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Top tags: 2016 NPSF Congress  ASPPS Member Spotlight  Voice of the Patient  ASPPS  culture  Leape  med errors  overtreatment  transparency  Ask Me 3  communication  leadership  undertreatment  apology  Boothman  burnout  Campbell  CPOE  decision support  dislosure  EHR  elctronic health record  engagement  error  falls  families  Gandhi  Health IT  health literacy  HIT 

Member Spotlight: Chenel Trevellini

Posted By Joanna Carmona, Wednesday, October 12, 2016
Updated: Wednesday, October 12, 2016

The American Society of Professionals in Patient Safety (ASPPS) is a membership program for professionals

and others interested in patient safety. This is part of a series of member profiles. 

by Joanna Carmona 


Chenel Trevellini is a member of ASPPS

Chenel Trevellini, MSN, RN, CWOCN, WOC nurse specialist, nurse educator, St. Francis Hospital


Why did you join the ASPPS?

“ASPPS helps me to approach my work in a more meaningful way. I often feel like a lone ranger in my field because there’s not that many of us, but the verbiage that is consistent with ASPPS gets the attention of the stakeholders, helps me to be able to tell my story better and to obtain resources for my department. The focus on patient safety and caregiver safety makes me realize what a great organization NPSF is. I felt as though this was an organization I had to be involved with because it is impacting patient safety on a global level.”


What does patient safety mean to you?

“It means having the correct systems and processes in place that make delivering care easy and safe on a regular basis. Care should be just as safe at 8:00 am on a Monday as it is on a Saturday at 2:00 am. I believe that having correct systems in place facilitate great care.”


What keeps you up at night?

“What keeps me up at night is that we have sicker and sicker patients in the hospital and coming up with the correct ways to meet all of their needs is difficult. I often wonder whether or not we can keep up with advances in technology. We can keep patients alive for longer than we ever have before, but that puts them at risk for all kinds of infections and other issues. It bothers me that we have advanced so far in medicine with extending how long we live, but we haven’t been able to ward off all of the secondary issues that are associated with it.”


In your opinion, what is the future of patient safety?

“The patient safety field needs to continue growing by really reaching out to different disciplines to join the organization, raising awareness of patient safety organizations, and getting more people on board so they aren’t operating in silos. Every specialist has something to do with patient safety. I feel very hopeful and renewed to understand that there’s this much work going on in improvement of patient safety. We are getting there.

I want to be in a place where doctors and other providers can talk to families about realistic expectations as far as their care. When you have crucial conversations with the families, families often open up. We don’t always see that in our health care colleagues, but I think patients and families would like to know the true prognosis because that would help with their decisions. For example, when someone asks me what I feel about the prognosis, I try to be open and compassionate, but I don’t mislead them. I think people appreciate that”

What’s something most people don’t know about you?

“I make puppets! I use items that people have thrown away to make gigantic puppets used in the plays that my husband writes.” 



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Joanna Carmona is communications coordinator at the National Patient Safety Foundation. Contact her at


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Tags:  ASPPS Member Spotlight 

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Getting the Lowdown on Opioids

Posted By Administration, Friday, October 07, 2016
Updated: Friday, October 07, 2016

The nation’s opioid crisis was a hot topic at the 2016 NPSF Patient Safety Congress.

by Patricia McTiernan, MS


A recent survey conducted by the National Patient Safety Foundation showed gaps in health professionals’ knowledge regarding use of opioid painkillers. Only two-thirds of respondents were familiar with the Joint Commission Sentinel Event Alert on the Safe Use of Opioids in Hospitals, for example, and only 14% were familiar with the National Action Plan for Adverse Drug Event Prevention.


It may come as no surprise, then, that one of the most well-attended breakout sessions at the NPSF Patient Safety Congress in May focused on “DEA Drug Trends.” Thomas Prevoznik, liaison unit chief for the U.S. Drug Enforcement Administration, addressed some of the current questions health professionals have about what they can do to mitigate unintended harm from opioids.


According to the Centers for Disease Control and Prevention, opioid prescription painkillers led to more than 19,000 overdose deaths in 2014. Moreover, the DEA reports that 8 out of 10 new heroin users began by abusing prescription painkillers.


At the NPSF Congress, attendees were most interested in learning about proper disposal of unused or unwanted pharmaceuticals and how the DEA and health care professionals can work together to combat the opioid epidemic to ensure public health and safety.


The DEA is in the process of conducting Pharmacy Diversion Awareness Conferences at the state level to educate health professionals about tactics they can use to minimize unintended outcomes. These events include speakers from the state’s pharmacy board, the police, the Department of Health and Human Services, and the DEA.


  Thomas Prevoznik

Thomas Prevoznik speaking at the 2016  

NPSF Patient Safety Congress

Mr. Prevoznik says the events offer an opportunity to provide practical tactics to pharmacists and clinicians, for example:


  • Asking patients if they have a place to keep the prescription opioid painkillers under lock and key.
  • Asking clinicians to be more aware of the opioid epidemic and more conscious of the unintended effects of overprescribing.

Disposing of unused medications is another effort under way. Twice each year, the DEA, in collaboration with state and local law enforcement, sponsors National Prescription Drug Take-Back Day, an opportunity for people to clean out their medicine cabinets and safely dispose of unused medication. The last event was held in late April of this year, yielding almost 900,000 pounds of drugs—the highest amount collected since these events began in 2010.


“People are getting the message that they don’t need to save that just-in-case bottle,” Mr. Prevoznik says. “It’s better to get rid of it.”


The next Prescription Drug Take-Back Day is scheduled for October 22. Get details at


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About the Author: Patricia McTiernan, MS is assistant vice president for communications at the National Patient Safety Foundation and editor of the P.S. Blog. Contact her at



Tags:  2016 NPSF Congress  opioids 

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Culture Change on the Agenda

Posted By Administration, Friday, September 30, 2016

Dana Siegal, RN, CPHRM, prompts attendees to think
30 years into the future and imagine how
health care culture has changed for the better.

The 9th Annual NPSF Lucian Leape Institute Forum & Keynote Dinner focused on safety culture, leadership, and strategies for the real world.

by Patricia McTiernan, MS

Imagine it is 2046. What changes will have taken place to improve the safety of patients and the health care workforce? What would you like to see happen over the next 30 years—and what are you willing to do to make it a reality?

Those were among the questions posed to attendees of the 9th annual NPSF Lucian Leape Institute Forum & Keynote Dinner held in Boston on September 15. Dana Siegal, RN, CPHRM, CPPS, director of patient safety services, CRICO Strategies, led an afternoon session punctuated by skits illustrating one dramatic change in health care culture over the years: the move to tobacco-free health care organizations.

Ms. Siegal recounted how, 30 years ago when she was a new nurse, smoking in hospitals was not uncommon among doctors, nurses, and even patients (unless on oxygen, of course!). Slowly, things began to change; smoking was confined to the “back room,” then to the outdoors. And finally, not all that long ago, tobacco was largely banned from the grounds of most hospitals, including parking lots.

What does smoking have to do with patient safety? The point Ms. Siegal hit upon is that culture change does not happen overnight. It takes time, sometimes a very long time, for norms and attitudes to spread throughout an organization, a community, a region, an industry, and in this case, across the country. She invited attendees to share their wishes for what health care and patient safety would look like in 30 years.


Here are just a few:



What would you want to see happen over the next 30 years?

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Looking Forward: New Models of Safety and Risk

The afternoon keynote speaker, renowned patient safety researcher Charles Vincent, PhD, MPhil, gave attendees a glimpse of what the future might look like.

    Charles Vincent 
     Prof. Charles Vincent provided an overview of new models
of assessing risk and promoting safety in health care.

Currently Emeritus Professor, Clinical Safety Research, at Imperial College, London, Prof. Vincent has an extensive background in research on the causes of harm to patients, consequences for patients and staff, and methods of improving the safety of health care. His most recent book, Safer Healthcare: Strategies for the Real World (co-authored with René Amalberti) is available at no charge as an e-book (download at

Prof. Vincent’s talk centered on the question of whether it is possible to develop a framework or menu of interventions around patient safety, rather than addressing issues by project or outcome. He noted the correlation to a recent NPSF report calling for an overarching shift from piecemeal approaches to total systems safety.

Prof. Vincent hypothesizes that a framework of strategies and interventions could be applicable across all settings (hospital, home, primary care) and across all levels of care (frontline, organizational, regulatory, and patient self-care). He outlined three models of safety:

  • Avoiding risk (ultra-safe): Examples from outside of health care include the airline industry. This model is characterized by a tough regulatory system and the need to avoid risk as much as possible.
  • Managing risk (high reliability): Risk is not sought out, but is inherent in the work, for example, firefighting. This model is marked by group intelligence and adaptation, with training and safety focused on flexibility and personal resilience being a key component.
  • Embracing risk (ultra-adaptive): An apt example here is deep-sea fishing, where risk is the essence of the profession. Working conditions are unstable and unpredictable.

While some areas of health care may fall into the ultra-safe category, where the goal is to avoid risk altogether, other areas may be categorized by the need to manage or mitigate risk.

Another example Prof. Vincent offered to illustrate the point is home dialysis. Patients and families performing dialysis in the home are trained in how to do it and in safety practices. But they are also schooled in what to do if something goes wrong, which Prof. Vincent said works better than drilling in to people that they have to do things perfectly every time.

“Absolute safety is not the aim,” he said. “We know it is never going to be safe; we need to manage the risk.”

Looking Back to Make Advances

    Dr. Pamela Cipriano, president of the American Nurses
Association, discussed the need to assess the impact and
success of patient safety initiatives.


During the evening keynote address, Pamela Cipriano, PhD, RN, NEA-BC, FAAN, president of the American Nurses Association, noted that those in attendance are already on board with the need to make patient safety the priority. “You’re all converted,” she said. “We can be zealots. The people who are missing haven’t gotten the message.”

Quoting Max DePree, Dr. Cipriano noted that, “When we talk about patient safety, the leader is the servant.” Leaders of health care organizations are the key to setting the bar for safety in their organizations, but not all health care leaders are aligned with the principles that are so important to patient safety.

Dr. Cipriano also cautioned that unintended consequences can result from aggressive agendas. “We don’t always go back and look at the impact” of initiatives, she said.

She offered the example of the practice of isolating patients with Methicillin-resistant Staphylococcus aureus (MRSA) and using contact precautions (gloves and gowns). For years, clinicians and regulators supported the practice of implementing contact precautions of patients found to have MRSA. This process was mandated in a number of states. In 2015, a study argued that the benefits of contact precautions had not been proven, no study had directly compared the effectiveness of contact precautions to standard precautions, even as we know that the use of contact precautions has deleterious effects (psychological and otherwise) on patients. As a result, some hospitals are now moving away from the use of contact precautions and isolation for patients with MRSA.

Excelling in patient safety requires that practices, protocols, and initiatives get reviewed and, if necessary, revised over time. Or, as Prof. Vincent notes in his book, patient safety is "a moving target." “In a very real sense innovation and improving standards create new forms of harm in that there are new ways the healthcare system can fail patients,” he writes.


So, we zealots have work to do.

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What would you like to see change about safety culture in health care? Comment on this post below. Note: to post a comment you must be logged in. Register or log in.

Patricia McTiernan, MS is assistant vice president for communications at the National Patient Safety Foundation and editor of the P.S. Blog. Contact her at

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Tags:  culture  leadership  Leape 

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Health Literacy’s Impact on Patient Safety

Posted By Administration, Wednesday, September 21, 2016

October is Health Literacy Month. Find out what you can do to be part of the solution to low health literacy.

by Patricia McTiernan, MS

The most frequently referenced survey of health literacy in the U.S., the National Assessment of Adult Literacy (NAAL), found that only 12% of English-speaking adults are at the “proficient” level of health literacy. That leaves an awful lot of us who sometimes struggle with common tasks such as reading and following directions for the use of prescription medications or adhering to other care plan activities.

Health literacy has been defined as “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.” Proficiency is dependent on much more than the ability or read. The ability to use numbers, communication and reasoning skills, and cultural backgrounds all contribute to health literacy.

October is Health Literacy Month, so there is no better time to learn more about the problem of low health literacy and what you can do to be part of the solution.

An Equal Opportunity Problem

The NAAL found that health literacy is an issue for all racial and ethnic groups. Although health literacy increases with higher levels of education, 44% of those with a high school education are at basic or below basic levels. Among age groups, those 65 years of age or older are more likely to have health literacy skills at the basic or below basic levels.

The National Action Plan to Improve Health Literacy (2010) lays out goals for improvement. Among them, a call to the health care system and health practitioners to simplify complex language and present information in ways that make it more easily understandable.


Lea Anne Gardner, PhD, RN,
senior patient safety analyst
at the Pennsylvania Patient
Safety Authority, will discuss
health literacy in the NPSF
Professional Learning Series
Webcast on September 27.

Read details and register.

Health Literacy and Adverse Events

Recently, the Pennsylvania Patient Safety Authority has been involved in a statewide initiative to provide health care practitioners with strategies they can use to help their patients understand and be involved in their care. Researchers at the Authority searched the Pennsylvania Patient Safety Reporting System and found 265 event reports over a 10-year period that were potentially related to low health literacy.

The most frequent outcomes of patients misunderstanding instructions or information were delayed or cancelled procedures, surgeries, treatments, or tests; or patients leaving without being seen, according to an advisory issued by the Authority in June.

The advisory also discusses ways that practitioners can recognize low health literacy and some of the tools and strategies they can use to communicate more effectively. Among the recommendations are using teach-back methods, plain language, and open-ended inquiry, such as “What questions do you have?” rather than “Do you have any questions?”

Another method included in the advisory is the Ask Me 3 program run by NPSF. A cornerstone of health literacy communications, the Ask Me 3 program is designed to facilitate open dialog between patients and providers by encouraging patients to ask three key questions when receiving care:

  1. What is my main problem?
  2. What do I need to do?
  3. Why is it important for me to do this?

During Health Literacy Month and beyond, NPSF urges organizations to adopt these strategies to communicate more effectively with patients. Ask Me 3 is easy to implement and materials and guidance information can be downloaded on this website.

Take Action

Even with a recognition of the problem, it takes time for clinicians and organizations to retool the information and methods they use to communicate with patients. Resources are available to help.

A wealth of information about health literacy, including links to state organizations, is available via the Centers for Disease Control and Prevention. Visit, and use Health Literacy Month as an opportunity to educate yourself, your colleagues, your family, or your patients.

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Do you have tips or strategies for clear communication with patients? Are you a patient who has used Ask Me 3 or another resource? Comment on this post below. Note: to post a comment you must be logged in. Register or log in.

Patricia McTiernan is editor of the P.S. Blog. Contact her at

Tags:  Ask Me 3  health literacy 

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Member Spotlight: Erin Graydon Baker

Posted By Administration, Thursday, September 15, 2016
Updated: Tuesday, September 13, 2016

The American Society of Professionals in Patient Safety (ASPPS) is a membership program for professionals

and others interested in patient safety. This is part of a series of member profiles. 

by Joanna Carmona 

Erin Graydon Baker is a lifelong

member of ASPPS


Erin Graydon Baker, MS, RRT, CPPS, patient safety officer, director, risk management and patient safety

Maine Medical Center


What does patient safety mean to you?

“I echo most in our profession that patient safety means having the patient receive the right treatment, at the right time, for the right reasons, and delivered without preventable harm. However, I also understand that without keeping our staff safe, healthy, engaged, and educated, we will not be able to truly accomplish patient safety.”


Why did you join the ASPPS? What does it mean to be a lifelong member?

“In 2011, I was given an incredible opportunity to join colleagues to help develop content for the Certified Professional in Patient Safety (CPPS) exam. When the first iteration of the exam was released, I was also part of the faculty for the first live preparatory course held at the NPSF Patient Safety Congress. It was through this work that I knew that I would always be committed to NPSF. What better way to show solidarity than to become a lifelong member.”


What keeps you up at night?

“I worry about the staff and their well-being in our fast paced environment. Our staff is so compassionate and hardworking, but I worry about burnout for our interprofessional staff, residents, and attending physicians. I worry about challenges with electronic medical records where it no longer shows us a longitudinal patient story, but is a series of reports that one has to know how to access. For example, our nursing colleagues couldn’t see some of the fields that providers had complete and vice versa, so we needed to create an interdisciplinary note that all could see. I could go on forever what keeps me up at night, but I guess that is part of the makeup of a patient safety professional.”


What is the future of patient safety?

“I think the future of patient safety lies within transitions of care from the hospital to long-term care to the home. Anytime we have a patient handoff, whether it is within the hospital setting or beyond, we risk losing critical pieces of the patient story. I look forward to the true one patient-one record. Patient safety challenges in the ambulatory setting include missed, delayed, or incorrect diagnoses. This should continue to be an area of focus for all of us.”

What’s something most people don’t know about you?

“I spent 12 years studying mixed martial arts. It gave me peace and an exhausted body when my mind was full of worry!”


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Joanna Carmona is communications coordinator at the National Patient Safety Foundation. Contact her at


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