Patient Safety

Earn CPHQ CE with the Center on March 13th!

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Join the Center for Patient Safety on March 13th for our 9th Annual Patient Safety Conference.  We just received confirmation of approval of 5.25 CE hours toward CPHQ recertification from the National Association for Healthcare Quality.  Registration and more information.

Medication Reconciliation Still a Challenge? AHRQ Announces New Hospital Resource

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The AHRQ-funded Multi-Center Medication Reconciliation Quality Improvement Study (MARQUIS) has produced a manual to help hospitals improve medication reconciliation practices to improve outcomes such as inpatient adverse drug events and readmission rates, which have significant patient safety and financial implications for hospitals. The manual describes a framework to assemble a team, adapt an implementation strategy and implement interventions aimed to improve med reconciliation.

Join us on March 13th for the Best Practices in Safe Care Panel – Sharing Successful Safety Programs

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We hope you will join us for updates and strategies for success of key safety practices that the Center has been involved in over the past decade. Come listen to and participate in discussions with these panelists at the Center’s 9th Annual Conference, March 13th! Visit our website for more information including registration.

  • Pat Posa will return for the Conference to share updates on successes of the CUSP program, challenges and potential for ongoing safety improvement
  • Rachel Wells, CoxHealth, will share successes in using the HSOPS safety assessments and system-wide implementation of Just Culture
  • Laura Hirshinger, MU Health Care will provide exciting updates on their Second Victim Program, including key learnings and growth into the future
  • Leslie Porth, MHA will discuss the importance of transparency, its debate and importance moving into the future for health care quality and safety improvement

Come Hear a Safety Commissioners Panel – Varying Perspectives on Safe Care – Then and Now

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We are excited to host a Panel of former Patient Safety Commissioners at the Center’s March 13th Annual Conference!  Each of the following panelists will share their perspective on the Commission’s work and safety over the past decade and needs for the future.

  • Kat Nelson, MHA, Mercy, Commission Co-Chair
  • Stephen Smith, MD , Anesthesiologist, Center for Patient Safety Board Member
  • Lori Scheidt – State of Missouri Board of Nursing
  • Pam Marshall, R.Ph, Walgreens and State of Missouri Board of Pharmacy Member
  • Sue Kendig, JD, MSN, FAANP– Health Policy Advantage, Center for Patient Safety Board Member

Information and registration is available on our website.

Sharing Lessons Learned – Abbreviations in Patient Communications

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Rules for abbreviation use generally focus on medication safety—identifying visual and textual ambiguities that may confuse other medical professionals. The ISMP List of Error-Prone Abbreviations, Symbols, and Dose Designations includes items like IU that could appear like IV or 10; and DPT, which could stand for Demerol-Phenergan-Thorazine or diphtheria-pertussis-tetanus.  Read more  Courtesy of CHPSO.

Let us know how you are celebrating Patient Safety Awareness Week! It’s less than 30 days away!

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Share how your organization is celebrating Patient Safety Awareness Week, March 8-14!  Tell us how you are raising awareness of your organization’s focus on safe care 24/7/365 at and we’ll  let others know about the great happening across the country!

A Starting Point for Any Project

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George Heilmeier was, according to Wikipedia, a pioneering contributor to liquid crystal displays.  Throughout his career, he researched and invented things for private industry and the government, eventually becoming the Chief Technology Officer for Texas Instruments.  He developed a set of questions that anyone proposing a research project or product development effort should be able to answer.  Known as “Heilmeier’s Catechism,” they should be helpful to anyone planning safety improvement projects, as well.  Those familiar with the PDSA cycle will recognize this as a valuable expansion of the planning phase.

  • What are you trying to do? Articulate your objectives using absolutely no jargon.
  • How is it done today, and what are the limits of current practice?
  • What’s new in your approach and why do you think it will be successful?
  • Who cares?
  • If you’re successful, what difference will it make?
  • What are the risks and the payoffs?
  • How much will it cost?
  • How long will it take?
  • What are the midterm and final “exams” to check for success?

EMS Services Participating with a PSO can improve quality, safety, & financial performance

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Written by Lee Varner, BS EMS, EMT-P
Mike Wallace,
EMS Captain, Central Jackson County Fire Protection District

Does this sound like your EMS service….

Your typical runs include calls for chest pain, shortness of breath, seizures, and even cardiac arrest.  You run these calls day in and day out.  You drop patients off at the hospital just in time to clear for another call.

At the end of the day, ask yourself these simple questions:

  • Do you look back at the calls to determine how well your providers performed from the perspective of protocol compliance or customer service?
  • Do you have performance benchmarks established, for example time to 12 lead or aspirin administration on chest pain patients?
  • Do you know the percentage of survival for cardiac arrest patients in your community?
  • Do you have a mechanism in place that allows for the self-reporting of events as they relate to medication errors, equipment malfunctions, or near misses?

If you answered yes to all of these questions, great job!  However, some of you probably said no to most.

Read More

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