Patient Safety

Strategy for a National EMS Culture of Safety

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Almost a year later…have you read it yet?

It’s been almost a year since once of the most important safety and culture documents has been released.  The Center for Patient Safety encourages you to read the Strategy for a National EMS Culture of Safety and support discussion with your peers.

Exciting Membership News

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The Center for Patient Safety is exited to announce our newly acquired membership with the American Ambulance Association (AAA). Our membership with AAA will support the opportunity to engage work with EMS leaders from diverse organizations around the country. The Center will be exhibiting at the AAA Annual Conference and Trade Show November 17-19 in Las Vegas.
For more information visit their website:

Senate Holds Hearing on Need to Improve Patient Safety, Reduce Harm, Solutions Proposed

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On July 17, a Subcommittee of the US Senate Committee on Health, Education, Labor and Pensions, held a hearing “More than 1,000 Preventable Deaths a Day is Too Many: The Need to Improve Patient Safety”; a topic near and dear to the heart of the Center for Patient Safety.

National patient safety experts testified before the subcommittee highlighting the need for increased attention on patient safety and the need to reduce patient harm. Highlights of testimony provided by these experts included updated statistics on preventable deaths being as high as 400,000 annually and a call for a focus on the science of safety, improving the safety culture, improving measurement, utilizing health information technology to link systems and providing more information to the public about quality and safety to make health care decisions.  Possible solutions offered by these experts include a greater role for the government such as expanding the role of the CDC to receive and report data, developing a National Patient Safety Board or expanding roles of The Joint Commission and CMS to increase health care oversight, enhancing information technology, increasing transparency and aligning leadership incentives focused on quality and safety.

Many of the topics are being addressed through the Center’s work:  The importance of assessing and improving the safety culture; collecting adverse event, near miss and unsafe conditions to identify what medical errors occur, evaluate why they occur and identify solutions to prevent harm; encouraging discussions across providers on medical error, harm and prevention to share learning and training and supporting evidence based practices to improve safety culture and reduce healthcare-acquired infections through our work in collaboration with the Missouri Hospital Association.

A Webcast of the hearing is available at

Just in from the Missouri Ambulance Meeting

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There was strong interest about ambulance design standards and safety at the MAA membership meeting last week.  Ron Thackery, AMR, Senior Vice President of Professional Services and Integration presented “National Ambulance Standards: What’s Ahead”.  Many EMS leaders wonder what the future holds as new design and safety standards will likely increase the cost of manufacturing.

Mr. Thackery’s discussion topics included:

  • National standards – do they exist for safety and what is their impact on EMS?
  • The differences between the GSA/KKK ambulance design standard, NFPA 1917 and CAAS GVS 2015.
  • Why so many EMTs/Medics do not currently wear seat belts in the back of an ambulance.
  • How you can improve the culture of safety in your organization.
  • Are bigger ambulances really better?
  • Now that you’ve seen powered cots and powered loading devices – what’s next on the horizon?
  • Do ergonomics matter in the back of the rig?

Terry Buddemeyer, Director for the Washington Area Ambulance District, commented about the presentation:  “The presentation was extremely helpful in understanding the different definitions that are being used in our industry… I also found the simulated crash information very concerning, in fact it would be good for our EMT’s and Paramedics to see what happens at a 30 mph crash.”

MAA logo_outlinedFor more information go to the Missouri Ambulance Association website. Serving all Missouri Emergency Medical Service Providers.

Exciting Opportunity for Nursing Home Infection Prevention!

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The Center is excited to be spending Tuesday July 15th in Chicago with colleagues from the Missouri Hospital Association, AHA’s Health Research and Education Trust and others to bring home everything we need to support interested nursing home in a collaborative opportunity focused on safety culture and infection prevention. The collaborative will bring national experts, evidence-based practices and expert support to participating nursing homes! Look for more information and recruitment information soon!

A Message from the Center’s Medical Director

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A message from Michael Handler, MD, Medical Director, Center for Patient Safety

From a physician’s perspective, organizations such as the Center for Patient Safety, including the role of a federally-designated Patient Safety Organization (PSO), are playing a key role in healthcare and can play an even greater role in the future.

I am proud to serve as the Center’s Medical Director supporting the Center’s work with health systems, hospitals, ambulance services, physician practices and nursing homes as well as its outreach to consumers.

As the healthcare landscape continues to change under the federal Affordable Care Act, implementation of Health Insurance Exchanges and the explosion of Accountable Care Organizations, the need for healthcare providers to work together across various settings is increasing exponentially. This work must focus on the assessment, evaluation and improvement of the quality and safety of healthcare delivery regardless of where that care is delivered. This is where organizations like the Center come into play!

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June 2014 AHRQ Web M&M Released

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The most recent release of the AHRQ Web M&M: morbidity & mortality rounds on the web, include the following cases and commentaries:

Review these cases and the commentaries provided for reasons these events occurred and tips and resources to prevent similar situations from occurring at your healthcare location.

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

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