Opportunity for Long Term Care Facilities!

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National Collaborative to Reduce Infections, Focus on CAUTI!  SIGN UP BY AUGUST 29th!

The Center for Patient Safety and Missouri Hospital Association are partnering to bring national faculty and resources to Missouri nursing homes to work collaboratively on reducing infections with a focus on eliminating CAUTI!  Sign-up for this opportunity is only available until August 29th!  There is no cost for participating in this collaborative!

Read additional information about the project, including an overview of the project, team leaders responsibilities.

If you are interested in signing up to participate, complete the AHRQ Safety Program for Long-Term Care: CAUTI Online Registration Form.

If you have any questions, please contact Kathy Wire at the Center for Patient Safety at kwire@mocps.org or Jessica Rowden at the Missouri Hospital Association at jrowden@mail.mhanet.com.

Mixed results from Kentucky Supreme Court

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

The Kentucky Supreme Court has issued its anxiously awaited opinion in Tibbs, et al. v. Bunnell (2012-SC-000603-MR). The opinion is available online here. Earlier in the case, the Kentucky Court of Appeals ruled that only work reflecting “self-examining analysis,” could be protected PSWP, eliminating data or reports used as part of that analysis from protection. The hospital appealed, with support from the national PSO community. The Kentucky Supreme Court rejected that restriction based on the language of the law and final rule.  It went on to examine the definition of PSWP as applied to the information sought by the plaintiff, which included incident reports. Read More

Falls Prevention Awareness Day is Sept 23, 2014

    Posted in Falls, Patient Safety, Resident Safety, Toolkit    |    Comments Off

From the Center for Healthy Aging, National Council on Aging (NCOA):

Strong Today, Falls Free® Tomorrow

Falls Free Coalition Logo

Date: September 23, 2014

The 7th annual Falls Prevention Awareness Day will be observed on September 23, 2014—the first day of fall. This year’s theme, Strong Today, Falls Free® Tomorrow, seeks to raise awareness about how to prevent fall-related injuries among older adults.

The Falls Free® Initiative is a national effort led by NCOA to address the growing public health issue of falls and fall-related injuries and deaths in older adults.

Norway uses smaller ambulances with big focus on safety

    Posted in EMS, EMS PSO, Patient Safety    |    Comments Off

ambulance design3Ever wondered what an ambulance from another country might look like?  Ronald Rolfsen from Oslo University Hospital recently spoke about Ambulance Safety and Design at the Kansas EMS Conference.  In Norway, there is a tradition to use smaller ambulances compared to USA. The ambulances are designed with a focus on automobile safety, occupant safety, ergonomics, and user friendliness. At the head of the stretcher is a seat where the airway of the patient would be managed. If you look closely you will see that equipment and necessary tools are within reach. Rolfsen says it’s important to set design standards so crews can take care of the patient and remain secure with seat-belts. The pictures are from Oslo ambulance services new intensive care ambulance.  Thank you for the great presentation at KEMSA, Ronald Rolfsen!

Click “Read More” to see interior photos of a Norway ambulance. Read More

PSOs Are Watching New Florida Decison about PSWP

    Posted in Patient Safety, Patient Safety Act, PSES, PSO, PSO case law, PSWP    |    Comments Off

A Florida trial court order regarding the discovery of hospital incident reports is circulating in PSO circles.  (Charles v. Southern Baptist Hosp. et al., Duyal County, Case No. 15-2012-CA-002677.)  The order expresses a very restrictive view of PSWP (more below) and the hospital has expressed an intention to appeal the order.  As a trial court order in Florida, it has no value as precedent in any other jurisdiction, even within Florida.  However, the order will be part of the ongoing discussion about PSO protections, so CPS wants its stakeholders to understand it. The key facts:

  • Florida has very specific requirements for hospital risk management, including staff licensure and submission of certain incident reports to the state.  The statute also requires the hospital to gather information via incident reports that may not be reported to the state, but which is necessary to carry out the mandated activities.
  • The discovery request specifically asked for reports prepared pursuant to parts of the statute.
  • The court recognized the applicability of the Patient Safety Act and accepted that the hospital had a PSES and that the information was utilized appropriately in that context, and therefore would be protected PSWP except for the state risk management and reporting requirements.
  • The court found that the need to gather the information under state law and to report some of it precluded it from being protected PSWP. Read More

CPS issues Safety Watch on EMS Stretchers

    Posted in EMS, EMS PSO, Events, Patient Safety    |    Comments Off

Safety WatchMultiple stretcher-related incidents have been reported to the Center’s Patient Safety Organization.  The areas of concern are from real events.  Read the full Safety Watch on EMS Stretchers.

Released 08.11.2014.

EMS Hand Washing Study

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EMT Hand-Washing Habits Need Improvement
Have you read this interesting and surprising study about EMS and hand sanitizing?  As an industry we might want to study and discuss it further as well as support each other for better compliance?  Does it raise a deeper question?  What about the equipment we touch while taking care of our patients?  When we are gloved are we risking cross contamination to ourselves and our next patient? Furthermore, think about the cab of our ambulances with the many things we touch and have contact with.  Is there any risk there?  Most services are vigilante and proactive with their disinfection process, however, we are prone to slips and drift from best practices.

What are your thoughts, do you wash your hands?

AHRQ Webinar Praises Effectiveness of "Stop and Watch" and CS for LTC Safety

    Posted in AHRQ, Communication, Patient Safety Culture    |    Comments Off

Communicating effectively about changes in a resident’s condition is always difficult.  However, in long-term care it is complicated by staffing patterns and the subtlety of the changes that can signal significant health events.  The Agency for Healthcare Research and Quality has hosted a series of webinars (accessible here) to support staff training for improvement in this critical area.

Participants on the webinars described how the “Stop and Watch” form (a part of the INTERACT program, form available here) can support efforts by all staff, but particularly CNAs and other non-licensed individuals, to spot the subtle changes that can indicate a need for intensified observation or care for residents.

They also found the C-U-S communication tool very helpful, especially with families.   That tool simply lists three ways to start communicating:  “I am Concerned, “  “I am Uncomfortable,” and, for more serious situations, “I believe the resident’s Safety is at risk.”  (The C-U-S tool is available here.) Organizations reported that they put C-U-S and/or Stop and Watch forms near the sign-in book to facilitate communication with family members or visitors about changes they notice.

AHRQ also offers training modules and tools for staff development on identifying and  communicating significant changes in resident condition, as well as fall prevention and management, on its website.  And all of their resources are available at no charge.

New ISMP Long-Term Care AdvisERR newsletter

    Posted in Patient Safety    |    Comments Off

The Institute for Safe Medication Practices (ISMP) has issued the July edition of its newsletter, Long-Term Care AdvisERR.  The newsletter includes tips on safe administration of U-500 Insulin, safe use of new oral dispensers for morphine sulfate, as well as addressing how to set up your MAR to avoid confusion.  Here is a link to subscribe to this free resource that offers advice on frequently reported medication safety events and access past issues.

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