS, LTC, medical offices, and hospitals will be presented.  Q&A available during webinar.  Register

St. Louis AHRQ SHARE Approach Workshop

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The U.S. Department of Health and Human Services (HHS) and Agency for Healthcare Research and Quality (AHRQ) is offering a free train-the-trainer workshop on shared decision making on January 23, 2015 in St. Louis, MO.

Using the SHARE Approach, a five-step process for shared decision making, these free workshops provide health care professionals with patient decision aids, conversation starters,  tips to communicate with patients, an implementation guide for clinical teams, and other tools that support shared decision making in clinical practice settings.

Clinicians who participate will learn how to implement the SHARE Approach and train peers in shared decision making. Participants can earn up to seven hours of continuing medical education credits (CME)/continuing education units (CEUs).  A learning network and webinar series will also be available to support ongoing implementation.

The January 23 workshop will take place at the Robert A. Young (RAY) Federal Building, 1222 Spruce Street, St. Louis, MO 63103 from 8:30 a.m. to 4:30 p.m. Click here to register. To learn more about the SHARE Approach please visit the AHRQ website.

Thoughts from David Maxfield of Vital Smarts on Change – Applicable to Culture Change in Healthcare

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Check out this recent article on changing culture, “When you’re trying to influence people who need motivation, but not information, don’t offer more information. Instead, use questions to create a safe environment where they can explore motivations they already have.” Read more.

Looking for a great gift idea that keeps giving?

    Posted in Patient Safety, Sponsor/vendor    |    Comments Off

Your tax-deductable donation to the Center for Patient Safety supports ongoing patient safety education and resources to thousands of healthcare providers across the country. Make a donation and support safer care today!

The Center for Patient Safety values partnerships with organizations and individuals who want to support improvement in healthcare quality and patient safety. Because the Center is a not-for-profit organization, donations are tax-deductible.

There are three ways to join the effort to spread safety culture throughout the healthcare community: individual donation, organizational sponsorship levels, and/or supporters can sponsor an event or initiative.

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Insulin Pens: Are your patients safe?

    Posted in Improvement Methods, Patient Safety    |    Comments Off

A success story from CoxHealth, Springfield, Missouri

Insulin pens were designed for convenience to permit a single person to administer multiple self-injections, using a new needle each time. Many hospitals began using the pens because of their convenience and accuracy. However, reports from several hospitals indicated that the pens were being reused, placing thousands of patients at risk. An alert from the Center for Disease Control in 2009 warned that the pens should be used on a single patient only and are not to be shared between patients. Despite this alert, inappropriate use in hospitals continues, indicating that some healthcare personnel do not adhere to safe practices and may be unaware of the risks to patients.
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