The latest newsletter from the Center for Patient Safety has been released. The Fall 2014 EMS PSONews contains information on the recently released PSO Safety Alert and EMS Safety Watch, articles on the legal environment to help maximize federal protections from the PSO, patient safety culture topics, and much more! Download the newsletter or view on Issuu.
Patient Safety Culture
Communicating effectively about changes in a resident’s condition is always difficult. However, in long-term care it is complicated by staffing patterns and the subtlety of the changes that can signal significant health events. The Agency for Healthcare Research and Quality has hosted a series of webinars (accessible here) to support staff training for improvement in this critical area.
Participants on the webinars described how the “Stop and Watch” form (a part of the INTERACT program, form available here) can support efforts by all staff, but particularly CNAs and other non-licensed individuals, to spot the subtle changes that can indicate a need for intensified observation or care for residents.
They also found the C-U-S communication tool very helpful, especially with families. That tool simply lists three ways to start communicating: “I am Concerned, “ “I am Uncomfortable,” and, for more serious situations, “I believe the resident’s Safety is at risk.” (The C-U-S tool is available here.) Organizations reported that they put C-U-S and/or Stop and Watch forms near the sign-in book to facilitate communication with family members or visitors about changes they notice.
AHRQ also offers training modules and tools for staff development on identifying and communicating significant changes in resident condition, as well as fall prevention and management, on its website. And all of their resources are available at no charge.
Wait a minute, not if there is no follow through on identified issues. If that’s the case, front line staff may become more cynical and perceptions of safety culture may actually worsen according to a recent study of 44 neonatal ICUs. When done appropriately, however, they can contribute to an improvement in safety culture.
Check out this recent article from AHRQs PSNet:Exposure to Leadership WalkRounds in neonatal intensive care units is associated with a better patient safety culture and less caregiver burnout
True or False? Safety culture impacts error rates. TRUE! AHRQ’s recent Safety Primer on Safety Culture reinforces the need to assess and improve the safety culture. The enhanced focus is also appearing as safety culture assessments are being mandated by National Quality Forum’s Safe Practices for Healthcare and the Leapfrog Group.
True or False? It’s more efficient and effective to assess my entire organization rather than assess individual units or departments. FALSE! While it’s easy to survey an entire organization, the Center makes it even easier to survey your organization by individual units and departments. It’s been found that the most meaningful results come from unit-level analysis.
True or False? Only hospitals survey their culture. FALSE! The Center administers culture surveys in standard AHRQ formats for physician offices, long-term care facilities, and pharmacies in addition to hospitals. Some surveys are also available in Spanish.
Our services remove the administrative burden from your organization and make it easier and more meaningful to conduct the survey on patient safety culture. The Center’s services include electronic templates for posters and emails; an online, secure, and anonymous survey platform; and, detailed reports including trend information from the previous survey. It’s well worth the investment to continually know how you measure up in the patient safety arena.
Initiated by the Association of PeriOperative Registered Nurses (AORN) in 2004, and consistently supported by The Joint Commission, the World Health Organization, and the Council on Surgical and Perioperative Safety (CSPS), National Time-out Day supports surgical nurses’ ability to speak up for safe practices in the operating room. This year, AORN urges members to evaluate how their time out fits into broader efforts to provide high quality care to every patient, every time. A poorly executed time out or lack of team communication may indicate areas for improvement within a safety culture. For more information, educational toolkits, as well as promotional materials, visit the AORN website.
SorryWorks! has been promoting transparency and disclosure since 2005 and has outstanding tools to support that effort. But often we struggle with setting patient expectations and opening up communication from the patient’s side. SorryWorks! has developed a letter that physicians and other providers can use as a temple for their own handout to open a dialog about how to communicate. The template is available here.
In the Fall of 2011, the Missouri Center for Patient Safety started a new service line to promote the AHRQ Survey on Patient Safety in an online format. Since implementation, the affordable service has received much interest from facilities in Missouri as well as other states across the country. The survey is an excellent tool to measure the safety culture of hospitals and medical staff offices.
The Center now provides the capability to conduct the AHRQ Hospital Survey on Patient Safety for an entire hospital, or just for individual departments, on a quarterly or annual basis. The survey is provided in an online format, allowing staff to take the survey in an anonymous, convenient, online environment. No more paper, no more data entry, no more hand tabulations!
National Time Out Day raises awareness of the need to conduct a time out for every patient, every time. National Time Out Day began in 2004 as an awareness campaign by the Association of periOperative Registered Nurses (AORN) and is supported by The Joint Commission, the World Health Organization (WHO), and the Council on Surgical and Perioperative Safety (CSPS) for its ability to increase awareness of safe practices for patients undergoing surgical procedures. This year, the AORN encourages evaluation of your time out procedure and how it fits into your broader patient safety efforts. Missouri Center for Patient Safety recognizes time outs as a best practice for reducing surgical errors.