Growing EMS Safety Culture, Center’s 2013 EMS Conference

Posted by chafley    Posted in EMS PSO, Events, Just Culture, Patient Safety    Posted May 21, 2013    |    No Comments

“We [the EMS industry] need  a unified message on safety,” was a key message tying together several presentations at the Center for Patient Safety’s 2013 EMS conference held on May 7th in Columbia, Missouri.

This year’s fourth annual event brought over 80 attendees a variety of updates and ideas about safety culture in EMS at national and local levels, from the broad-based need for an industry safety culture being developed through the National Culture of Safety Project; learning to recognize expertise and its influence on perceptions of safety; understanding that “you can’t be curious and angry at the same time,” to perform unbiased event investigations; and learning about one agency’s success at identifying medication errors, and how they have changed their system for administering medications.Comments from attendees included:   “This conference featured some of the best speakers that I have heard in a long time”; “The topics presented were useful, relevant, and interesting”; and “I will be taking a hard look at medication errors.”

Visit our conference web page for downloads and recordings!!

Center Supports Clean Hands Day, 2013! Resources Available!

Posted by bmiller    Posted in Hand Hygiene Project, Infection Prevention, Patient Safety    Posted May 3, 2013    |    Comments Off

The Center has joined the World Health Organization’s Clean Hands Day on May 5.  Join the cause by reinforcing the importance of Clean Hands with CPS-packaged WHO tools and resources.

The Second Victim Experience: Train-the-Trainer Workshop in June

Posted by Alex Christgen    Posted in Center Info, Events, Second Victim Experience    Posted May 1, 2013    |    Comments Off

The Second Victim Experience:  Train-the-Trainer Workshop
Presented by Sue Scott, RN, MSN and Laura Hirschinger, RN, MSN

The Center for Patient Safety is pleased to offer this unique workshop on June 11, 2013 to learn and teach the skills to support staff members and physicians who are impacted by adverse and/or unexpected clinical outcomes. Participants will gain insights into the “second victim” experience as well as supportive interventions from faculty who developed and implemented the University of Missouri Health System’s successful “second victim” program. Participants will also acquire the knowledge, skills and techniques necessary to implement a “second victim” program for peers at their organizations.

Space is limited to 40 participants and will be made available on first come first serve basis. 

PROGRAM OBJECTIVES:

  • To discuss the ‘second victim’ phenomenon
  • To describe the various stages of second victim recovery
  • To identify and reflect on several second victim events
  • To recognize high risk clinical events which could expose clinicians to the ‘second victim’ phenomenon
  • To identify various interventional strategies to support clinicians experiencing the ‘second victim’ phenomenon
  • To identify and practice ways to initiate a crucial conversation with a second victim
  • To describe the various steps necessary to deploy a support team

DATE: June 11, 2013
TIME:  8:00 AM to 4:00 PM (registration and continental breakfast 7:30-8:00 AM)
FEE: $375 per person (continental breakfast, lunch, and snacks included)

REGISTER NOW!!

PSO Participation

Posted by Alex Christgen    Posted in AHRQ, Patient Safety, PSO    Posted April 25, 2013    |    Comments Off

FROM EUNICE HALVERSON, Patient Safety Specialist, Center for Patient Safety

Having spent the last 3 days at the annual AHRQ PSO Conference, it is clear to me that PSOs are gaining momentum across the United States.  It’s been reiterated that the Affordable Care Act requires all hospitals with > 50 beds will be required to participate in a PSO (and participation means actively submitting data) in order to receive reimbursement from the Hospital Insurance Exchange plans.  While this regulation is not effective until January 1, 2015, it’s not far off!

There is increased focus on working with EHR vendors to improve technology to assist our patient safety efforts.  The Office of the National Coordinator for HIT (ONC)is taking a lead role in these discussions, and is supportive of errors being reported through PSOs.  Speaking with leaders of PSOs across the US, it’s evident that the Center for Patient Safety continues to be a leader, remaining ahead of most PSOs as far as receiving and analyzing data.  Thanks to all providers who participate in the Center’s PSO!

Center Releases 2012 Annual Report

Posted by Alex Christgen    Posted in Patient Safety    Posted April 22, 2013    |    Comments Off

The Center for Patient Safety’s seventh year was one of growth. Read our 2012 Annual Report.

One highlight in 2012 was establishing a “doing business as” (DBA) for the Center for Patient Safety to more accurately reflect the work that we continue to perform outside of Missouri. As we experienced growth in services along with our new name, we were also pleased to welcome new staff members and our new Medical Director, Dr. Michael Handler.

Our mission remains the prevention and reduction of harm to individuals who receive medical care. To achieve this target, we have focused our efforts on learning what kinds of medical mistakes occur, understanding why they occur, and facilitating implementation of solutions to prevent harm. To show you how we are reaching our goals, we are pleased to share the highlights of 2012 with you and encourage you to read more about our work throughout this report. We also invite you to follow our work through our website, Twitter, and LinkedIn.

Top 10 Essentials for Effective Instrument Cleaning

Posted by Alex Christgen    Posted in ecri, Infection Control, Infection Prevention, Patient Safety    Posted April 19, 2013    |    Comments Off

Top 10 essentials for effective instrument cleaning from the ECRI Institute PSO:

  1. Provide adequate trained staff, facilities, and resources for the sterile processing department.
  2. Standardize and simplify procedures in all areas where instruments are reprocessed.
  3. Monitor the quality of instrument reprocessing through post-cleaning inspections.
  4. Seek input from reprocessing department staff on instrument and equipment purchases.
  5. Limit the operating room’s dependence on immediate-use sterilization.
  6. Establish delivery criteria for loaned instruments and prohibit immediate-use sterilization of them.
  7. Require regular competency assessments of staff who reprocess instruments.
  8. Foster collaboration and teamwork among reprocessing department and operating room staff.
  9. Recognize and respect the contribution by reprocessing staff to patient safety and quality care.
  10. Encourage prompt reporting of events or near misses involving contaminated instruments.

Read the full article at “Infection Control Today“.

CMS Memo on Event Reporting Using Common Formats

Posted by Alex Christgen    Posted in AHRQ, CMS    Posted April 18, 2013    |    Comments Off

On March 15, 2013, the Centers for Medicare and Medicaid Services (CMS) released a memo about the Agency for Healthcare Research and Quality’s (AHRQ’s) Common Formats. The memo provides information on the Common Formats and how their use may help hospitals meet the CMS Quality Assessment and Performance Improvement (QAPI) requirements.

Hospitals are required to track adverse patient events as a Condition of Participation (CoP) for QAPI requirements.  Although Common Formats use is voluntary, CMS is encouraging surveyors to become familiar with them. CMS states that, “Use of the AHRQ Common Formats by hospitals is not required under the QAPI CoP.  We suggest, however, that a hospital that uses the Common Formats and is adept at the analysis that this structured system permits, will be in a better position to meet the CMS QAPI requirements.”

To view the memo, please go to CMS’ Web site at: https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Policy-and-Memos-to-States-and-Regions-Items/Survey-and-Cert-Letter-13-19.html

RCAs – A key part of patient safety work

Posted by Alex Christgen    Posted in Patient Safety    Posted March 27, 2013    |    Comments Off

Root Cause Analysis is a key part of patient safety work.   Think Reliability offers periodic FREE webinars that examine aspects of this critical discipline, usually through discussion of a great example.  A recent program discussed the interrelationship between process maps (that flow from start to finish) and RCA’s (which flow from the finish to the start).  The company offers its excel-based RCA tool free on its website if you register at www.thinkreliability.com, where you can also get information on upcoming webinars.

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