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

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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What Does Patient Safety Mean to You?

Posted By Administration, Friday, September 02, 2016
Updated: Friday, September 02, 2016

As part of ASPPS Member Appreciation Month this August, we asked the ASPPS community to tell us what patient safety means to them. Thanks to everyone who participated!


We received many great responses and chose a few that resonated with us to share with you. 


What does patient safety mean to you?

“Patient Safety means that every patient who comes to our organization is given care that surpasses their expectations and is given in a way that prevents avoidable harm to them. It means that the processes that our staff and providers are following are modeled after best practices and are evidenced-based and that our staff feels safe to speak up and report issues that are occurring to prevent further issues. Patient safety is about being mindful of an expectation that mistakes can happen and consistently looking to prevent them. Patient safety is about putting our patients first! Patient safety means that I am doing what can be done to provide the right care at the right time, every time.” 

—Sandy Dimas, Accreditation & Patient Safety Manager

Keck Medical Center of USC, California 

“Patient safety means doing the right thing for the right reason when no one else is looking!”

—Diane Schloeder, BSN, director

Scripps Mercy Hospital, California 


“I am a public health professor who loves to awaken the next generation of patient safety champions through my courses. Our students take a long, hard look at the patient safety movement over the last two decades, study improvement successes, and consider the challenges ahead. And then we commit to making personal and professional efforts to advance patient safety through safety culture, leadership, technology, staff training, and patient educationPatient safety and quality professionals can support providers and institutions in efforts to achieve greater transparency. We also have the equally important role of engaging and educating consumers about patient safety. There can be no competing over patient safety. For when one of us, whether patient, family, professional, or institution, loses, we all lose. The solutions lie in our open and honest discoveries and shared goals of safe care, patient engagement, and meaningful work.”

—Judy Tupper, DHed, CHES, CPPS
Managing Director, Population Health & Health Policy

Muskie School of Public Service, Maine

“Patient safety is the building block to creating the vision of a highly reliably community, free from harm

in which everyone is physically and emotionally healthy.”

—Bryan Buckley, MPH, Project Manager, Performance Improvement

MHA Keystone Center, Michigan

“Patient safety means commitment of leadership in developing a just culture in the organization. Leadership should take all steps to reach to zero harm. Leaders should develop ways to achieve happiness and trust among all staffHappy staff will work more efficiently and create a healthy environment which more safe. This is the reason that our government is the first in the world that have appointed a Minister of Happiness. I believe that all leaders' vision and strategies should start and end with safety and quality.”

—Sharifa Alamadi, Deputy Director

Al Baraha Hospital, Dubai 


"Patient Safety means to heal not to harm."

Muhammad Eltawansi
Patient Safety Specialist, Security Forces Hospital Program Makkah
Saudi Arabia

We’d like to keep the conversation going beyond Member Appreciation Month, so we invite you to add a comment to tell us what patient safety means to you or share what you think about these responses.

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Contact the P.S. Blog by writing to the editor, Patricia McTiernan, at


Tags:  ASPPS 

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Mrs. B's Story: How Excessive Testing Can Do More Harm Than Good

Posted By Administration, Wednesday, August 31, 2016
Updated: Wednesday, August 31, 2016

When it comes to medical procedures, always do your homework and speak honestly with your doctor about any concerns you have. 

by Michael Kelleher, MD


There are many medical situations where more care and more testing does not translate to better care. The American Board of Internal Medicine (ABIM) and its partners, through the Choosing Wisely campaign, have compiled lists of tests and procedures that should be carefully considered.


Let’s take a look at how excessive testing and procedures can do more harm than good. This is the case of a real patient. We’ll call her “Mrs. B.”


Physicians often perform tests

of marginal value because of
patient demands.

Mrs. B’s Multiple Procedures

Mrs. B had been experiencing upper abdominal pain after meals. Her ultrasound test revealed gallstones were the cause. One of her liver tests, a gamma-glutamyl transpeptidase (GGTP), was also mildly abnormal, so her husband, who had been a critical care nurse, pressed the gastroenterologist to proceed with more testing. Her husband wanted to exclude the possibility of her bile duct being blocked by a gallstone.


The physician performed an endoscopy test called an ERCP as a prelude to surgery. That ERCP test revealed no abnormality, but within an hour after the procedure, Mrs. B begin having severe abdominal pain and very low blood pressure. Her daughter alerted the nursing staff, and Mrs. B was rushed to the operating room for repair of a ruptured loop of bowel, a known complication of ERCP, which extended her recovery by three months and caused several postoperative infections.


What Went Wrong?


First, the ERCP test was not necessary in this case. It caused a serious complication, which was preventable. The mildly elevated GGTP test by itself did not suggest blockage of the bile duct with a stone, and is not recognized by experts as an indication for ERCP testing.


Secondly, physicians often perform tests of marginal value because of patient demands, to reduce their perceived risk of a malpractice lawsuit. Neither patient nor physician are well-served by such misguided testing.


Finally, over-testing can have negative results for patients. Screening tests for healthy patients represent a special challenge for shared decision-making. It is imperative for clinicians to make sure that patients have a thorough understanding of the risks, benefits, and limitations of such testing.


Low-Value Testing

Consumer Reports has worked with the Choosing Wisely campaign to create patient-friendly summaries of more than 50 medical tests and procedures that are of low value. Before agreeing to treatment, patients can look through evidence-based information on what may or may not be appropriate. There’s a wealth of information on procedures from colonoscopies to Lyme disease tests.


The campaign is meant to empower patients to start a conversation with medical staff regarding which treatments are appropriate or necessary. When it comes to medical procedures, always do your homework and speak honestly with your doctor about any concerns you have. 


This post was adapted with permission from Avoidable Medical Mishaps: A Patient Guide.


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Michael Kelleher, MD, past member of the Massachusetts Medical Society's Quality of Medical Practice Committee, has 34 years of experience as a physician and medical executive responsible for patient safety and quality of care in large group practices.




Tags:  overtreatment 

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Stand Up Standout: Fairview Health Services

Posted By Administration, Tuesday, August 23, 2016
Updated: Wednesday, August 24, 2016

The Stand Up for Patient Safety Program is an organizational membership program that supports patient safety initiatives.

This is part of a series of member profiles.  

by Joanna Carmona 

Susan Noaker (middle left) and Pat Schlagel (middle right) 

of Fairview Health Services accepting the Stand Up for Patient Safety Award

at the 2016 NPSF Patient Safety Congress in Scottsdale, Arizona.


Fairview Health Services and their collective commitment to a culture of excellence in their hospitals is what stood out to the National Patient Safety Foundation when awarding this year’s Stand Up for Patient Safety Management Award. This award is given each year in recognition of the successful implementation of an outstanding patient safety initiative that was led by, or created by, mid-level management.


Fairview Health Services, consisting of six hospitals within Minnesota, aimed to prevent errors in specimen management to make care safer for their patients. Fairview identified specimen mismanagement as a “never event” and thus started the complex process of reducing the risk of mishandling.  


According to the Agency for Healthcare Research and Quality (AHRQ), mislabeling errors are one of the most common preanalytic errors in laboratories. Many initiatives were put in place, including Fairview’s use of specimen label printers which made a big difference in specimen management. As a result of system-wide changes, including standardizing processes of surgical debriefing, handoffs, and labeling, there was a 70% decrease in the risk of specimen mismanagement.


Here’s what Fairview Health Services had to say about this important work.


What were the biggest challenges involved in a project such as this?

Our two biggest challenges were information technology issues, including getting various programs to talk to each other and making our electronic medical record more user-friendly, and standardizing processes. Initially, we assumed our processes varied widely from site to site, but after mapping out processes across our system, we learned we had more in common than we previously thought.


What surprised you about the process, either in regard to the way the project team worked or in regard to something you learned about the processes that you did not already know?

“Learning that labels and specimens were labeled and logged by hand, which is not best practice, reinforced our drive to improve. We knew we could do better for our patients. On the plus side, our team became highly functional very quickly. We used multi-voting techniques to prioritize the work so that all voices were heard, not just those belonging to squeaky wheels.”


You mentioned that patients are often unaware of the life-altering consequences of error in specimen management. How do you explain the importance of specimen management to your friends or family (i.e., someone unfamiliar with this topic) and what it means for their safety? 

“If a specimen—something we obtained from a biopsy—is lost, we may not be able to make a diagnosis in a speedy manner. We may need to repeat the biopsy. Furthermore, some specimens are so unique that they are irreplaceable. A lost specimen of that type may mean losing essential information about the patient’s health. It may not sound all that important, but proper specimen management is utterly essential to helping us drive a healthier future for our patients.”


What are some ways to successfully engage physicians in the problem-solving process?

“We know physicians appreciate seeing data that proves the need for change and demonstrates the likelihood that the change will result in improved patient outcomes. Also, like most employees, physicians want to be asked for their input and know that their contributions are valued and acted upon.”


What are two tips you would offer others undertaking similar projects that might help them succeed? 

“First, system-wide changes require system-wide representation. In addition to the appropriate subject matter experts, you should also include people who provide support services, such as IT, Operations, Communications, and Human Resources. These team members help the group think of broader implications of a proposed change, and can often contribute to coming up with corresponding solutions.


Second, getting people to agree to serve on yet another committee or workgroup can be tough. Show participants you value their time by creating unusual, but effective meetings. Get people up and moving by breaking into small groups spread out across the room. Record ideas on flipcharts and draw process flow maps on white boards. Award small prizes for attending. Improving patient safety is serious work, but by engaging employees and physicians in different ways, we can often come up with better solutions.”


Could you talk in general about lessons learned from this process?

“It’s important to obtain the support of an executive sponsor—someone at the highest levels of leadership. This indicates to everyone involved that the project is a high priority and reinforces the urgency of successfully completing the change. Get IT involved in the project from the start and know who to turn to when you need to escalate concerns. Use a system team of stakeholders that is truly representative of all entities and divisions. Be aware of unintended consequences. When you change one part of a process, there may be unintended negative consequences. Be open to discovering, and correcting this. In fact, embracing a spirit of discovery can make all the difference for improving the health of our patients.”


Responses from Beth Thomas, DO, Fairview interim chief medical officer & Susan Noaker, PhD, LP, Fairview project manager, surgical services 

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Have you worked on a similar improvement project at your organization? Comment on this post below.

Note: to post a comment you must be logged in. Register or log in.

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


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