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<strong>PSO</strong><br />
THE CENTER FOR PATIENT SAFETY<br />
NEWS<br />
SUMMER 2016 NEWSLETTER<br />
MEETING OF<br />
THE MINDS<br />
CPS' ANNUAL PATIENT SAFETY CONFERENCE BRINGS<br />
TOGETHER EXPERTS FROM ACROSS THE COUNTRY<br />
WITH A SINGULAR GOAL: ELIMINATE HARM.
MAKING THE ROUNDS | IN THIS EDITION<br />
ON THE COVER:<br />
LEARNING<br />
OPPORTUNITIES<br />
Just culture, keynote speakers<br />
among the highlights as this<br />
year's <strong>PSO</strong> Day and Patient<br />
Safety Conference bring<br />
together attendees from<br />
across the nation, all who have the<br />
same goal in mind: eliminate<br />
patient harm! 12<br />
ALSO INSIDE:<br />
A NEED FOR SPEED<br />
Improving Event Investigation through<br />
the Development of SPRINT: Serious<br />
Patient Safety Event Rapid Investigation<br />
Teams. 4<br />
THE ORANGE DOOR<br />
Facing use of street drugs and alcohol,<br />
and decreased availability of medical<br />
care and facilities for individuals suffering<br />
mental or behavioral illnesses, Liberty<br />
Hospital has been able to stem the tide<br />
using a multi-disciplinary approach to<br />
helping create a safer care environment<br />
for staff and patients alike. 6<br />
8TH ANNUAL AHRQ <strong>PSO</strong><br />
MEETING<br />
What the AHRQ guidance<br />
means for providers and their<br />
patients. 11<br />
<strong>PSO</strong> LEGAL UPDATE:<br />
Cases involving the<br />
Patient Safety and Quality<br />
Improvement Act continue to<br />
work their way through state<br />
and federal courts. 15<br />
EMS UPDATE:<br />
New CPS report seeks<br />
to raise awareness of<br />
safety concerns in the EMS<br />
community. 16<br />
ALSO IN THIS ISSUE:<br />
SAFETY INSIDER 9<br />
<strong>PSO</strong> UPDATE 18<br />
2<br />
<strong>PSO</strong>NEWS SUMMER SPRING 2016<br />
CENTERFORPATIENTSAFETY.ORG THE CENTER FOR PATIENT SAFETY
CALL TO ACTION | REPORT HIGHLIGHTS NEED FOR CHANGE<br />
CALL TO ACTION:<br />
CHANGE THE STATISTIC<br />
AN ARTICLE RELEASED IN MAY FROM BMJ INDICATES MEDICAL ERRORS<br />
ARE THE THIRD LEADING CAUSE OF DEATH IN HEALTHCARE IN THE UNITED<br />
STATES AFTER HEART DISEASE AND CANCER. CALL TO ACTION RECOMMENDS<br />
CULTURE IMPROVEMENTS.<br />
BY ALEX CHRISTGEN, BS, CPPS<br />
Center for Patient Safety<br />
The article follows the 1999 IOM report which made the first attempt to determine preventable harm<br />
in healthcare. The IOM report estimated a staggering 44,000 to 98,000 patient deaths each year due to<br />
medical errors. In 2013, the IOM's reported numbers were determined to be grossly underestimated<br />
based on a newer study suggesting the actual number was likely to be more than 400,000 deaths per<br />
year as result of medical errors.<br />
In 2013, the IOM's reported numbers were determined to be<br />
grossly underestimated based on a newer study suggesting the<br />
actual number was likely to be more than 400,000 deaths per<br />
year as result of medical errors.<br />
Although the BMJ article specifically references medical<br />
errors in the inpatient hospital setting, CPS’ recently released<br />
annual report suggests medical errors in LTC, home care, and<br />
EMS settings may be just as prevalent.<br />
The following call to action is recommended:<br />
1. make errors more visible when they occur so their<br />
effects can be intercepted<br />
2. have remedies at hand to rescue patients<br />
3. make errors less frequent by following principles that<br />
take human limitations into account<br />
This Call to Action aligns with the recent IOM update in 2015,<br />
which lists eight recommendations for improving patient safety,<br />
and specifically diagnostic errors, in healthcare. Two of the<br />
eight recommendations call for:<br />
1. an enhanced focus on a culture that supports the open<br />
discussion of errors<br />
2. a collaboration of patient safety across the continuum<br />
of care through organizations, such as a Patient Safety<br />
Organization (<strong>PSO</strong>), that support safe sharing and<br />
learning.<br />
The Center for Patient Safety (CPS) has recognized these<br />
areas as strategic approaches to reduce harm for quite some<br />
time. We’ve embedded supportive culture improvement<br />
programs (Just Culture, CUSP, TeamSTEPPS, Second Victims<br />
Programs, and culture assessments) and offer safe sharing<br />
opportunities (as a <strong>PSO</strong>) that support CPS’ vision of improving<br />
patient safety for all patients and healthcare providers, in all<br />
processes, all the time.<br />
Through our program objectives of Protecting, Learning,<br />
and Preventing, CPS is currently working with hundreds of<br />
organizations and thousands of healthcare providers in 38<br />
states across the country to improve patient safety every day.<br />
Together, we will reduce preventable harm in healthcare.<br />
Contact me if you have questions about any of the recently<br />
released reports or if you would like to talk about what you can<br />
do to join the healthcare movement to safer care.<br />
ALEX CHRISTGEN is the interim Executive Director for the<br />
Center for Patient Safety. You can reach her at achristgen@<br />
centerforpatientsafety.org.<br />
THE CENTER FOR PATIENT SAFETY CENTERFORPATIENTSAFETY.ORG <strong>PSO</strong>NEWS SUMMER SPRING 2016<br />
3
A NEED FOR SPEED<br />
IMPROVEMENT OF EVENT INVESTIGATION THROUGH THE DEVELOPMENT<br />
OF SPRINT: SERIOUS PATIENT SAFETY EVENT RAPID INVESTIGATION TEAM<br />
BY BECKY DOERHOFF, RN, MSN, CNL<br />
& MICHAEL LANE, MD, MPHS, CPPS<br />
BJC Healthcare<br />
The Joint Commission (TJC) adopted a formal Sentinel Event Policy in 1996 to help promote careful<br />
investigation and analysis of patient safety events as well as to encourage effective corrective actions<br />
to prevent future events. Accredited institutions are expected to identify and respond appropriately to<br />
all sentinel events (such as unintended retained foreign items) and are subject to review by The Joint<br />
Commission.1<br />
The pioneering efforts initiated by TJC attempted to set the framework for healthcare investigators to take a<br />
systems-based approach to event analysis. This initiative alone has been not been sufficient in preventing events<br />
of harm that occur every year. In a study released this spring from Johns Hopkins, it is suggested that medical error<br />
be considered the 3rd leading cause of death in the CDC ranking of most common causes of death, which would<br />
translate to roughly 400,000 lives.2<br />
4<br />
<strong>PSO</strong>NEWS SUMMER SPRING 2016 2016<br />
CENTERFORPATIENTSAFETY.ORG THE CENTER FOR PATIENT SAFETY
Foundational to the SPRINT process is the application of<br />
Just Culture, which ensures justice in response to human<br />
error and behavioral choices. High Reliability and Human<br />
Factors Engineering principles were also integrated into the<br />
process. A few of the standard process tools utilized by the<br />
team include: causal diagrams, timelines, process maps,<br />
diagrams and payoff matrix for proposed interventions.<br />
Weekly calls, using a standard agenda template, occur to<br />
discuss new and ongoing events with all the Patient Safety<br />
and Risk Managers across the system. Event action plans are<br />
discussed at the system Risk and Patient Safety Council and<br />
selected interventions are rated for strength of action based<br />
on Human Factors Engineering principles.<br />
In 2014, representatives from Risk and<br />
Patient Safety across the BJC Health Service<br />
Organizations (HSOs) began to design<br />
and pilot a core team that could assist in<br />
the analysis, action plan development and<br />
the dissemination of learning from serious<br />
patient safety events (SPSEs)* throughout<br />
the system. The vision of the process was<br />
to have ‘a cadre of well-trained, highly respected<br />
expert investigators guiding local<br />
investigations...’ that would reinforce the<br />
values of the organization and provide a<br />
standard and robust investigation lifecycle.<br />
The process was inspired by several investigative<br />
methods, such as, The London<br />
Protocol, James Reason Model of Accident<br />
Causation, RCA2: Improving Root Cause<br />
Analyses and Actions to Prevent Harm.<br />
The team was named ‘SPRINT’ and<br />
launched with Patient Safety Specialists<br />
from the system level and volunteers from<br />
three other facilities, representing community,<br />
academic and alternate sites. During<br />
the pilot phase roughly 20 events were<br />
investigated over 6 months using the new<br />
process. The team was composed of a HSO<br />
lead, a SPRINT lead, key HSO leadership,<br />
staff or subject matter experts and physicians.<br />
SPSE and close call events that had a<br />
high likelihood of harm if a barrier had not<br />
been in place were in scope for the pilot.<br />
See content above for more information<br />
on process components and event action<br />
plans.<br />
Investigations during the pilot phase<br />
were more robust and resulted in stronger<br />
action items. A rapid improvement event<br />
was held to further enhance the process.<br />
Resource allocation was deemed essential<br />
for ongoing success and to ensure that<br />
appropriately trained, dedicated facilitators<br />
for event investigation were available<br />
to achieve consistent and reliable results.<br />
The 2nd phase was launched in the fall<br />
of 2015. Process Improvement Engineers<br />
were added to the team composition to<br />
expand the expertise and independent assessment<br />
of the process. Automatic action<br />
plan check-in’s were added at 6 months<br />
and 1 year to aid in identifying barriers that<br />
were not predicted when initially planning<br />
for stronger more entailed interventions.<br />
Weekly updates of events are communicated<br />
to the system executive team. The<br />
executive team receives a quarterly update<br />
with process metrics and themes.<br />
SPRINT continues to evolve and refine<br />
over time. Areas of focus for improvement<br />
include: disseminating pertinent information<br />
to frontline staff, providing consistent<br />
clinician support by trained experts in a<br />
systematic way and incorporating proactive<br />
risk assessment into the process.<br />
BECKY DOERHOFF is the Manager for<br />
Patient Safety for the Center of Clinical<br />
Excellence at BJC Healthcare. You can reach<br />
her at rjdoerhoff@bjc.org.<br />
MICHAEL LANE is an Outcomes Physician<br />
at the Center of Clinical Excellence at BJC<br />
Healthcare and Assistant Professor of<br />
Medicine, Division of Infectious Diseases at<br />
Washington University School of Medicine.<br />
You can reach him at michael.lane1@bjc.<br />
org.<br />
REFERENCES:<br />
1.<br />
The Joint Commission. Sentinel Event Policy and Procedures. https://www.jointcommission.org/sentinel_event_policy_and_<br />
procedures/. Published January 6th, 2016. Accessed May 10th, 2016.<br />
2.<br />
Makary, Martin & Daniel, Michael. Medical error-the third leading cause of death in the US. BMJ. http://www.bmj.com/content/<br />
bmj/353/bmj.i2139.full.pdf. Published May 3rd, 2016. Accessed May 10th, 2016.<br />
* SPSEs are events in medical care that are clearly identifiable, preventable, and resulted in severe temporary harm, permanent<br />
harm or death. Severe temporary harm is critical, potentially life-threatening harm lasting for a limited time with no permanent<br />
residual, but requires transfer to a higher level of care/monitoring for a prolonged period of time, transfer to a higher level of care for<br />
a life-threatening condition or additional major surgery, procedure, or treatment to resolve the condition. In contrast, some events,<br />
although serious and adverse, relate to a patient’s underlying medical condition. Preventability implies that methods for averting<br />
a given injury are established and that an adverse event results from failures to apply that knowledge. SPSEs include those events<br />
deemed preventable upon review and defined by the Joint Commission as reportable and reviewable Sentinel Events, National<br />
Quality Forum (NQF) Serious Reportable Events in Healthcare.<br />
THE CENTER FOR PATIENT SAFETY CENTERFORPATIENTSAFETY.ORG <strong>PSO</strong>NEWS SUMMER SPRING 2016<br />
5
THE ORANGE DOOR<br />
BY JOANIE PETERSON, RN, JD<br />
Liberty Hospital<br />
It’s been more than four years since Liberty Hospital, a 233-bed medical center north of Kansas City, began<br />
its “Orange Door” program. With the increased use of street drugs and alcohol, and decreased availability<br />
of medical care and facilities for individuals suffering mental or behavioral illnesses, patient violent behavior<br />
was getting out of control. Unfortunately, in the past, healthcare providers traditionally accepted violent<br />
behavior as “part of the job” and were reluctant to speak up or report incidents. This culture presented an unsafe<br />
environment for staff, patients and visitors.<br />
TAKING ACTION - CODE WHITE<br />
In 2012 Liberty Hospital took action to address this growing<br />
challenge. They partnered with the “Handle with Care” (HWC)<br />
Behavior Management program to provide de-escalation training<br />
for all patient care staff. A small multi-disciplinary team revisited<br />
their process for getting additional security personnel to the scene<br />
of the disruptive behavior. The team realized that sometimes a<br />
person in uniform can escalate tension rather than de-escalate.<br />
It also was determined that a “show of force/support” can deter<br />
some from becoming aggressive when faced with more than one<br />
staff member. A multi-disciplinary approach was identified for this<br />
process instead of just using security officers. “Code White” was<br />
developed, which alerts the crisis intervention response team that<br />
additional assistance is needed to handle a violent patient, family<br />
member or visitor. View Code White Policy - CPS <strong>PSO</strong> participants<br />
only<br />
THE “ORANGE DOOR”<br />
Staff needed a way to identify patients as imminent risk to self<br />
or others. Clear communication to identify which patients are at<br />
risk is addressed by the “Orange Door”, which includes:<br />
• A placard placed on the door of any patient at risk for violent<br />
behavior to self or others;<br />
• Revision of the communication board at the nursing stations<br />
so the patient’s name is highlighted in light orange for all staff to<br />
be alerted of potential violence;<br />
• Additional training for staff to understand and identify suicide-imminent<br />
risk to self and others<br />
• Communication with the patient, family members and/or visitors<br />
regarding expectations as defined in the Suicide: Imminent<br />
Risk to Self or Others policy. View Policy - CPS <strong>PSO</strong> participants<br />
only; and<br />
• Constant Observation program - Training and brochures for<br />
6<br />
<strong>PSO</strong>NEWS SUMMER SPRING 2016 2016<br />
CENTERFORPATIENTSAFETY.ORG THE CENTER FOR PATIENT SAFETY
Liberty Hospital is a 250-bed facility in Liberty, Mo.<br />
the staff member who is sitting with the patient and one for the<br />
patient and their families on what to expect while under Constant<br />
Observation.<br />
IT TAKES A VILLAGE<br />
Education is key for the success of this program. All staff have<br />
three hours of de-escalation training at orientation. Patient care<br />
and other identified staff members are recertified every 2 years.<br />
The ED, ICU, Nursing Supervisors, Social Services, and Code White<br />
(Critical Incident Response Team) staff members take a full eighthour<br />
training in addition to the three-hour education and again<br />
are recertified every 2 years. In-house instructors for Handle With<br />
Care are recertified every year. The hospital works closely with local<br />
law enforcement agencies, fire departments, and EMS services,<br />
educating on what happens when a non-medical patient with violent<br />
behavior is brought to Liberty Hospital’s ED. Since Liberty<br />
has no behavioral medicine beds, the patient must be assessed<br />
in the ED and be held until staff can arrange a safe transfer to a<br />
facility that provides mental healthcare. These first responders are<br />
taught how to identify the need for behavioral care in the field so<br />
patients can be taken to the appropriate facilities whenever possible.<br />
When known behavioral health/violent patients are brought<br />
WORKMAN'S COMP COSTS<br />
DUE TO VIOLENT BEHAVIOR<br />
YEAR: COST: INJURIES:<br />
2014 $57,000 3<br />
2015 11,000 1<br />
2016 0 0<br />
CODE WHITE CALL RESOLUTIONS<br />
BY VERBAL DEESCALATION<br />
YEAR:<br />
DEESCALATIONS:<br />
2014 80<br />
2015 65<br />
2016 17<br />
to the ED, they are admitted to a “safe room”, when available. This<br />
room (located just inside the ambulance bay foyer) has been designed<br />
specially with a small “garage door” that can be activated<br />
to come down to cover medical equipment/gas connections. In<br />
the remote situation where the door needs to be closed to help<br />
with de-escalation, there also is a computer that can monitor the<br />
patient via camera, allowing staff to remain safe and keep a constant<br />
visual of the patient during the de-escalation process. The<br />
adjoining bathroom is specially equipped with metal fixtures that<br />
deter any attempts at self-harm or destruction of property. The<br />
patient can de-escalate in a safe environment and staff members<br />
are able to assist without excess equipment that could get in the<br />
way if restraint becomes necessary in the therapeutic process.<br />
Recently “Orange Door” visitor lockers were installed on each of<br />
the patient care units to ensure safe keeping of visitors’ belongings<br />
and to keep dangerous items out of the patient rooms. In a recent<br />
situation, a visitor was thankful the hospital provided lockers for her<br />
to store her items, which assisted in loss prevention or damage.<br />
Another wife was grateful that no one had been hurt when her<br />
husband became aggressive, swinging and kicking, and told Josh<br />
Stewart (a certified instructor and member of the critical incident<br />
response team) she had never been anywhere where she felt she<br />
had more assistance with her husband and said it was great.<br />
THE RESULTS<br />
Liberty Hospital has seen solid results from the “Orange Door”<br />
program.<br />
Many times staff don’t feel they need to call for a Code White<br />
because they are able to verbally de-escalate the situation before<br />
it becomes violent.<br />
Changing the hospital’s approach to managing aggressive behavior<br />
is difficult because it requires a change in mindset that any<br />
patient can pose a risk. Caregivers are trained to give care, not to<br />
think of patients as potential risk for aggressive behavior, violence<br />
and harm. Liberty Hospital continues to change that mindset as<br />
the bedside caregivers, medical staff members and first responders<br />
work together to mitigate the risks of this issue.<br />
FOR MORE INFORMATION on implementing the Orange Door<br />
process, contact Joanie Peterson. You can reach her at Joanie.<br />
Peterson@libertyhospital.org.<br />
THE CENTER FOR PATIENT SAFETY CENTERFORPATIENTSAFETY.ORG <strong>PSO</strong>NEWS SUMMER SPRING 2016 2016<br />
7
The Center for Patient Safety,<br />
in collaboration with the University<br />
of Missouri Health System’s Second<br />
Victim Program is pleased to host<br />
the following workshop...<br />
SECOND VICTIM<br />
TRAIN-THE-TRAINER<br />
WORKSHOP<br />
The Center for Patient Safety, in<br />
collaboration with the University of Missouri<br />
Health System’s Second Victim Program is<br />
pleased to host the following workshop:<br />
Date: November 7<br />
Time: 7:30 a.m. to 3 p.m.<br />
Location: Saint Luke’s North Hospital –<br />
Barry Road, 5830 Northwest Barry Road,<br />
Kansas City, MO 64154, located just 10<br />
minutes from the Kansas City International<br />
Airport (MCI).<br />
Cost: $399 per person ($349 for<br />
each additional person from the same<br />
organization)<br />
Registration: https://www.eventbrite.<br />
com/e/second-victim-train-the-trainerworkshop-registration-20923246995<br />
“Healthcare team members involved in an unanticipated patient event,<br />
a medical error and/or a patient related injury can become victimized in<br />
the sense that they are traumatized by the event. Frequently, these<br />
individuals feel personally responsible for the patient outcome.<br />
Many feel as though they have failed the patient, second<br />
guessing their clinical skills and knowledge base.”<br />
Who can benefit:<br />
When patients suffer an unexpected clinical event, healthcare clinicians involved in the care may<br />
also be impacted and are at risk of suffering as a “second victim”. Understanding this experience and<br />
recognizing the need for supportive interventions is critically important. This workshop will provide<br />
insights into the experience as well as interventions of support. This workshop will also provide<br />
instruction so that each participant will return to their organization with the knowledge, skills, and<br />
techniques necessary to support and train their peers.<br />
PRESENTED BY THE CENTER FOR PATIENT<br />
SAFETY AND THE UNIVERSITY OF MISSOURI<br />
HEALTH SYSTEM’S SECOND VICTIM PROGRAM<br />
8<br />
<strong>PSO</strong>NEWS SPRING 2016<br />
CENTERFORPATIENTSAFETY.ORG THE CENTER FOR PATIENT SAFETY
PATIENT SAFETY INSIDER | NEWS YOU CAN USE<br />
CHECKLISTS, CHANGES BRING<br />
TRANSFORMATIONS TO THE<br />
PATIENT SAFETY COMMUNITY<br />
“The best bet right now for organizations to support learning is to be part of a <strong>PSO</strong>. <strong>PSO</strong>s represent<br />
a learning community. I urge <strong>PSO</strong>s to be open and generous with their work and share<br />
great stuff.” Dr. Donald Berwick, past president of IHI<br />
SAFETY CHECKLISTS<br />
The American Hospital Association’s<br />
Hospital Engagement Network (HRET)<br />
has published 16 safety checklists to<br />
eliminate patient harm. The checklists<br />
are developed from evidence-based best<br />
practices and include improvement strategies,<br />
action items and resources that<br />
may be effective within your organization.<br />
Use each checklist to assess your<br />
organization to identify your opportunities<br />
for improvement.<br />
RECOMMENDATIONS<br />
FROM THE NPSF<br />
Last year the National Patient Safety<br />
Foundation convened an expert panel to<br />
assess the state of patient safety across<br />
the nation and set the stage for the next<br />
15 years. Their focus is on the establishment<br />
of a total systems approach<br />
resulting in an improved culture of safety.<br />
Government, regulators, health professionals,<br />
and others are called to place<br />
higher priority on patient safety science<br />
and implementation by following these<br />
eight recommendations:<br />
1. Ensure that leaders establish and<br />
sustain a safety culture<br />
2. Create centralized and coordinated<br />
oversight of patient safety<br />
3. Create a common set of safety metrics<br />
that reflect meaningful outcomes<br />
4. Increase funding for research in<br />
patient safety and implementation<br />
science<br />
5. Address safety across the entire<br />
care continuum<br />
6. Support the health care workforce<br />
7. Partner with patients and families<br />
for the safest care<br />
8. Ensure that technology is safe and<br />
optimized to improve patient safety<br />
Read the full report here.<br />
<strong>PSO</strong> HOLDS VALUE<br />
FOR LONG TERM CARE<br />
Do you have an affiliation with a longterm<br />
care facility (LTC)? The value of participating<br />
in a <strong>PSO</strong> is spreading across the<br />
continuum of care. CPS has historically<br />
offered <strong>PSO</strong> services to hospitals, medical<br />
clinics, ambulatory surgery centers and<br />
emergency medical services. However,<br />
LTC providers may now join the <strong>PSO</strong>.<br />
Many are already taking advantage of<br />
Just Culture training and measuring their<br />
culture with the safety culture survey.<br />
For further information, contact Kathy<br />
Wire, kwire@centerforpatientsafety.org.<br />
CPS RELEASES ITS<br />
2015 ANNUAL REPORT<br />
The Center’s 2015 Annual <strong>PSO</strong> Report<br />
was released earlier this year and contains<br />
information on the data received<br />
through the <strong>PSO</strong>. More than 45,000<br />
events are summarized in the report.<br />
If you have not already reviewed the<br />
report, we encourage you to download<br />
it here.<br />
HOW TO AVOID DEADLY<br />
INFECTIONS ASSOCIATED<br />
WITH ENDOSCOPES<br />
Many hospitals across the US are dealing<br />
with infections caused by inappropriate<br />
duodenoscope reprocessing. Don’t<br />
be one of them! The Center for Patient<br />
Safety partnered with the North Carolina<br />
Quality Center <strong>PSO</strong> in April to sponsor<br />
a webinar addressing the issue. CPS<br />
<strong>PSO</strong> participants heard from Dr. William<br />
Rutala, Director of Epidemiology at the<br />
University of North Carolina Health, as<br />
he explains the breadth of the challenge,<br />
alternatives to scope processing and how<br />
to prevent future infections.<br />
PROMOTING SAFETY<br />
WITH LEUR CONNECTORS<br />
Historically, the Luer connector was<br />
used for many incompatible purposes:<br />
intravenous infusions, epidural catheters,<br />
enteral feedings, blood pressure cuffs,<br />
etc. Misconnections have occurred with<br />
catastrophic results. California law will<br />
soon mandate that hospitals use mutually<br />
incompatible connectors for three<br />
purposes: intravenous, neuraxial (e.g.,<br />
epidural), and enteral. While the law driving<br />
the adoption deadline is in California,<br />
hospitals throughout the world will be<br />
making this change.<br />
Dr. Rory Jaffe, Executive Director of<br />
the California Hospital <strong>PSO</strong>, is actively<br />
engaged in the ISO standards process and<br />
device manufacturers’ rollout planning.<br />
Hear the inside story, from one of the few<br />
on the International Standards Working<br />
Group involved in planning the deployment<br />
of the new devices. Major changes<br />
will occur in the supply chain and at<br />
hospitals. Prepare your hospital for the<br />
change, and understand some of the<br />
potential pitfalls ahead.<br />
THE CENTER FOR PATIENT SAFETY CENTERFORPATIENTSAFETY.ORG <strong>PSO</strong>NEWS SPRING 2016<br />
9
8TH ANNUAL AHRQ <strong>PSO</strong> MEETING<br />
The Agency for Healthcare Research and Quality is headquartered in Rockville, Maryland.<br />
A UNITED FRONT<br />
TO IMPROVE CARE<br />
Center for Patient Safety (CPS) staff<br />
Kathy Wire, Lee Varner and Eunice<br />
Halverson joined other <strong>PSO</strong> representatives<br />
from around the country at<br />
the Agency for Healthcare Research<br />
and Quality (AHRQ) Headquarters in<br />
Rockville, Maryland, for the 8th Annual<br />
AHRQ <strong>PSO</strong> Meeting in April. As one of<br />
81 <strong>PSO</strong>s certified nationally, operating<br />
within 28 states and District of Columbia,<br />
CPS continues to be a leader in<br />
<strong>PSO</strong> activity. CPS is:<br />
• 1 of nine <strong>PSO</strong>s with more than<br />
250 <strong>PSO</strong> contracts<br />
• 1 of 67 <strong>PSO</strong>s receiving reports<br />
• 1 of 23 <strong>PSO</strong>s with more than<br />
10,000 reports<br />
• 1 of 38 <strong>PSO</strong>s offering services in<br />
all states<br />
• 1 of 2 <strong>PSO</strong>s providing services to<br />
EMS services<br />
• 1 of 36 <strong>PSO</strong>s receiving reports in<br />
all AHRQ defined safety categories<br />
• 1 of 11 <strong>PSO</strong>s submitting data to<br />
the national <strong>PSO</strong> database (<strong>PSO</strong>PPC)<br />
ONLINE: To learn more about<br />
the Agency for Healthcare Research<br />
and Quality, visit their<br />
website at ahrq.gov.<br />
BY EUNICE HALVERSON, MA<br />
Center for Patient Safety<br />
• AHRQ and CMS representatives discussed<br />
the regulations for Section 1311(h)<br />
of the Affordable Care Act which were<br />
released earlier this year. The Section requires<br />
hospitals with more than 50 beds<br />
to engage with either an AHRQ-certified<br />
<strong>PSO</strong> or alternative evidence-based initiatives,<br />
in order to be eligible to participate<br />
in Health Insurance Exchanges. This regulation<br />
is effective January 1, 2017. CMS<br />
strongly encourages organizations to report<br />
patient safety events using AHRQ’s<br />
standardized common data formats.<br />
• Nidhi Singh Shah, CMS, noted that<br />
the AHRQ and CMS have “reached an<br />
agreement in principle” regarding coordination<br />
of <strong>PSO</strong> activity and protections and<br />
needs of CMS state surveyors to ensure<br />
regulatory compliance.<br />
• David Hunt, MD, Medical Director<br />
of the Office of the National Coordinator<br />
(ONC), advised that the ONC Health IT<br />
Committee continues to work with NQF<br />
to “learn, improve and lead” in the patient<br />
safety world. They are seeking to identify<br />
HIGHLIGHTS OF THE MEETING<br />
and prioritize IT patient safety measures.<br />
• <strong>PSO</strong> legal updates were shared by<br />
Andrea Timashenka of the Department<br />
of Health and Human Services. Details of<br />
current legal cases can be found on the<br />
CPS website (click to review). A team<br />
from Baptist Health in Florida described<br />
how hospitals across the state have<br />
worked with their state regulators and<br />
agreed how documents in patient safety<br />
evaluation systems will be addressed. Despite<br />
Amendment 7 in Florida, hospitals<br />
have been successful in protecting their<br />
patient safety work product. Presenters<br />
cautioned, however, that <strong>PSO</strong> participants<br />
need to have well-defined policies and report<br />
to their <strong>PSO</strong> in order to successfully<br />
claim the federal protections of the Patient<br />
Safety and Quality Improvement Act<br />
of 2005 in court. If you need help updating<br />
your <strong>PSO</strong> policy, contact Eunice Halverson.<br />
• The AHRQ has provided, and will continue<br />
to develop, resources to help providers<br />
better understand <strong>PSO</strong>s and select<br />
a <strong>PSO</strong> on its website at www.pso.ahrq.gov.<br />
FOR MORE INFORMATION, or for assistance updating your <strong>PSO</strong> policy, contact Eunice<br />
Halverson. You can reach her at ehalverson@centerforpatientsafety.org.<br />
10<br />
<strong>PSO</strong>NEWS SUMMER SPRING 2016 2016<br />
CENTERFORPATIENTSAFETY.ORG THE CENTER FOR PATIENT SAFETY
AHRQ GUIDANCE | WHAT DOES IT MEAN TO ME?<br />
INCREASING OUR<br />
UNDERSTANDING<br />
WHAT THE AGENCY FOR HEALTHCARE RESEARCH AND QUALITY’S GUIDANCE<br />
MEANS FOR HEALTHCARE PROVIDERS AND THEIR PATIENTS.<br />
BY KATHY WIRE, JD, MBA, CPHRM<br />
Center for Patient Safety<br />
Patient Safety Organizations (<strong>PSO</strong>s) and their participants have<br />
struggled with interpreting the Patient Safety and Quality<br />
Improvement Act (PSQIA) with respect to handling patient<br />
safety work that may be necessary to satisfy mandatory<br />
reporting or other operational requirements. In an effort to ease<br />
anxiety and develop a common understanding, the Agency for Healthcare<br />
Research and Quality (AHRQ) has issued a statement (“Guidance”) on the<br />
interface of (1) <strong>PSO</strong> protection of Patient Safety Work Product (PSWP) and<br />
(2) mandatory reporting and operational requirements. AHRQ’s statement<br />
is available online (click here). Below are some highlights, based on the<br />
questions CPS gets most often from its participants. CPS participants are<br />
encouraged to contact the Center’s staff with questions.<br />
• The PSQIA has always required that<br />
<strong>PSO</strong> participants keep the information<br />
required to satisfy mandatory reporting<br />
requirements outside of the PSWP “protected”<br />
space. The Guidance reinforces<br />
that requirement. However, the PSQIA and<br />
the Final Rule allow participants to gather<br />
information inside the PSES until they<br />
know whether it will need to be reported.<br />
If outside reporting is required, then the<br />
information gathered in the PSES that has<br />
not yet been reported to the <strong>PSO</strong> can be<br />
pulled back out, so that it can be used to<br />
satisfy the outside reporting requirement.<br />
The Guidance recognizes both this early<br />
PSES protection and the opportunity to<br />
pull information from the protected space<br />
when necessary.<br />
• Like the Final Rule, the Guidance emphasizes<br />
that analysis that takes place in<br />
the PSES cannot be “dropped out.” It must<br />
remain as PSWP.<br />
• If a participant has a known obligation<br />
under state or federal law to report certain<br />
information, the provider should plan on<br />
developing it outside the PSES, as it cannot<br />
be PSWP.<br />
• The Kentucky Supreme Court’s Tibbs<br />
decision held that work surrounding mandatory<br />
state reporting could not be protected,<br />
as the state retained the right to<br />
investigate how the provider was accomplishing<br />
its reporting obligations. AHRQ’s<br />
Guidance seems to question that position,<br />
noting instead that information related<br />
to the required reporting “form” could<br />
be protected once the essential reporting<br />
obligation has been fulfilled by submitting<br />
the actual form, as long as the original documents<br />
from which the report was developed<br />
are still available.<br />
• A variety of projects may take place<br />
after a patient safety event. AHRQ’s Guidance<br />
contains some helpful examples on<br />
pages 6-7 of how that work can be viewed<br />
as inside or outside of the PSES, and when<br />
it will have to be non-PSWP because of<br />
outside reporting requirements.<br />
• AHRQ encourages <strong>PSO</strong>s and their participants<br />
to work with state agencies and<br />
regulators to determine what information<br />
they need access to and what can reliably<br />
be viewed as PSWP, so that there are fewer<br />
confrontations on the front lines about<br />
those issues. (NOTE: CPS has historically<br />
supported its participants wherever possible.)<br />
• The Guidance emphasizes that PSWP<br />
is protected because it has been developed<br />
for reporting to the <strong>PSO</strong>, and that the PSES<br />
is a protected space for developing that<br />
information. CPS has encouraged its participants<br />
to view <strong>PSO</strong> reporting as the end<br />
point of their PSES activities, and to actually<br />
report to the <strong>PSO</strong>. AHRQ’s Guidance<br />
underscores the importance of reporting.<br />
• The Guidance specifically mentions<br />
hospitals’ requirement under the Conditions<br />
of Participation to track adverse<br />
events, noting that there is a “legitimate<br />
outside obligation” to keep those records.<br />
42 CFR 482.21(a)(2) (https://www.law.<br />
cornell.edu/cfr/text/42/482.21). Incident<br />
reports have been a flashpoint in many<br />
states with respect to surveyors’ ability to<br />
see PSWP. <strong>PSO</strong> participants should carefully<br />
consider what routinely reported<br />
event information goes into or out of the<br />
PSES. For example, some <strong>PSO</strong> advisors<br />
recommend that basic incident data that<br />
includes just patient name, date, location<br />
and a brief description would allow regulators<br />
to conduct their own investigations<br />
while protecting the <strong>PSO</strong> participant’s<br />
deeper investigation and analysis of those<br />
events.<br />
• The action plans or other actions or<br />
changes that result from analysis inside the<br />
PSES cannot be protected and can always<br />
be shared with surveyors.<br />
THE CENTER FOR PATIENT SAFETY CENTERFORPATIENTSAFETY.ORG <strong>PSO</strong>NEWS SUMMER SPRING 2016<br />
11
LEARNING<br />
OPPORTUNITIES:<br />
HIGHLIGHTS FROM THIS YEAR’S <strong>PSO</strong> DAY AND PATIENT SAFETY CONFERENCE<br />
BY EUNICE HALVERSON, MA<br />
Center for Patient Safety<br />
Each year the Center for Patient Safety (CPS)<br />
offers a <strong>PSO</strong> Day for its participants to meet<br />
face-to-face to network and learn from each<br />
other. This year’s Safe Table discussions on<br />
April 6 centered around early identification of<br />
sepsis and management of suicide ideation for patients<br />
not on behavioral medicine units. One participant<br />
noted, “I appreciate the opportunity to meet others<br />
who often have the same challenges we face at our<br />
hospital. I always look forward to learning from my<br />
colleagues and determining what changes we can<br />
implement to improve patient care, thus decreasing<br />
the chances of future harm to our patients.” Safe<br />
Table information is available to the Center’s <strong>PSO</strong><br />
participants. (CPS <strong>PSO</strong> Participants only)<br />
SAFETY CONFERENCE<br />
Over 140 health care professionals from several states gathered<br />
at CPS’ 2016 Patient Safety conference in St. Louis on April 7.<br />
Highlights included:<br />
High Reliability - David Marx, the “father of Just Culture” and<br />
well-known author and systems design engineer, provided insights<br />
into “The Human Role in High Reliability”. Using his recent personal<br />
experience of a family member’s hospitalization, Marx challenged<br />
attendees to maximize human reliability by influencing the<br />
design of the health care system and its processes. Throughout<br />
the day, Marx spoke with attendees and autographed his newly<br />
released book, “Dave’s Subs: A Novel Story about Workplace Accountability”,<br />
a gift for each attendee.<br />
Just Culture - Professionals from CoxHealth in Springfield, MO<br />
shared their experience with the implementation of Just Culture<br />
across their system. Vicki Good (Quality and Patient Safety), Mark<br />
Alexander (Pre-hospital Services) and Cheryl Dunn (Employee Relations)<br />
each explained the significance of their role in not only<br />
implementing Just Culture but what they do to ensure it continues<br />
12<br />
<strong>PSO</strong>NEWS SPRING SUMMER 2016 2016<br />
CENTERFORPATIENTSAFETY.ORG THE CENTER FOR PATIENT SAFETY
POSTERS<br />
Posters from ten organizations in six states<br />
provided more opportunities for learning:<br />
• Antibiotic Stewardship – Hannibal Regional<br />
Healthcare System – Missouri<br />
• Implement a Clinic-Centered Safety<br />
Program – Mercy Clinic East Community –<br />
Missouri<br />
• Integrating an Institution-Wide Multidisciplinary<br />
Safe Learning Environment to<br />
Address Patient Safety Issues and Quality<br />
Initiatives – VA Nebraska Western Iowa<br />
Health Care System – Nebraska<br />
• Medication Safety: Less Noise – Hannibal<br />
Regional Healthcare System – Missouri<br />
• Mitigating Preventable Adverse Events<br />
with the Use of Safety Advisors – The Hospitals<br />
of Providence Sierra Campus – Texas<br />
• Novel Cutaneous Identification Device as<br />
an Inpatient Identifier – Lenox Hill Hospital<br />
– New York<br />
• Population Health – Hannibal Regional<br />
Healthcare System – Missouri<br />
• Revitalizing the Traditional Hospital-Based<br />
Root Cause Analysis with Lean Six Sigma –<br />
Memorial Health System – Illinois<br />
• Stay Standing: A Falls Prevention Collaboration<br />
– Still University – Area Health<br />
Education Center - Missouri<br />
• Using Human Performance Tools to Reduce<br />
Pediatric Medication Errors – University<br />
of Michigan Health System – Michigan<br />
to be “alive and well” at CoxHealth. Contact vicki.good@coxhealth.com for<br />
more information.<br />
Staff Empowerment – Jerry Reinke, representing the National Association<br />
of Health Care Assistants, shared how improving relationships between<br />
all caregivers, including nurse assistants, has a positive impact on direct patient<br />
care.<br />
Patient Safety Across the Continuum of Care – Michael Handler, MD,<br />
Medical Director for CPS, as well as other Center staff challenged attendees<br />
to consider patient safety concerns across the many settings of care: EMS,<br />
ED, inpatient, surgery, ancillary departments, rehab, long-term care and<br />
hospice. Ensuring complete and accurate communication, especially during<br />
hand-offs of care, will help prevent errors which sometimes result in patient<br />
harm.<br />
Pediatric Errors in EMS – Peter Antevy, MD and EMS Medical Director<br />
for several fire departments in southern Florida, explained how the human<br />
brain contributes to human errors – and it can’t be avoided! He shared his<br />
ongoing research to improve outcomes of pediatric arrests outside the hospital.<br />
Many positive comments were received from <strong>PSO</strong> Day and conference<br />
attendees, all who have the same goal in mind: eliminate patient harm!<br />
FOR MORE INFORMATION on <strong>PSO</strong> Day or the Conference, email Eunice<br />
Halverson at ehalverson@centerforpatientsafety.org.<br />
“Don’t tell the Board how you messed up last month,<br />
but rather tell them how you are preventing harm next<br />
month. You can do this by completing RCAs on near<br />
misses and measuring behavioral choices. Design good<br />
systems to support good decisions. In the end, you will<br />
help wonderful nurses be wonderfully safe nurses who<br />
make good choices to be great caregivers.”<br />
— David Marx, CEO, Outcome Engenuity<br />
THE CENTER FOR PATIENT SAFETY CENTERFORPATIENTSAFETY.ORG <strong>PSO</strong>NEWS SUMMER SPRING 2016 2016<br />
13
WATCH YOUR STEP!<br />
BY TINA HILMAS, RN, BSN<br />
Center for Patient Safety<br />
For the past 3 years (2013, 2014 and 2015)<br />
falls have remained in the top 5 reported<br />
sentinel events. Despite the multitude of fall<br />
prevention toolkits, healthcare organizations<br />
continue to struggle with preventing falls.<br />
There are many factors which contribute to falls<br />
from balance to toileting activities to confusion to<br />
medication. Medication as a contributing factor is<br />
one of the more challenging factors to assess. While<br />
medications such as anesthesia and pain medication<br />
post-operatively automatically raise red flags, many<br />
others do not.<br />
In reviewing the data submitted to CPS, 146 falls were reportedly<br />
associated with medication. Looking at the medications most<br />
frequently cited:<br />
1. Oxygen – 28 events<br />
2. Pain medication/Anesthesia – 26 events<br />
3. Blood thinners – 13 events<br />
Oxygen is a major medication that automatically increases the<br />
risk of falling. It is often overlooked because many times oxygen<br />
is not considered a medication but rather a treatment. Many of<br />
the events involving oxygen involved a patient not utilizing their<br />
oxygen as prescribed. Oxygen deprivation can lead to confusion,<br />
which can contribute to an unsteady balance and increase the risk<br />
for falls. Also the oxygen tubing is a risk for a fall. It is important<br />
to keep it out of the pathway of the patient utilizing the oxygen.<br />
Pain medication and anesthesia post-operatively are also factors<br />
that automatically increase a patient's risk for falling. While<br />
this category automatically receives the most attention in regards<br />
to increasing a person’s risk for falling, what isn’t always kept in<br />
mind is the effect that anesthesia and medication have on the elderly.<br />
Physiological changes that occur as a person ages also affect<br />
how pain medications or anesthesia are metabolized by the elderly.<br />
It can cause confusion, such as an elderly person who is no<br />
longer weight bearing thinking they can stand. Age and post-op<br />
status should automatically raise a patient’s risk factor for falling.<br />
Patients who fall while taking blood thinners are at an increased<br />
risk for harm. If these patients fall, the caregiver must always<br />
consider whether an whether an intra-cranial hemorrhage<br />
has occurred. Due to the dangerous potential consequences, this<br />
patient population should always be considered high risk for falls<br />
with appropriate precautions in place.<br />
Be mindful if patients have any of these other medication factors:<br />
1. Four or more medications<br />
2. Anti-hypertensives such as Procardia<br />
3. Antihistamines such as Benadryl or Atarax<br />
4. Anti-platelets such as Persantine<br />
5. Anti-depressants such as Elavil<br />
6. Benzodiazepines such as Valium<br />
7. Non-benzodiazepines such as Ambien or Lunesta<br />
8. Cardiovascular agents such as Nifedipine<br />
9. Insulin<br />
In summary, when addressing falls, while many factors play a<br />
part and can increase a patient's risk, one of the first areas to assess<br />
for risk factors are the patient’s medications. It’s important<br />
to evaluate not only the top 10% of the iceberg that is visible, but<br />
also the 90% that is unseen that could truly help prevent a patient<br />
from falling!<br />
TINA HILMAS is a project manager at the Center for Patient Safety.<br />
You can reach her at thilmas@centerforpatientsafety.org.<br />
ONLINE: To access additional resources about preventing falls can be found on the following websites:<br />
1. www.priorityhealth.com/provider/clinical-resources/ loads/2015/12/Collaborative-Assessment-Falls-in-Missouri.<br />
medication-resources/~/media/documents/pharmacy/ pdf<br />
cms-high-risk-medications.pdf<br />
4. www.jointcommission.org/assets/1/18/SEA_55.pdf<br />
2. www.drugguide.com/ddo/view/Davis-Drug-<br />
5. www.ahrq.gov/sites/default/files/publications/files/fallpxtoolkit.pdf<br />
Guide/109640/all/Drugs_Associated_with_Increased_Risk_<br />
of_Falls_in_the_Elderly<br />
6. www.centerfortransforminghealthcare.org/tst_pfi.aspx<br />
3. www.centerforpatientsafety.org/wp-content/up-<br />
7. psnet.ahrq.gov/resources/resource/29414<br />
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<strong>PSO</strong>NEWS SUMMER SPRING 2016 2016<br />
CENTERFORPATIENTSAFETY.ORG THE CENTER FOR PATIENT SAFETY
LEGAL UPDATE | IMPACTING THE PATIENT SAFETY WORLD<br />
FOUR PATIENT SAFETY CASES<br />
WORK THROUGH COURTS<br />
BY KATHY WIRE, JD, MBA, CPHRM<br />
Center for Patient Safety<br />
Cases involving the Patient Safety and Quality<br />
Improvement Act continue to work their way<br />
through state and federal courts with no major<br />
changes.<br />
Here is a status update on the significant cases:<br />
1. Tibbs v. Bunnell (Kentucky)<br />
The U.S. Supreme Court denied the hospital’s application for a<br />
writ of certiorari (a request for the Court to review an issue that<br />
relates to Federal law) filed in Tibbs v. Bunnell, No. 2012-SC-000603-<br />
MR (Ky. Aug. 21, 2014). This means the Kentucky Supreme Court<br />
decision will stand, in which the Kentucky Supreme Court ruled that<br />
any work performed in order to meet State requirements could not<br />
be patient safety work product, whether or not the work itself, or<br />
other products of it, had to be reported. This decision, as it stands<br />
now, applies only to Kentucky<br />
2. Carron v. Newport Hospital (Rhode Island)<br />
A plaintiff presented a Tibbs-type argument in Rhode Island. The<br />
trial court simply entered an order requiring production of the protected<br />
documents without any analysis. The case was appealed and<br />
the state Supreme Court has agreed to hear it. This is good news,<br />
in that the RI Supreme Court is interested in determining if the trial<br />
court inaccurately overlooked the federal protection of the documents<br />
declared by the defendant as patient safety work product.<br />
3. Charles v. Southern Baptist Hospital (Florida)<br />
The Florida Supreme Court has decided to accept the case on appeal.<br />
A decision is expected this summer or fall. The (<strong>PSO</strong>-favorable)<br />
appellate court decision rejected the Tibbs rationale. The trial court<br />
had followed Tibbs and found that any document or other work<br />
produced as part of compliance with a state requirement could not<br />
be protected PSWP. The appellate court rejected that claim.<br />
4. Baptist Richmond v. Agee (Kentucky)<br />
This is an appeal before the Kentucky Supreme Court in which<br />
the trial court ruled that the PSQIA protections only apply to information<br />
being collected for the “sole purpose” of reporting to a<br />
<strong>PSO</strong>. In other words, if being collected for any other purpose the<br />
protections would not apply. The appellate court did not accept<br />
the appeal, noting that this decision was consistent with the Tibbs<br />
Kentucky Supreme Court ruling. This case is still being briefed and is<br />
pending before the Kentucky Supreme Court.<br />
The Center for Patient Safety has participated with other <strong>PSO</strong>s to<br />
file briefs in these cases, supporting the protections available under<br />
what the <strong>PSO</strong>s believe is the clear language of the Act and the Final<br />
Rule. Important rulings will be published with a special alert to all<br />
of the Center’s <strong>PSO</strong> participants.<br />
THE CENTER FOR PATIENT SAFETY will continue to issue<br />
immediate legal updates about important decisions. If <strong>PSO</strong><br />
participants or their attorneys have any questions, please contact<br />
Kathy Wire at kwire@centerforpatientsafety.org.<br />
THE CENTER FOR PATIENT SAFETY CENTERFORPATIENTSAFETY.ORG <strong>PSO</strong>NEWS SUMMER SPRING 2016 2016<br />
15
EMS FORWARD | IN THE COMMUNITY<br />
NEW CPS REPORT SEEKS<br />
TO RAISE EMS AWARENESS<br />
BY LEE VARNER, MSEMS, EMT-P<br />
Center for Patient Safety<br />
Emergency Medical Services (EMS) is a special and unique profession with many dedicated men and<br />
women. These professionals bring compassion, enthusiasm and dependability in often very challenging<br />
environments. The Center for Patient Safety (CPS) is committed to provide support, resources and tools to<br />
improve safety in the EMS setting. In light of that, CPS published the PS-10 Report to raise awareness of<br />
patient safety concerns in EMS.<br />
#EMSFORWARD<br />
SAFETY TOPICS<br />
• Airway Management<br />
• Behavior Health<br />
Encounters<br />
• Crashes: Ambulance<br />
and Helicopter<br />
• Device Failures<br />
• Medication Errors<br />
• Mobile Integrated<br />
Healthcare<br />
• Pediatric Patients<br />
• Safety Culture<br />
• Second Victim Intervention<br />
• Transition of Care<br />
Ten Safety Topics for EMS<br />
The ten selected safety topics are reflective of<br />
those most often identified as risks to patient and<br />
provider safety and are forecasted to be of greater<br />
concern for EMS in 2016. This report is not an all-inclusive<br />
list of the patient safety concerns in EMS, but<br />
complements current patient safety and quality programs<br />
and provides resources to take proactive steps<br />
to eliminate harm.<br />
It would be difficult for an organization to effectively<br />
and efficiently address all ten topics in a<br />
12-month period. Since many topics overlap, leaders<br />
are encouraged to select one or two areas to implement<br />
change and monitor improvement, which will<br />
result in secondary benefits in other areas.<br />
The topics in this report were selected following<br />
a review by CPS experts and a review of leading EMS<br />
industry publications and journals. CPS also analyzed<br />
the <strong>PSO</strong>’s database of actual event information<br />
from EMS providers nationwide. As one EMS leader<br />
shared, “There is an illusion that EMS is so safe now -<br />
[we] have forgotten how inherently dangerous it is”.<br />
This PS-10 should be shared with frontline providers,<br />
middle managers, and executive leaders. Click here<br />
to download the PS-10: EMSForward report.<br />
THE CENTER FOR PATIENT SAFETY is a private<br />
not for profit organization that works across<br />
the continuum of care to improve quality as<br />
well as greater patient and provider safety. To<br />
learn more contact Lee Varner at lvarner@<br />
centerforpatientsafety.org.<br />
16<br />
<strong>PSO</strong>NEWS SUMMER SPRING 2016<br />
CENTERFORPATIENTSAFETY.ORG THE CENTER FOR PATIENT SAFETY
PATIENT SAFETY IN EMS | EMS SAFETY CONVERSATIONS<br />
CPS UNVEILS NEW WEBSITE<br />
The Center for Patient Safety (CPS) is<br />
proud to announce the launch of its newly<br />
revamped website. The site offers quick<br />
and easy access to essential information,<br />
resources and features while providing a<br />
more comprehensive understanding of the<br />
critical role that the Center plays in helping<br />
promote safe and quality healthcare<br />
through the reduction of medical errors.<br />
The site, which went live on June 6,<br />
also features comprehensive sections with<br />
news, events and educational resources, as<br />
well as a blog and corporate information.<br />
As a <strong>PSO</strong> participant, we know your<br />
access to resources is important. We’ve<br />
worked to improve your access by providing<br />
you with your own login information<br />
to easily access the toolkit and participant-only<br />
resources.<br />
The new website boasts a clean design<br />
aimed at improving functionality with<br />
enhanced content and improved security<br />
measures focused on helping CPS fulfill its<br />
mission to promote a safe and just culture.<br />
NEW CPS WEBSITE REQUIRES REGISTRATION<br />
CPS’ new website will be updated on<br />
a regular basis with news, resources, and<br />
safety alerts and a newsletter aimed to<br />
help healthcare organizations reduce medical<br />
errors.<br />
Visitors are encouraged to explore the<br />
PARTICIPANTS ONLY:<br />
DON'T MISS OUT ON ACCESS TO SPECIAL RESOURCES<br />
1. Visit www.centerforpatientsafety.org<br />
2. Select Members in the top right corner<br />
3. Click on “Not A Member” to register a username<br />
and password<br />
4. Once approved, you’ll receive confirmation via<br />
email<br />
website and sign up for the Safety Snapshot<br />
at www.centerforpatientsafety.org.<br />
QUESTIONS about the new website?<br />
Contact Jennifer Lux at jlux@<br />
centerforpatientsafety.org.<br />
PUT THE FOCUS ON SAFER<br />
CARE IN EMS COMMUNITY<br />
Early this year the CPS team started a pilot program to introduce the safety huddle concept to <strong>PSO</strong><br />
participants. One group that started the huddle pilot program was a select group of EMS medical directors.<br />
What are huddles and how can they improve patient safety as well as the quality of care?<br />
Huddles are timely, structured, secure and confidential conversations<br />
that allow for discussions in a rapid-fire format that explore<br />
real-time safety concerns. These virtual meetings provide an opportunity<br />
to assess risk and share ways that mitigate future safety<br />
concerns. Huddles are offered through the Center’s Patient Safety<br />
Evaluation System, so conversations are protected by the federal<br />
Patient Safety and Quality Improvement Act. The huddles have included<br />
timely conversation on current issues with input to improve<br />
event investigations and action planning.<br />
AREAS OF RECENT DISCUSSION INCLUDE:<br />
Airway Management: the importance of utilizing capnography<br />
for airway monitoring as well as confirmation of airway placement.<br />
Time Critical Diagnosis: early identification and transportation<br />
to appropriate destinations for this patient population.<br />
Transition of Care: Improving the hand-offs between providers<br />
so that important information is not lost or omitted which might<br />
contribute to an unsafe event reaching a patient.<br />
Steps are underway by CPS staff to support process improvements<br />
around these areas as well as collaborating with providers,<br />
leaders and other stakeholders to improve and standardize the huddle<br />
process. The CPS team looks forward to continuing the huddles<br />
with EMS medical directors -- stay tuned for more opportunities in<br />
the future. For more information, contact Lee Varner.<br />
THE CENTER FOR PATIENT SAFETY CENTERFORPATIENTSAFETY.ORG <strong>PSO</strong>NEWS SUMMER SPRING 2016 2016<br />
17
<strong>PSO</strong> PARTICIPANTS | DATA UPDATE<br />
IMPORTANT UPDATE!<br />
FOR <strong>PSO</strong> PARTICIPANTS...<br />
ANNOUNCEMENTS<br />
The Center for Patient Safety's <strong>PSO</strong><br />
continues to grow with new organizations<br />
joining regularly. Participating organizations<br />
have reported thousands of events<br />
in 2016 so far. The reported information is<br />
used for sharing and learning purposes.<br />
Following review and analyses of the<br />
reported events, CPS has issued more than<br />
a half dozen watches and alerts as mechanisms<br />
to raise awareness about the patient<br />
safety trends reported to the <strong>PSO</strong>.<br />
PATIENT SAFETY<br />
ALERTS AND WATCHES<br />
ISSUED<br />
1. AHRQ Guidance<br />
2. Contaminated Supplies<br />
3. Home Health Medication<br />
Management<br />
4. Patient Destination<br />
Decisions<br />
5. EKG Strips<br />
6. Intranasal Medication<br />
Administration<br />
7. Find more online<br />
CPS is excited to announce several new<br />
services and features for <strong>PSO</strong> participants:<br />
1. We have made an investment in analytical<br />
software, SAS, to expand on<br />
current analyses and provide more<br />
robust reporting to participants.<br />
You'll see more on this soon!<br />
2. VergeSolutions is preparing to<br />
roll out enhanced options within<br />
their data collection portal. One<br />
new feature will allow for secure<br />
communication about events from<br />
participant to <strong>PSO</strong> and vice-a-versa.<br />
Stay tuned!<br />
3. We've launched a new website with<br />
specific member access for you.<br />
When logged in, you'll have direct<br />
access to your toolkits, huddle<br />
report-outs, and more, as well as a<br />
new Q&A area to ask and answer<br />
questions from other participants.<br />
See the page 17 for details about<br />
setting up your access!<br />
2016 DATA UPDATE<br />
Data submitted to the Center for Patient<br />
Safety's <strong>PSO</strong> for 2016 reveals an increase in<br />
the number of reported medication events.<br />
Of the medication events reported:<br />
• 60 events were associated with<br />
opioids<br />
• 36 were associated with benzodiazepines<br />
• 3 events were associated with a<br />
handoff to or from another unit<br />
• The most commonly cited contributing<br />
factor was the human factor<br />
of inattention with communication<br />
among staff and team members<br />
being the second most commonly<br />
cited contributing factor.<br />
Please see our 2015 Annual <strong>PSO</strong> Report<br />
for resources to improve communication<br />
and tools for decreasing medication<br />
events.<br />
2016 EVENTS (JAN-JUN)<br />
Type of Event<br />
# of Events<br />
Blood 20<br />
Device 71<br />
Falls 826<br />
HAI 24<br />
Medication 1156<br />
Perinatal 101<br />
Pressure Ulcer 23<br />
Surgery 303<br />
VTE 2<br />
Other 2906<br />
Harm Level<br />
# of Events<br />
Death 8<br />
Severe 9<br />
Moderate 43<br />
Mild 384<br />
No harm 3668<br />
Unknown 1370<br />
18<br />
<strong>PSO</strong>NEWS SUMMER SPRING 2016<br />
CENTERFORPATIENTSAFETY.ORG THE CENTER FOR PATIENT SAFETY
TAKE<br />
Benefits of CPS Safety<br />
Culture Survey Services:<br />
PATIENT SAFETY INSIDER | SAFETY CULTURE SURVEY<br />
• Deepest feedback reports in the industry!<br />
ADVANTAGE!<br />
Anyone can use CPS safety culture survey services,<br />
but CPS <strong>PSO</strong> Participants receive a 20% discount!<br />
REQUEST A PROPOSAL TODAY!<br />
• Comprehensive reports at the organization and<br />
department-level!<br />
• SAVE TIME & MONEY! Save 30+ hours of<br />
administrative time. You'll need about 2 hours for<br />
the entire process and we'll take care of the rest!<br />
• ACCESSIBLE - online, anonymous survey with<br />
access via computer, smart-phone, tablet, etc<br />
• DATA ANALYSIS - data is analyzed for you<br />
• SUPPORT - we'll talk with you about your results<br />
and guide you to your next steps<br />
Culture surveys now available for:<br />
• Hospitals<br />
• Ambulatory Surgery Centers<br />
• Long Term Care<br />
• Home Health<br />
• Medical Offices<br />
• Pharmacies<br />
• EMS - NEW!<br />
We want you to be successful!<br />
PRICING IS AFFORDABLE FOR ORGANIZATIONS OF ALL SIZES<br />
THE CENTER FOR PATIENT SAFETY CENTERFORPATIENTSAFETY.ORG <strong>PSO</strong>NEWS SUMMER SPRING 2016 2016<br />
19
2410A HYDE PARK RD.<br />
JEFFERSON CITY, MO. 65109<br />
PHONE: 1.888.935.8272<br />
www.centerforpatientsafety.org<br />
The Center for Patient Safety,<br />
established in 2005, is an<br />
independent, not-for-profit<br />
organization dedicated to<br />
promoting safe and quality<br />
healthcare through the<br />
reduction of medical errors.<br />
FOR MORE INFORMATION, CONTACT ANY MEMBER OF THE <strong>PSO</strong> TEAM:<br />
ALEX CHRISTGEN, BS, CPPS<br />
Interim Executive Director<br />
achristgen@centerforpatientsafety.org<br />
EUNICE HALVERSON, MA<br />
Patient Safety Specialist<br />
ehalverson@centerforpatientsafety.org<br />
KATHRYN WIRE, JD, MBA, CPHRM<br />
Project Manager<br />
kwire@centerforpatientsafety.org<br />
LEE VARNER, MS-EMS, EMT-P<br />
Project Manager - EMS Services<br />
lvarner@centerforpatientsafety.org<br />
TINA HILMAS, RN, BSN<br />
Project Manager<br />
thilmas@centerforpatientsafety.org<br />
MICHAEL HANDLER, MD, MMM, FACPE<br />
Medical Director<br />
AMY VOGELSMEIER, PHD, RN, GCNS-BC<br />
Researcher/Data Analyst<br />
JENNIFER LUX<br />
Office Coordinator<br />
jlux@centerforpatientsafety.org<br />
WELCOME NEW STAFF!<br />
AIMEE TERRELL<br />
Administrative Assistant<br />
aterrell@centerforpatientsafety.org<br />
Find us. Follow us. Like us.<br />
Visit www.centerforpatientsafety.org<br />
for additional information on the<br />
Center’s <strong>PSO</strong> activities, resources,<br />
toolkits, upcoming events,<br />
safety culture resources, and more.<br />
If you have questions about any<br />
Center resources or articles within<br />
this newsletter, please contact the<br />
Center for Patient Safety at:<br />
info@centerforpatientsafety.org<br />
or call 888.935.8272<br />
NOTE: Some articles contained within this newsletter may reference materials available to<br />
Center for Patient Safety <strong>PSO</strong> participants only.<br />
The information obtained in this publication is for informational purposes only and does not constitute<br />
legal, financial, or other professional advice. The Center for Patient Safety does not take any<br />
responsibility for the content of information contained at links of third-party websites.