Table of Contents

1. Application of an Aviation Model of Incident Reporting and Investigation to the Neurosurgical Scenario: Method and Preliminary Data
2. As She Lay Dying: How I Fought to Stop Medical Errors from Killing My Mom
3. Counting Matters: Lessons from the Root Cause Analysis of a Retained Surgical Item
4. Duplication of Surgical Site Marking
5. Effects of Nursing Unit Spatial Layout on Nursing Team Communication Patterns, Quality of Care, and Patient Safety
6. A Framework for Encouraging Patient Engagement in Medical Decision Making
7. The Heart of Health Care: Parents’ Perspectives on Patient Safety
8. How-To Guide: Prevent Obstetrical Adverse Events
9. Impact of a Hospital-Wide Hand Hygiene Initiative on Healthcare-Associated Infections: Results of an Interrupted Time Series
10. The Impact of Medication Reconciliation Program at Admission in an Internal Medicine Department
11. Improving Patient Safety through the Systematic Evaluation of Patient Outcomes
12. Online, Direct-to-Consumer Access to Insulin: Patient Safety Considerations and Reform
13. Pediatric Medical Line Safety: The Prevalence and Severity of Medical Line Entanglements
14. Pharmacy Dispensing of Electronically Discontinued Medications
15. The Role of the Electronic Health Record in Patient Safety Events
16. A Study of the Prevalence of Adverse Events in Primary Healthcare in Spain
17. Surgical Fires: Trends Associated with Prevention Efforts
18. A Systematic Approach to the Identification and Classification of Near-Miss Events on Labor and Delivery in a Large, National Health Care System
19. “Team Time-Out” and Surgical Safety—Experiences in 12,390 Neurosurgical Patients
20. Thirty-Day Outcomes Support Implementation of a Surgical Safety Checklist

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• Members in the News
  • ASPPS member Tim Morgenthaler, MD, publishes on Zolpidem as a fall risk for inpatients, in the Journal of Hospital Medicine
• NPSF News
  • The National Patient Safety Foundation’s interim president, Patricia McGaffigan, recently participated in a Congressional briefing on the issue of patient safety and cancer care
• Patient Safety in the News
  • The Joint Commission issues Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation
  • Nurse Burnout and Long Shifts
  • A recent article in the New England Journal of Medicine proposes EHR-specific safety goals
• Save the date for the 15th annual NPSF Patient Safety Congress, May 8-10, 2013, in New Orleans. Keynote Speaker: Suzanne Gordon

...

Table of Contents

1. Cognitive Errors and Logistical Breakdowns Contributing to Missed and Delayed Diagnoses of Breast and Colorectal Cancers: A Process Analysis of Closed Malpractice Claims
2. A Collaborative, Systems-Level Approach to Eliminating Healthcare-Associated MRSA, Central-Line–Associated Bloodstream Infections, Ventilator-Associated Pneumonia, and Respiratory Virus Infections
3. Diagnostic Errors and Flaws in Clinical Reasoning: Mechanisms and Prevention in Practice
4. Error Reporting in Transfusion Medicine at a Tertiary Care Centre: A Patient Safety Initiative
5. Errors and Near Misses in Digestive Endoscopy Units
6. The Feedback Intervention Trial (FIT)—Improving Hand-Hygiene Compliance in UK Healthcare Workers: A Stepped Wedge Cluster Randomised Controlled Trial
7. Impact of Automated Alerts on Follow-Up of Post-Discharge Microbiology Results: A Cluster Randomized Controlled Trial
8. Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation
9. Interruption Handling Strategies during Paediatric Medication Administration
10. Intravascular Retained Surgical Items: A Multicenter Study of Risk Factors
11. Medication Problems Are Frequent and Often Serious in a Danish Emergency Department and May Be Discovered by Clinical Pharmacists
12. Non-Technical Skills Training to Enhance Patient Safety: A Systematic Review
13. Partnering with Family Members to Improve the Intensive Care Unit Experience
14. Patterns in Neurosurgical Adverse Events and Proposed Strategies for Reduction
15. Preventing Wrong-Site Surgery in Minnesota: A 5-Year Journey
16. Restructuring the Morbidity and Mortality Conference in a Department of Pediatrics to Serve as a Vehicle for System Changes
17. Safety Climate and Medical Errors in 62 US Emergency Departments
18. Sharing Lessons Learned to Prevent Incorrect Surgery
19. Surgical Debriefing: A Reliable Roadmap to Completing the Patient Safety Cycle
20. Ultrasound to Reduce Cognitive Errors in the ED

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Webcast held November 15, 2012

Please note: Continuing education credits are not available for archived programs.

Featured Faculty:

Matthew K. Wynia, MD, MPH, FACP
Director
The Institute for Ethics and Center for Patient Safety
American Medical Association
Clinical Assistant Professor for Infectious Diseases
University of Chicago

Learning Objectives

Attendees of this webcast will be able to:

1. Describe the frequency of and harms associated with errors in the outpatient setting
2. List the most common types of errors in outpatient care
3. Explain at least 3 factors that make care in the ambulatory setting different from care in the hospital in regard to potential for errors and harm
4. Challenge conventional thinking about the roles of patients in safety
5. Formulate plans for how to incorporate ambulatory issues in future quality and safety work

...

Table of Contents

1. Adjusting Team Involvement: A Grounded Theory Study of Challenges in Utilizing a Surgical Safety Checklist as Experienced by Nurses in the Operating Room
2. Adverse Drug Events Caused by Serious Medication Errors
3. Certain Uncertainties: Modes of Patient Safety in Healthcare
4. Designing for Distractions: A Human Factors Approach to Decreasing Interruptions at a Centralised Medication Station
5. Designing for Patient Safety: Developing Methods to Integrate Patient Safety Concerns in the Design Process
6. The Effect of the WHO Surgical Safety Checklist on Complication Rate and Communication
7. Electronic Health Records and National Patient-Safety Goals
8. More Quality Measures versus Measuring What Matters: A Call for Balance and Parsimony
9. Multiple Patient Safety Events within a Single Hospitalization: A National Profile in US Hospitals
10. A Nurse Learns Firsthand That You May Fend for Yourself after a Hospital Stay
11. Patient Safety Culture in Home Care: Experiences of Home-Care Nurses
12. Procedural Safety in Emergency Care: A Conceptual Model and Recommendations
13. Reduced Mortality with Hospital Pay for Performance in England
14. Rethinking Opioid Prescribing to Protect Patient Safety and Public Health
15. Serious Safety Events: Getting to Zero™
16. A Systematic Review of Hand Hygiene Improvement Strategies: A Behavioural Approach
17. TeamSTEPPS®: The Patient Safety Tool That Needs to Be Implemented
18. Top 10 Health Technology Hazards for 2013
19. Utah Tenth Anniversary (2001-2011) Patient Safety Report: Identifying Opportunities for Improvement
20. What Keeps Facilities from Implementing Best Practices to Prevent Wrong-Site Surgery? Barriers and Strategies for Overcoming Them

...

ASPPS member Tim Morgenthaler, MD, chief patient safety officer at Mayo Clinic in Rochester, MN, is among the authors of a study that found the rate of falls was four times higher among inpatients who took Ambien than among other patients.

Read the abstract in the Journal of Hospital Medicine.

Read a summary article from the Philadelphia Inquirer.

Cancer services cover a wide range of activities, from health promotion and screenings to diagnosis, surgery, medical or radiotherapy, palliative care, and disease management. Likewise, the safety risks and opportunities for error are broad and far-reaching in consequence, and include adverse drug interactions, patient misidentification and cross-contamination of laboratory specimens. The risk of error grows with the introduction of new therapies and the advance of personalized medicine.

In written comments to his colleagues prior to the meeting, Rep. Barber said, “As Congress continues to address health issues, a concise overview of some of the key issues, challenges, and solutions related to cancer and patient safety should help guide the institution’s analysis, debate, and action.”

Patricia McGaffigan, RN, MS, interim president of NPSF, represented the Foundation’s commitment to supporting health systems in their efforts to improve safety in cancer care. She also recounted personal experience with the health care system that served to illustrate some of the very issues under discussion.

Joining Ms. McGaffigan on the expert panel were Mara Aspinall, president and CEO, Ventana Medical Systems, Inc., and global head, Roche Tissue Diagnostics; Maurie Markman, MD, senior vice president of clinical affairs and national director of medical oncology, Cancer Treatment Centers of America; and Eric Walk, MD, FCAP, senior vice president, medical and scientific affairs, Ventana Medical Systems.

Ms. McGaffigan also answered questions informally after the session. View the video below.

Part I

Part II

Table of Contents

1.  Characteristics and Costs of Surgical Scheduling Errors
2. Developing a Culture of Safety in the Epilepsy Monitoring Unit: A Retrospective Study of Safety Outcomes
3. The Economic Burden of Patient Safety Targets in Acute Care: A Systematic Review
4. The Economics of Health Care Quality and Medical Errors
5. Effectiveness of a Radiofrequency Detection System as an Adjunct to Manual Counting Protocols for Tracking Surgical Sponges: A Prospective Trial of 2,285 Patients
6. Effect of Nonpayment for Preventable Infections in U.S. Hospitals
7. Effects of an Online Personal Health Record on Medication Accuracy and Safety: A Cluster-Randomized Trial
8. Evaluating the Evidence: Direct-to-Consumer Screening Tests Advertised Online
9. Impact of Complexity and Computer Control on Errors in Radiation Therapy
10. Improving Medication Safety with Accurate Preadmission Medication Lists and Postdischarge Education
11. Medication Errors in Pediatric Emergencies: A Systematic Analysis
12. Medication Errors, Routines, and Differences between Perioperative and Non-perioperative Nurses
13. Minnesota Hospital Association Statewide Project: SAFE from FALLS
14. The Problem with Peripherally Inserted Central Catheters
15. A Review of Medication Incidents Reported to the National Reporting and Learning System in England and Wales over 6 Years (2005–2010)
16. Risk Factors Associated with Incorrect Surgical Counts
17. Risks Related to Patient Bed Safety
18. Safety Threats and Opportunities to Improve Interfacility Care Transitions: Insights from Patients and Family Members
19. Seen through Their Eyes: Residents’ Reflections on the Cognitive and Contextual Components of Diagnostic Errors in Medicine
20. Types and Patterns of Safety Concerns in Home Care: Staff Perspectives

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• ASPPS News
  • Leadership Transition: A Special Note to Members from Diane Pinakiewicz as she steps down from her positions as president of ASPPS and NPSF
• NPSF News
  • Lucian Leape Institute Report on Care Integration — Order from Chaos: Accelerating Care Integration
  • Call to Action: Safeguarding the Integrity of Healthcare Quality and Safety Systems
• Patient Safety in the News
  • Patient Safety Starts with Nurse Managers
  • Bridging the Health Literacy Gap
  • Caring for Patients with Limited English Proficiency
  • Medication Reconciliation Toolkit
• Upcoming Professional Learning Series Webcasts

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Webcast held October 25, 2012 | 1-2 pm EDT

Please note: Continuing education credits are not available for archived programs.

Featured Faculty:

Michael R. Cohen, RPh, MS, ScD (hon), DPS (hon)
President, Institute for Safe Medication Practices

Learning Objectives

Attendees of this webcast will be able to:

1. Identify types of medication errors related to treatment with insulin in the hospital setting and at home.
2. Identify common product-related issues that can lead to confusion and errors with insulin.
3. Examine barriers to effective communication of insulin orders.
4. Discuss ways to minimize sources of potential errors with insulin.

...