The National Patient Safety Foundation is proud to partner with the American Hospital Association in sponsoring the AHA-NPSF Comprehensive Patient Safety Leadership Fellowship. This year-long program provides essential training in patient safety, quality, and performance improvement.

The fellowship consists of four in-person learning sessions, periodic teleconferences, webinars, various self and organizational assessments, and individual coaching.

This curriculum is based on the 2009 paper Transforming Healthcare: A Safety Imperative from the Lucien Leape Institute at NPSF. It prepares health care leaders to guide patient safety improvement initiatives and drive transformational change within their organizations.

The fellowship framework includes a focus on foundational elements of patient safety, such as leadership roles, culture and communication, and incorporates them into four pillars of patient safety:

• Care coordination
• Patient centeredness
• Organizational culture
• Transparency and learning organization

Fellows complete an action learning project to bring real change within their organizations and demonstrate their ability to apply the concepts learned. This rigorous approach ensures that Fellows can translate knowledge and best practices learned into action within their own organizations.

Applications for the 2013-2014 are being accepted through March 15, 2013. Please visit the fellowship website for more information.

The AHA and the National Patient Safety Foundation are sponsors of this program.

Partners include: The Health Education & Research Trust, Health Forum, the American Society for Healthcare Risk Management, the American Organization of Nurse Executives and the Society of Hospital Medicine.

ASPPS is pleased to recognize members who have recently earned the designation of Certified Professional in Patient Safety (CPPS):

Marney Prouse, LLM, LLB, BA, RN, CPPS, AED, Patient Safety, Hamad Medical Corp.

Tamim Qaum, MD, CPE, COE, CASC, FAWN, CPPS, Physician, Via Christi Clinic

 Pat Shute, RN, BS, MS, CPHQM, CPPS, Sr. Director, Performance Improvement, Voluntary Hospitals of America

Deb Smith, RN, BSN, CPPS, Patient Safety Coordinator, Phelps County Regional Medical Center

Miguel Venereo, MD, CPPS, Safe Care Professional Consultants Corp.

 Deve Vetter, RN, MS, CPPS, System Associate Vice President, Patient Safety Officer, Norton Healthcare

If you have become certified and would like to be recognized in our newsletter, or if you have other professional news to share, please write to ASPPSinfo@npsf.org.

Webcast held August 21, 2012 | 2-3 pm EDT

Faculty

Michael Kanter, MD
SCPMG Medical Director, Quality & Clinical Analysis
Kaiser Permanente Southern California

Andrea Smith, RN, BSN, PHN
Regional Safety Net Nurse Consultant, Clinical Operations
Kaiser Permanente Southern California

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

Learning Objectives

The content of this session is designed for health care professionals whose level of expertise includes the following: beginner, intermediate, expert.

Attendees of this webcast will be able to:

• Identify where opportunities might exist in their organizations to systematically address patient safety issues outside of the traditional inpatient setting
• Outline specific patient populations within four primary areas of outpatient safety: medication monitoring, potentially harmful interaction avoidance, necessary follow-up care, and diagnosis
• Plan an outpatient safety program by creating a series of centralized safety nets to catch important tests not properly followed up, drugs not properly monitored, and missed follow-up care

...

As a member of the Leape Institute, Dr. Wachter joins a distinguished panel of national thought leaders working to provide vision and calls to action to forge transformational paths to safer health care. The Institute’s namesake, Dr. Lucian Leape, serves as chairman.

“An outstanding innovator, writer, and student of health policy, Bob Wachter brings substantial knowledge and a unique perspective to our work. We are delighted and honored that he is joining the Lucian Leape Institute,” said Dr. Leape.

Dr. Wachter is a recipient of the John M. Eisenberg Award (2004), the country’s top honor in patient safety. For the past five years, Modern Healthcare magazine has named him one of the 50 most influential physician-executives in the US (number 14 in 2012), the only academic physician with this distinction. In 2011, as a Fulbright scholar, he studied patient safety and hospital medicine at Imperial College London.

In the course of his clinical and academic career, Dr. Wachter has authored more than 250 articles and 6 books, including Understanding Patient Safety (2012) and Internal Bleeding: The Truth Behind America’s Terrifying Epidemic of Medical Mistakes (2005). He also serves as editor of the US federal government’s two leading websites on safety.

Earlier this year, Dr. Wachter became chair of the American Board of Internal Medicine. Having coined the term “hospitalist” in 1996, he is a past-president of the Society of Hospital Medicine. He is also professor and associate chair of the Department of Medicine at the University of California, San Francisco, where he directs the Division of Hospital Medicine.

Dr. Wachter has served on the health care advisory boards of several companies, including Google; and is a member of the Board of Governors at the National Patient Safety Foundation. His blog, Wachter’s World, is one of the nation’s most popular health care blogs.

Dr. Wachter’s background and expertise are in close parallel to the Leape Institute’s work. In recent years the Institute has focused on identifying and framing vital transforming concepts that require system-level attention and action, including medical education reform; consumer engagement in health care; transparency; care integration; and restoring joy and meaning in work and addressing workforce safety.

To read more about the Lucian Leape Institute and its members, visit www.npsf.org/lli.

 About the Lucian Leape Institute

The Lucian Leape Institute at NPSF, established in 2007, is charged with defining strategic paths and calls to action for the field of patient safety, offering vision and context for the many efforts under way within health care, and providing the leverage necessary for system-level change. Its members comprise national thought leaders with a common interest in patient safety whose expertise and influence are brought to bear as the Institute calls for the innovation necessary to expedite the work and create significant, sustainable improvements in culture, process, and outcomes critical to safer health care.

 About The National Patient Safety Foundation

The National Patient Safety Foundation (NPSF) has been pursuing one mission since its founding in 1997–to improve the safety of care provided to patients. As a central voice for patient safety, NPSF is committed to a collaborative, multi-stakeholder approach in all that it does. NPSF is an independent, not-for-profit 501(c)(3) organization. To learn more about the work of the National Patient Safety Foundation, please visit: www.npsf.org.

Contact: Patricia McTiernan
E-mail: pmctiernan@npsf.org

Attendees will engage in an interactive afternoon dialogue with LLI members, followed by an evening networking reception and dinner featuring guest speaker Donald Berwick, MD, MPP, FRCP, former president and CEO of the Institute for Healthcare Improvement and former administrator, Centers for Medicare & Medicaid Services.

“As a health care innovator and staunch advocate for patient safety, Don Berwick has long inspired all of us in health care,” said Diane C. Pinakiewicz, MBA, CPPS, president of LLI and president of NPSF. “We are honored to have one of the LLI’s founding members share his thoughts on the future of health care.”

The afternoon forum takes place from 12:30 to 4 pm at the Westin Boston Waterfront. The evening gala, at the State Room, begins with a reception at 5 pm, followed by the keynote address and dinner.

Details and more information are available at http://bit.ly/LLI2012.

To register for this event, click here.

Organizations interested in opportunities to visibly support the work of the Lucian Leape Institute are encouraged to contact David Coletta at dcoletta@npsf.org.

About the Lucian Leape Institute

The Lucian Leape Institute at NPSF, established in 2007, is charged with defining strategic paths and calls to action for the field of patient safety, offering vision and context for the many efforts under way within health care, and providing the leverage necessary for system-level change. Its members comprise national thought leaders with a common interest in patient safety whose expertise and influence are brought to bear as the Institute calls for the innovation necessary to expedite the work and create significant, sustainable improvements in culture, process, and outcomes critical to safer health care.

About The National Patient Safety Foundation

The National Patient Safety Foundation (NPSF) has been pursuing one mission since its founding in 1997– to improve the safety of care provided to patients. As a central voice for patient safety, NPSF is committed to a collaborative multi-stakeholder approach in all that it does. NPSF is an independent, not-for-profit 501(c)(3) organization. To learn more about the work of the National Patient Safety Foundation, please visit: www.npsf.org.

Table of Contents

1. Common Patterns in 558 Diagnostic Radiology Errors
2. Comparative Economic Analyses of Patient Safety Improvement Strategies in Acute Care: A Systematic Review
3. Correlation between Glove Use Practices and Compliance with Hand Hygiene in a Multicenter Study with Elderly Patients
4. Economic Evaluation in Patient Safety: A Literature Review of Methods
5. Errors in Fluid Therapy in Medical Wards
6. Getting Doctors to Clean Their Hands: Lead the Followers
7. Impact of a Pharmacist-Prepared Interim Residential Care Medication Administration Chart on Gaps in Continuity of Medication Management after Discharge from Hospital to Residential Care: A Prospective Pre- and Post-Intervention Study (MedGap Study)
8. Incorporating the World Health Organization Surgical Safety Checklist into Practice at Two Hospitals in Liberia
9. Interdisciplinary Team Training: Five Lessons Learned
10. A New Perspective on Blame Culture: An Experimental Study
11. Patient Safety Attitudes and Behaviors of Graduating Medical Students
12. Perspectives on Diagnostic Failure and Patient Safety
13. Preventing Ventilator-Associated Pneumonia: Does the Evidence Support the Practice?
14. Productive Complications: Emergent Ideas in Team Communication and Patient Safety
15. A Prospective, Multicenter Study of Pharmacist Activities Resulting in Medication Error Interception in the Emergency Department
16. Successful Risk Assessment May Not Always Lead to Successful Risk Control: A Systematic Literature Review of Risk Control after Root Cause Analysis
17. Understanding Patient Safety, Second Edition
18. Using Care Bundles to Improve Health Care Quality
19. What Constitutes Patient Safety Culture in Chinese Hospitals?
20. Write the Wrong: Narrative Documentation

...

The College of American Pathologists estimates that 1 in 1,000 blood specimens ends up being labeled with the wrong patient identifiers. That type of error can potentially harm two patients—the patient whose blood was mislabeled as well as the patient who was incorrectly linked to that specimen. Both patients may end up with incorrect diagnoses, missed treatment, or treatment that they do not need.

Now, a collaboration between Palmetto Health Richland Hospital, the South Carolina Hospital Association, and Outcome Engenuity, LLC, has resulted in a simple intervention that hospitals can use to dramatically reduce the rate of mislabeled blood specimens. Called The Final Check, the intervention was used for the first time at Palmetto Health in 2011, resulting in a 90 percent decrease in mislabeled specimens in the first month it was used. Those results have since been validated at five other hospitals in South Carolina and sustained for five consecutive months to date.

Outcome Engenuity offers The Final Check Toolkit free of charge via the website, www.thefinalcheck.org.

David Marx, chief executive officer of Outcome Engenuity, described the intervention as being created through prospective risk modeling that looked at the various ways mislabeling can occur. Palmetto Health had previously tried to reduce the rate of mislabeled specimens through a highly rigorous Red Rule that required nurses and phlebotomists to ask the patient’s name and date of birth, and then to check both the 9-digit medical record number and the 10-digit patient account number.

After observing the staff at work, and realizing that few were actually following the Red Rule, Marx and his team turned that punitive routine upside down. “Instead of adding steps, we eliminated steps,” he said.

The Final Check still calls for the patient’s name and date of birth to be confirmed. But instead of checking the complete medical record number, the nurse or phlebotomist now reads only the last three digits of the medical record number on the label and on the patient’s wristband—and recites them out loud.

According to Marx, saying the numbers out loud ensures that the person is “on the task,” and also makes the staff accountable to the patient.

Marx, who was recently appointed to the National Patient Safety Foundation’s Board of Governors, is well known in the health care industry for his work around Just Culture principles, human factors engineering, and the design of socio-technical systems. The Final Check was designed with certain principles in mind—that people have free will, that effective systems make it easy for people to do the right thing, and that disciplining people for making errors does not necessarily stop errors from occurring.

View and download the Final Check Toolkit or visit www.thefinalcheck.org.

Webcast held June 25, 2012, 2-3 pm

Faculty

Maria Cvach, RN, MS, CCRN
Assistant Director of Nursing, Clinical Standards
The Johns Hopkins Hospital

Marjorie Funk, PhD, RN, FAHA, FAAN
Professor
Yale University School of Nursing

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

Learning Objectives

Attendees of this webcast will be able to:

• Define the problem and implications of alarm fatigue for caregivers and patients.
• Identify best practice strategies to reduce alarm fatigue.
• State three methods to assure secondary alarm notification.
• Specify four recommendations for the design of future research on monitor alarm fatigue.

...

“We are extremely pleased and honored to welcome these distinguished health care leaders to our boards,” said NPSF President Diane C. Pinakiewicz, MBA, CPPS “They each bring a wealth of experience, knowledge, and a proven commitment to patient safety to their new roles, and join a remarkable group of visionaries who continue to serve on the NPSF boards. We look forward to their unique perspectives and contributions.”

The NPSF Board of Directors provides strategic and operational oversight and is vested with fiduciary responsibilities for the Foundation. The Board of Governors offers direction and insight on NPSF program development, in keeping with the Foundation’s mission.

Joining the Board of Directors as new members:

Alan D. Aviles, President and Chief Executive Officer, New York City Health and Hospitals Corporation

Anne Scott Blouin, PhD, MSN, MBA, RN, Executive Vice President, Accreditation and Certification Operations, The Joint Commission
Dr. Blouin previously served on the NPSF Board of Governors.

Lillee Smith Gelinas, RN, MSN, FAAN, Vice President and Chief Nursing Officer, VHA, Inc.

 Gregg Meyer, MD, MSc, Chief Clinical Officer and Executive Vice President for Population Health, Dartmouth Hitchcock Medical Center
Dr. Meyer previously served as Chairman of the NPSF Board of Governors. He has been named Vice Chair of the NPSF Board of Directors.

Assuming new roles on the Board of Directors:

Gerald Hickson, MD, previously Vice Chairman, has been named Chairman. Dr. Hickson holds a number of appointments at Vanderbilt University Medical Center, including Assistant Vice Chancellor for Health Affairs, Associate Dean for faculty Affairs, and Director, Center for Patient and Professional Advocacy.

Gary Kaplan, MD, FACMPE, previously Chairman, remains on the board as Immediate Past Chair. Dr. Kaplan is Chairman and Chief Executive Officer of Virginia Mason Medical Center.

Joining the NPSF Board of Governors:

Paul W. Abramowitz, PharmD, FASHP, Chief Executive Officer and Executive Vice President, American Society of Health-System Pharmacists.

Michael R. Cohen, RPh, MS, ScD, President, Institute for Safe Medication Practices

Tom Evans, MD, FAAFP, President and CEO, Iowa Healthcare Collaborative

Helen Haskell, President, Mothers Against Medical Error

David Marx, JD, CEO, Outcome Engenuity, LLC

Patty Skolnik, Founder and Executive Director, Citizens for Patient Safety

Pamela Thompson, MS, RN, FAAN, Chief Executive Officer of the American Organization of Nurse Executives
Ms. Thompson was most recently Immediate Past Chair of the NPSF Board of Directors.

Assuming new roles on the NPSF Board of Governors:

Saul Weingart, MD, PhD, Vice President for Patient Safety, Dana-Farber Cancer Institute, has been named Chairman.

Tejal K. Gandhi, MD, MPH, Director, Patient Safety, Partners Healthcare, has been named Vice-Chair.

For more information about the Foundation’s governance and complete lists of the NPSF Board of Directors and Board of Governors, visit the governance page of our website.

About the National Patient Safety Foundation

NPSF has been pursuing one mission since its founding in 1997–to improve the safety of care provided to patients. As a central voice for patient safety, NPSF is committed to a collaborative, multi-stakeholder approach in all that it does. NPSF is an independent, not-for-profit 501(c)(3) organization. To learn more about the work of the National Patient Safety Foundation, please visit www.npsf.org.

Contact: Patricia McTiernan
(617) 391-9922
pmctiernan@npsf.org

]]> http://www.npsf.org/updates-news-press/press/national-patient-safety-foundation-announces-new-members-of-board-of-directors-board-of-governors/feed/ 0 http://www.npsf.org/updates-news-press/healthy-doses-of-respect-in-medicine/ http://www.npsf.org/updates-news-press/healthy-doses-of-respect-in-medicine/#comments Tue, 19 Jun 2012 01:03:04 +0000 pmctiernan http://www.npsf.org/?p=13135 In an interview with the Boston Globe, Lucian Leape, MD, talks about respectful behaviors and how culture impacts patient safety. Read the full interview on the Boston Globe website.