Patient Safety

2014 EMS Patient Safety Conference Success!

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The Center for Patient Safety’s Annual EMS Patient Safety Conference was a success!  We had great speakers who brought new ideas and concepts that helped stretch the imagination of those attending.

  • David Williams from the Institute for Healthcare Improvement shared the Plan-Do-Study-Act method for organizational change and success.
  • Tom Judge, Executive Director of Lifeflight of Maine having years of EMS experience, offered practical advice regarding the changes that he has witnessed in EMS.  He also discussed how organizations can utilize a culture of safety to help manage risk.
  • Michael Bachman from Wake County EMS in Raleigh, NC shared his insights and experience regarding the coordination of patient safety using mobile integrated healthcare, focusing on “For the patient, not to the patient”.

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NQF Endorses Eight Patient Safety Measures

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A continued focus on the need for measurement in patient safety has led to the endorsement by the National Quality Forum of eight measures related to patient safety conditions. These include NHSN’s CAUTI and CLABSI outcome measures, Prevention of catheter-related blood stream infections, severe sepsis and septic shock, radiology-based exposure and AHRQs’ general and pediatric composite safety measures. The NQF will consider appeals relating to these measures through December 12.

Now Available: CDC Training Modules for Ebola PPE

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The proper use of personal protective equipment (PPE) is an integral part of infection prevention.  The recent emergence of the Ebola virus has created a need to re-educate and train workers on the proper use of PPE.  The CDC asked Johns Hopkin’s Armstrong Institute for Patient Safety and Quality to assist in creating training modules.  The Armstrong Institute worked with leading experts in the areas of infection control, human factors engineering, pscyhology, instructional design, and more to produce an online program to train healthcare workers in the appropriate use of PPE.  Available from the CDC’s website at no charge, the training modules are thorough, yet simple.


The CPS and TJC Agree – Safety is the Key to Learning

    Posted in Patient Safety    |    Comments Off

The Joint Commission is enhancing its focus on patient safety in hospitals, as evidenced by their October 20, 2014 announcement of a “first time event” – publishing a standards chapter on-line to ease access to key patient safety standards spread throughout their accreditation standards. Ana Pujols McKee, M.D., executive vice president and chief medical officer of the TJC states, “A solid foundation for patient safety is a safety culture. For leaders, our hope is they will study this chapter and use it as a tool to build or improve their safety culture program. Developing a culture of safety starts at the top of the chain of command, and then works its way through the layers of management and employees to build trust which is an essential ingredient for improvement. In order for improvement to take root and spread, leaders need to be engaged and know the current state of the culture in their organization.” The chapter is oriented toward leaders to establish a safety culture that leads to learning from patient safety events. Go to the Center’s website to learn more about the Center’s safety culture assessment and training services.

A Message from the AHA – Patient Safety Begins with YOU.

    Posted in CDC, Infection Control, Infection Prevention, Patient Safety    |    Comments Off

All of us have the power to think and act in ways that keep patients safe. That means that everyone must use every tool at our disposal to avoid infection. That includes following CDC recommendations to get an annual flu vaccine. Our responsibility for patient safety means that we all must employ appropriate infection control procedures, not just when an infectious disease such as Ebola is in the headlines, but every single day. It means that hospital leaders must be vigilant in keeping clinical and nonclinical staff updated on policies, procedures and protocols relating to infectious diseases. And it means putting all of this into practice through training and exercises. Please check the AHA website for updated Ebola preparedness resources.


ISMP LTC AdviseERR Addresses Distractions and Interruptions

    Posted in LTC, Patient Safety    |    Comments Off

CPS has given the ISMP’s LTC AdviseERR shout outs in the past.  We also talk a lot about distractions and interruptions as one of the most widespread causes of mistakes.  ISMP takes on the distraction issue in its latest issue of its long-term care medication safety newsletter, available here.  This issue speaks to the scope of the problem and has some great suggestions for controlling it.  Subscribe to the newsletter.

2015 Changes in Nursing Home Oversight and Consumer Reporting

    Posted in CMS, Patient Safety    |    Comments Off

Beginning in 2015, CMS will implement the following improvements to the Nursing Home Five-Star Quality Rating System:

• Beginning in January, focused survey inspections for a sample of nursing homes improve verification of staffing and quality measure information that is part of the Five-Star Quality Rating System.

• Implementing a quarterly electronic reporting system to audit payrolls to verify staffing information to improve accuracy and timeliness of data, and allow for the calculation of quality measures for staff turnover, retention, types of staffing, and staffing levels.

• Increasing the number and type of quality measures used in the Five-Star Quality Rating System.

• Strengthening requirements for states to maintain user-friendly websites and complete inspections of nursing homes in a timely and accurate manner.

• Improving the scoring methodology for calculation of facility quality measure ratings that are used for the Five-Star rating.

TeamSTEPPS Training Courses Posted, TeamSTEPPS in Primary Care

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The Center gets many questions about TeamSTEPPS training.  Nationally, Master Training Course information for 2015 is now available!  Registration for TeamSTEPPS Master Training Course for Primary Care, adapting the core concepts of TeamSTEPPS for primary care office-based teams, is available at  Additionally, general Master Training Course registration for classes January through May is expected to be available in early November at

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