Just Culture

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    |    Comments Off

“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!!

Just Culture in EMS Continues to Grow

Posted by Alex Christgen    Posted in EMS PSO, Just Culture    Posted June 29, 2012    |    Comments Off

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.

3rd Annual Missouri EMS Patient Safety Conference

Posted by Alex Christgen    Posted in EMS PSO, Events, Just Culture, Patient Safety Conference    Posted May 18, 2012    |    Comments Off

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 Carol Hafley at the Missouri Center for Patient Safety.

MOCPS Just Culture Collaborative Work Cited as Reference for Certification in Patient Safety

Posted by admin    Posted in Amy Vogelsmeier, Becky Miller, Center Info, Just Culture, National Patient Safety Foundation, Patient Safety Culture    Posted April 23, 2012    |    Comments Off

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/.

Fear of Punitive Response to Hospital Errors

Posted by MOCPS    Posted in Just Culture    Posted March 2, 2012    |    Comments Off

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.

Hospitals face fines for overdose, leaving sponge in patient

Posted by MOCPS    Posted in Culture of Safety, Just Culture, Medical Error, Patient Safety    Posted December 16, 2011    |    Comments Off

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.

Read More

MOCPS Hosts Table at Health Literacy Missouri – Sorrel King reinforces our mission

Posted by MOCPS    Posted in CUSP, Events, Just Culture, Media, Medical Error, Patient Safety, Sorrel King    Posted October 12, 2011    |    Comments Off

The MOCPS was pleased to host a table at the October 5th Health Literacy Missouri awards luncheon.  Keynote, Sorrel King, is always a pleasure to hear, although the story of her 18 month old daughter, Josie’s, death from failures in the health care system is heart wrenching.  Read More

5 Current Trends in Patient Safety (from ASC Review)

Posted by MOCPS    Posted in Just Culture, Patient Safety, PSO    Posted August 8, 2011    |    Comments Off

Article from GE Healthcare Performance Solutions on current safety trends worth reading:  PSOs, Just Culture, review of policies and procedures, use of simulation, and reduction of variance.  PSOs is listed as the #1 trend, identified as the only way health care providers can share stories and learning without fear of litigation “because big improvements in safety are about learning.”

Read more

Switch to our mobile site