One response to adverse events is the “crackdown” or, as David Marx from the Just Culture Community puts it, “getting whacked.” The more productive response is to learn from the events and improve systems and staff performance. In a call on March 13, CMS indicated that it plans to respond to the high number of LTC adverse events outlined in the recent OIG report by doubling down its support of QAPI. This focus on improvement rather than punishment is reassuring and will lead to better care for LTC residents. This is SUCH good news! The call was reported by McKnight’s Long-Term Care News, and is available HERE.
The Agency for Healthcare Research and Quality’s “Web M & M” this month addresses the challenge of managing increasingly complex residents in skilled nursing facilities. In addition to a general discussion, the article includes a table (Page 4) outlining some of the most significant issues, along with strategies and resources to address those. Here is a link to the article. Among the tools: TeamSTEPPS and workforce development using programs such as Just Culture, both offered by CPS for Missouri LTC organizations.
“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!!
MOCPS was excited to learn of a new associate at Outcome Engenuity. Paul LeSage, from the Portland, Oregon area, has over 30 years in fire and EMS service as a flight paramedic, assistant chief, and expert in front-line emergency service operations. Paul brings his unique application of the Just Culture concepts to the EMS community. MOCPS is looking forward to working with Paul (and the rest of the Outcome Engenuity team) in the future! Find out more on Outcome Engenuity’s site.
On Tuesday, May 15, the Missouri Center for Patient Safety sponsored its 3rd annual EMS Patient Safety Conference. More than 60 EMS agencies from across the state of Missouri were represented in Columbia by EMS personnel, gathering to learn the latest information on patient safety topics specific to their field.
Highlights of the day included speaker, Dr. Coy Callison, a leading researcher in communications from Texas Tech, who presented his latest findings regarding communication in the workplace and its important role in patient safety in EMS; Matt Zavadsky, a former paramedic and manager of private sector ambulance services, spoke of the importance of building processes related to vehicle response times and other safety issues in EMS within a “Just” culture. Attendees received a sneak peak at the recently released Just Culture EMS staff training materials provided by Outcome Engenuity. Those who attended received continuing education units.
To find out more about how your EMS agency can improve patient safety, contact Lee Varner at the Center for Patient Safety.
MOCPS’s Just Culture collaborative work was cited as a resource by the Certification Board for Professionals in Patient Safety. We are excited to learn a publication of the Center’s Just Culture work is being used as a resource for those seeking certification as a patient safety professional. The article, Influencing leadership perceptions of patient safety through just culture training; Vogelsmeier A, Scott-Cawiezell J, Miller B. J Nurs Care Qual. 2010 Oct-Dec;25(4):288-94 is available at: http://journals.lww.com/jncqjournal/Abstract/2010/10000/Influencing_Leadership_Perceptions_of_Patient.3.aspx.
Information about the NPSF certification is available at http://www.npsf.org/.
Hospitals are developing a culture of safety in which open discussion and reporting about adverse events, mistakes, disruptive behavior and unsafe conditions is applauded rather than punished. However, a February Agency for Healthcare Research and Quality survey showed that healthcare professionals working in hospitals believe hospitals are still more interested in a punitive system and enforcing hierarchy rather than creating a culture of safety and open communication. About 54 percent said that when adverse events are reported, “it feels like the person is being written up, not the problem,” and nearly 67 percent said they are concerned that mistakes are being held in their personnel files. Less than 50 percent believe they are free to question decisions or actions of superiors. The survey also indicates that 20 percent of hospitals have improved in terms of non-punitive response to errors, while 16 percent have worsened.
From Fear of Punitive Response to Hospital Errors Lingers
American Medical News (02/20/12) O’Reilly, Kevin B.
L.A. NOW – Southern California
The California Department of Public Health issued $850,000 in fines against 14 hospitals for medical errors that caused — or were likely to cause — serious injury or death to patients, officials announced Thursday.
Three of the hospitals — Henry Mayo Newhall Memorial Hospital, Los Angeles County-USC Medical Center and Torrance Memorial Medical Center — were in Los Angeles County.