Patient Safety

Center Releases 2012 Annual Report

Posted by Alex Christgen    Posted in Patient Safety    Posted April 22, 2013    |    Comments Off

The Center for Patient Safety’s seventh year was one of growth. Read our 2012 Annual Report.

One highlight in 2012 was establishing a “doing business as” (DBA) for the Center for Patient Safety to more accurately reflect the work that we continue to perform outside of Missouri. As we experienced growth in services along with our new name, we were also pleased to welcome new staff members and our new Medical Director, Dr. Michael Handler.

Our mission remains the prevention and reduction of harm to individuals who receive medical care. To achieve this target, we have focused our efforts on learning what kinds of medical mistakes occur, understanding why they occur, and facilitating implementation of solutions to prevent harm. To show you how we are reaching our goals, we are pleased to share the highlights of 2012 with you and encourage you to read more about our work throughout this report. We also invite you to follow our work through our website, Twitter, and LinkedIn.

Top 10 Essentials for Effective Instrument Cleaning

Posted by Alex Christgen    Posted in ecri, Infection Control, Infection Prevention, Patient Safety    Posted April 19, 2013    |    Comments Off

Top 10 essentials for effective instrument cleaning from the ECRI Institute PSO:

  1. Provide adequate trained staff, facilities, and resources for the sterile processing department.
  2. Standardize and simplify procedures in all areas where instruments are reprocessed.
  3. Monitor the quality of instrument reprocessing through post-cleaning inspections.
  4. Seek input from reprocessing department staff on instrument and equipment purchases.
  5. Limit the operating room’s dependence on immediate-use sterilization.
  6. Establish delivery criteria for loaned instruments and prohibit immediate-use sterilization of them.
  7. Require regular competency assessments of staff who reprocess instruments.
  8. Foster collaboration and teamwork among reprocessing department and operating room staff.
  9. Recognize and respect the contribution by reprocessing staff to patient safety and quality care.
  10. Encourage prompt reporting of events or near misses involving contaminated instruments.

Read the full article at “Infection Control Today“.

RCAs – A key part of patient safety work

Posted by Alex Christgen    Posted in Patient Safety    Posted March 27, 2013    |    Comments Off

Root Cause Analysis is a key part of patient safety work.   Think Reliability offers periodic FREE webinars that examine aspects of this critical discipline, usually through discussion of a great example.  A recent program discussed the interrelationship between process maps (that flow from start to finish) and RCA’s (which flow from the finish to the start).  The company offers its excel-based RCA tool free on its website if you register at www.thinkreliability.com, where you can also get information on upcoming webinars.

Reminders to Keep Patients Safe

Posted by Alex Christgen    Posted in Patient Safety, Patient Safety Awareness Month    Posted March 27, 2013    |    Comments Off

The Center for Patient Safety believes the focus on patient safety is more than the month of March – rather it’s every hour, every day, all year long!  We share ASHRM’s five quick reminders to help keep patients safe:  wash hands, avoid fatigue, ensure good hand-offs, don’t tolerate inappropriate behavior, and involve patients/families in their care.  Also download their 10 Tips to Promote Patient Safety.

Thirteen Ways to Prevent Falls

Posted by Alex Christgen    Posted in AHRQ, Falls, Falls Reduction, Patient Safety    Posted March 8, 2013    |    Comments Off

To reduce the risk of falls among all patients, health professionals in hospitals should:

  • Familiarize the patient with the environment.
  • Have the patient demonstrate call light use.
  • Maintain call light within reach.
  • Keep personal possessions within safe reach of the patient.
  • Have sturdy handrails in patient bathrooms, rooms and hallways.
  • Place the hospital bed in a low position when a patient is resting in bed; raise it to a comfortable height when the patient is getting out of bed.
  • Keep hospital bed brakes locked.
  • Keep wheelchair wheels in the locked position when it is stationary.
  • Keep nonslip, comfortable, well-fitting footwear on the patient.
  • Use night lights or supplemental lighting.
  • Keep floor surfaces clean and dry. Clean up all spills promptly.
  • Keep patient care areas uncluttered.
  • Follow safe practices when helping patients in and out of bed.

Source: “Preventing Falls in Hospitals: A Toolkit for Improving Quality of Care”, Agency for Healthcare Research and Quality, January – http://www.ahrq.gov/professionals/systems/long-term-care/resources/injuries/fallpxtoolkit/index.html

Virtual Conference Brings National Speakers to Organizations

Posted by Alex Christgen    Posted in Excellence in Safe Care Awards, Patient Safety, Patient Safety Awareness Month    Posted March 4, 2013    |    Comments Off

March 2013 is Patient Safety Awareness Month! It’s an exciting time to celebrate and recognize the efforts at your organization.  What better way to complement your focus than by bringing national speakers to your organization?  Any and all of the following sessions are available for presentation within your organization for one low registration fee (discount available for all sessions, one registration offers one line access to unlimited viewers for use within, for example, a conference or assembly room), include continuing education* hours for all participants, live Q&A with the speakers, and an available recording after the session to continue the sharing!  Click on any of the following sessions to learn more:

March 5, 2013 @ 2pm CST – Dr. Bob Wachter presents “Healthcare Safety in 2013: How the lessons of the past inform the future”… Sharing the principles of safe care, as highlighted in his book series, Understanding Patient Safety.

March 14, 2013 @ 12pm CST – Christopher Jerry presents “The Emily Jerry Story”…Sharing a poignant personal story about a tragic, preventable medication error that resulted in the loss of Chris’s daughter and significantly impacted the pharmacist involved in the mistake. The session will focus on how the tragedy and collaboration between family and professionals is positively improving medication safety.

March 20th, 2013 @ 12pm CST – Sue Scott and Laura Hirschinger present “The 2nd Victims Program: Taking Care of Our Own – An Executive Primer“…Sharing the leadership imperative to support programs to help clinicians who are impacted by unexpected clinical events.

March 27th, 2013 @ 12pm CST – James Conway presents “The More Things Change… the More They Stay the Same“…Sharing the role of governance, management, and front-line staff in providing safe care.

March 28th, 2013 @ 12pm CST – Becky Miller and the Center Team present “Continuing the Journey, Recognizing Successes“…Sharing in the success – includes Missouri Excellence in Safe Care Award winners and virtual poster sessions.

*This program has been approved for a total of 7.5 contact hours of continuing education credit toward fulfillment of the requirements of ASHRM designations of Fellow (FASHRM) and Distinguished Fellow (DFASHRM) and towards Certified Professional in Healthcare Risk Management (CPHRM) renewal.

*This program has been approved for a total of 7.5 continuing education hours for CPHQ recertification by the National Association of Healthcare Quality.

*Approved by the Missouri Board of Pharmacy for 7.5 hours of pharmacist continuing education.

AHRQ Introduces Patient Safety Education & Training Resources Database

Posted by Alex Christgen    Posted in AHRQ, Culture of Safety, Patient Safety, TeamSTEPPS    Posted February 5, 2013    |    Comments Off

A new catalog consisting of 333 patient safety programs has been introduced by AHRQ.  A variety of topics are searchable to assist in locating patient safety education and training.  Each topic is provided with links directly to various educational providers.

Available directly from the AHRQ website, topics can be searched by mode of delivery (such as classroom, self-directed, or web-based), target audience, content, reach, and certification applicability. Topics include TeamSTEPPS, patient satisfaction, culture of safety, handoffs, discharge, and communication (just to name a few).

Take advantage of this capability to quickly locate valuable patient safety education and training resources.  Visit the AHRQ Patient Safety Education and Training Catalog.

ALERT: Glacial Acetic Acid Solutions not recommended for patient care

Posted by Alex Christgen    Posted in Alerts, Patient Safety    Posted January 25, 2013    |    Comments Off

The National Alert Network (NAN) has released a warning regarding the potential for severe patient burns and scarring from “accidental application of ‘glacial’ acetic acid (less than or equal to 99.5%) to skin or mucous membranes instead of a much more diluted form.  Glacial acetic acid is the most concentrated form of acetic acid available.”  The article recommends replacing current stocks of glacial acetic acid with vinegar or a commercially available diluted acetic acid, educating staff about the differences between glacial acetic acid and diluted acetic acid, and put safety guards in place to restrict purchasing.  Read the full alert

The NAN bases alert information on errors reported to the National Medication Errors Reporting Program and is operated by the Institute for Safe Medication Practices.

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