November 20 is National Rural Health Day – Celebrate!

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The National Organization of State Offices of Rural Health and national and state partners are raising awareness of the Power of Rural on November 20th for National Rural Health Day.  Many resources include information about the care provided in rural communities including quality and safety of health care delivery.

Violent Resident Behaviors: Significant Safety Concern

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Resident-to-resident aggression is a significant issue for up to 20% of residents in skilled nursing units, according to a study from Cornell University, described in this article in Long Term Living magazine.  The Center for Patient Safety looks forward to working with long-term care providers through its PSO services to document and address these issues.  Want more information? 

AHRQ Issues 2014 Report on Nursing Home Safety Culture

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AHRQ has now collected data from thousands of nursing home safety culture surveys, representing 263 communities.  In October, AHRQ released a comprehensive report of that data.  It contains a number of interesting patterns based on the size, ownership (for profit or not-for-profit—the homes in the database are split about 50-50) and location (urban or rural) of respondents, and is available to anyone  on the AHRQ website. It also includes helpful material on how to analyze the results of your own survey and tools to use in developing action plans to improve safety culture.  Some highlights and lowlights:

  • Respondents consistently rated their homes well for providing safe care to residents and their willingness to tell someone if they see something that would harm a resident.
  • The scores also reflected a strong sense that there is good communication and feedback about incidents and how to respond to keep residents safe.
  • On the other hand, many respondents felt that their homes have a punitive response to errors, punishing the person rather than looking at the event.

The highest scores came from the Midwest, though those still left room for improvement.

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2014 EMS Patient Safety Conference Success!

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The Center for Patient Safety’s Annual EMS Patient Safety Conference was a success!  We had great speakers who brought new ideas and concepts that helped stretch the imagination of those attending.

  • David Williams from the Institute for Healthcare Improvement shared the Plan-Do-Study-Act method for organizational change and success.
  • Tom Judge, Executive Director of Lifeflight of Maine having years of EMS experience, offered practical advice regarding the changes that he has witnessed in EMS.  He also discussed how organizations can utilize a culture of safety to help manage risk.
  • Michael Bachman from Wake County EMS in Raleigh, NC shared his insights and experience regarding the coordination of patient safety using mobile integrated healthcare, focusing on “For the patient, not to the patient”.

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NQF Endorses Eight Patient Safety Measures

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A continued focus on the need for measurement in patient safety has led to the endorsement by the National Quality Forum of eight measures related to patient safety conditions. These include NHSN’s CAUTI and CLABSI outcome measures, Prevention of catheter-related blood stream infections, severe sepsis and septic shock, radiology-based exposure and AHRQs’ general and pediatric composite safety measures. The NQF will consider appeals relating to these measures through December 12.

Now Available: CDC Training Modules for Ebola PPE

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The proper use of personal protective equipment (PPE) is an integral part of infection prevention.  The recent emergence of the Ebola virus has created a need to re-educate and train workers on the proper use of PPE.  The CDC asked Johns Hopkin’s Armstrong Institute for Patient Safety and Quality to assist in creating training modules.  The Armstrong Institute worked with leading experts in the areas of infection control, human factors engineering, pscyhology, instructional design, and more to produce an online program to train healthcare workers in the appropriate use of PPE.  Available from the CDC’s website at no charge, the training modules are thorough, yet simple.


Interested in TeamSTEPPS Master Training? Courses Scheduled Across the Country!

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Registration now open for TeamSTEPPS Master Training Courses for Hospitals

Registration for an AHRQ TeamSTEPPS Master Training Course for healthcare professionals at MetroHealth in Cleveland, on December 9 and 10 is now open.

Upcoming hospital Master Training Courses are planned for next year at the following AHRQ regional training centers: University of Tulane, New Orleans; University of California, Los Angeles; Northwestern University, Chicago; University of Washington, Seattle; Duke University, Durham, NC; MetroHealth, Cleveland; North Shore-Long Island Jewish Health System, Long Island, NY; and the University of Minnesota, Minneapolis, MN. Registration for these courses is open November 3. Others are being planned.  Go to the national project website for more information and updates.

Safety Watch Issued: Cricothyrotomy

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Safety WatchThis Safety Watch is to advise you that having multiple different types of cricothyrotomy kits can lead to confusion during an airway emergency.  We believe standardizing your equipment including cricothyrotomy kits within an organization or within a region would help to reduce the likelihood of an adverse event.

Cricothyrotomy also commonly called a “cric” is an emergent procedure for establishing an immediate airway.  The procedure can be performed several ways with various commercially prepared kits or with specialty prepared equipment.  The skill requires the provider to access the cricothyroid membrane to establish an airway for oxygenation and ventilation.

Possible reasons for these events:

  • Access to different types of kits can lead to confusion during an airway emergency

View the full Safety Watch to see recommendations for mitigating risk.

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