Patient Safety

Alarm fatigue continues to be a challenge

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Alarm fatigue continues to be a challenge to patient safety across the nation.  Learn what interventions Boston Medical Center implemented over the past two years to reduce their audible alarms by 89% with no adverse events attributed to the changes.  A bonus:  they significantly increased satisfaction among both nurses and patients!

AHRQ Health Care Innovations Exchange: Innovations and tools to improve quality and reduce disparities

An EMS PSO Call to Action

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

We are fortunate in Missouri to have the opportunity to work with an EMS Patient Safety Organization (PSO). As you know, the Center, as a PSO is collecting data you have indicated to be important to you, including ambulance crashes.

Please take a moment to read an interesting and concerning article about ambulance crashes in JEMS online.  The article concludes with an opportunity to share events and find ways to improve our industry, however, the authors do not mention the opportunity to do just that, through a Patient Safety Organization (PSO).

CALL TO ACTION: When you finish reading the article, please consider taking a moment to post a comment supporting the importance of the PSO to EMS.

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Ghostbusters and QIO Program Turn 30: Who You Gonna Call for Medicare Concerns?

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Primaris will no longer handle Missouri Medicare case reviews beginning August 1, 2014.

COLUMBIA, Mo. — Thirty years ago, Ghostbusters made the question “Who you gonna call” go viral long before the days of social media. 1984 was the same year Quality Improvement Organizations (QIOs), like Missouri-based Primaris, began answering the call of Medicare patients with concerns about their care or when they believe a healthcare service is ending too soon.

Beginning August 1, 2014, Missourian patients and providers will no longer call health care quality-improvement consulting company Primaris. All current and future beneficiary quality review case work and appeals will be conducted by KEPRO, located in Seven Hills, Ohio.

What does this mean for you and your organization?

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CPS Hosting Safe Table Discussions with PSO Participants

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This Summer, the Center for Patient Safety (CPS) is hosting regional meetings for healthcare providers that have a current PSO agreement with CPS.  It’s a rewarding afternoon that focuses on patient safety and promotes networking with peers through Safe Tables.

What is a “Safe Table”?  It’s a members-only shared learning meeting among healthcare providers to network and exchange patient safety experiences and best practices in an open, uninhibited and legally protected environment.  The venue allows participants to share de-identified adverse events with other hospitals, gain input and support and learn from their own mistakes as well as the mistakes of others.  Ultimately, the end result is safer care for patients in all the participants’ hospitals.

Registration information will be delivered directly to CPS PSO participants.

If you have questions or are interested in joining the Center’s PSO, please contact any member of our PSO team or call 888.935.8272.

  • Becky Miller, MHA, CPHQ, FACHE, CPPS, Executive Director, bmiller@mocps.org
  • Eunice Halverson, MA, Patient Safety Specialist, ehalverson@mocps.org
  • Kathy Wire, JD, MBA, CPHRM, Project Manager, kwire@mocps.org
  • Alex Christgen, BSBA, Project/Operations Manager and Analyst, achristgen@mocps.org
  • Lee Varner, BS EMS, EMT-P, Project Manager, EMS Services, lvarner@mocps.org
  • Michael Handler, MD, MMM, FACPE, Medical Director
  • Amy Vogelsmeier, PhD, RN, GCNS-BC, Contractor

Alarm Safety Resources to Reduce Patient Risk

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ECRI has established a variety of online resources to help healthcare providers better understand the issues related to alarm safety within facilities and reducing patient harm.

Study of Long Term Care Shows Improvements but More Work Needed

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AARP recently released a study on nursing home care ranking each state based on 26 variables, including access and affordability of long term care services.  The study was performed due to the declining number of caregivers available to address the growing elderly population.  While the study showed some improvements have been made in the past 2-3 years, more improvements are needed.  Read the full blog.

WHO Saves Lives Campaign Highlights Hand Hygiene and Resources

    Posted in Hand Hygiene Project, Infection Prevention, Patient Safety, WHO    |    Comments Off

The World Health Organization has compiled resources from its May 5 Save Lives Campaign focusing on hand hygiene. These resources include:

  • WHO webpages with a photo story of hand hygiene improvement from Costa Rica  HERE
  • More than 30 countries organized activities, many initiated by WHO CleanHandsNet, including from New Zealand, Hong Kong, Singapore, Argentina, Malta, Belgium, Croatia, Austria, Romania, Serbia, France, Viet Nam, South Africa, Wales, Albania, Macedonia, Spain, England, Scotland, Egypt, Ireland, India, Switzerland, Brazil, Germany, Northern Ireland and Italy.
  • Web page information from societies and leading organizations HERE
  • Many translated WHO posters in to their local language HERE
  • WHO Private Organizations for Patient Safety (POPS) played a key role in spreading messages HERE
  • Professor Pittet’s Webber teleclass on 5 May featured many examples of activities and is an excellent summary. Additional training resources also available.

NQF Accepting Comments on Patient Safety Measures Through June 26

    Posted in LTC, Patient Safety, Readmissions    |    Comments Off

In response to the ongoing concerns about medical errors and unsafe care killing tens of thousands of Americans each year, the NQF is undertaking a project to evaluate patient safety measures that can be used for accountability and public reporting for all populations and in all settings of care. This project will address topic areas including but not limited to:

  • Measures from applicable settings, such as skilled nursing facilities and inpatient rehabilitation facilities;
  • Unplanned admission-related measures from other settings (i.e., hospitalization for patients on dialysis);
  • All-Cause and condition specific admission measures;
  • Condition-specific readmissions measures and Measures examining length of stay.

The project will also continue to evaluate patient safety measures such as healthcare-associated infections, medication safety, and imaging safety.  Public comments on the NQF safety measures are encouraged through June 26th.

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