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Stand Up Standout: Fairview Health Services

Posted By Administration, Yesterday
Updated: 9 hours ago

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.

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


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Member Spotlight: Sunil K. Sinha

Posted By Administration, Tuesday, August 02, 2016
Updated: Tuesday, August 02, 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 

Sunil Sinha is a member of ASPPS


Sunil K. Sinha, MD, MBA, FACP, director, clinical quality and patient safety

ChenMed Neighborhood Medical Centers, Virginia


Why did you join the ASPPS?

“I feel that the ASPPS provides a great balance of education, training, and networking for those who have a passion for making health care safe. I have found that the number of resources and blogs available online at NPSF are helpful, especially in my current position at ChenMed.”


What are some of the unique patient safety challenges in the ambulatory setting?

“On a personal note, my father has been hospitalized four times in the past year and has had numerous visits to his PCP, specialists, urgent care facilities, and the emergency room. I find that the common gap in most of these interactions has been inadequate or missing communication between treating physicians, other health care providers, and my parents.


With health care providers rendering care for the same patients at, and from, multiple locations, real-time communication and effective handoffs become a challenge. Not having information readily available adds to the complexity and makes the delivery of care inefficient, ineffective, and possibly untimely and unsafe.  At least within the four walls of a hospital, you almost always have the luxury of real-time electronic or direct communication with providers who are working in close proximity, which is not always the case in the ambulatory setting.” 


You’ve been a judge for the Baldrige National Performance Excellence Award Program. Has this experience influenced you in any way?

“The last three years as a national judge has been a great learning experience. I had the opportunity to review and discuss the applications of some very high performing organizations with a panel of experts having a wealth of experience and diversity of expertise. What has been very obvious is that health care organizations performing at a very high level have a few common traits: leadership committed to safety and quality, dedicated resources made available to accomplish identified goals, and a culture conducive for high performance.”


What keeps you up at night?

“Although the patient safety movement has garnered much needed attention over the past decade and a half, we remain largely focused on the acute care side. Even though there has been a significant shift of focus to prevention and management of care on the ambulatory side, there is much that can and needs to be done.”


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

“My desire to become a physician came at the age of seven, during a summer vacation visit to my grandparents in rural India. One of their tenants was a physician who had the ‘magical touch’ of bringing people back to life without the aid of a hospital. What I learned much later was that he was ‘magically resuscitating’ villagers who were extremely dehydrated with a basic combination of fluids and antibiotics. Many years later I still marvel at the simplicity and power of health care at the bedside.” 

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


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Member Spotlight: Rupa Lloyd

Posted By Joanna Carmona, Thursday, July 14, 2016
Updated: Wednesday, June 29, 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 

Rupa Lloyd is a member of ASPPS.


Rupa Lloyd, JD, LHRM, CPPS, Dell Graham, PA 


What does patient safety mean to you? 

It means equipping clinicians with systems and processes that help them to avoid error, and keeping patients from suffering from injuries from the very place they sought out healing.”


You did pro-bono work as a law clerk at the Pennsylvania Health Law Project, which advocates for low-income patients. What are some patient safety issues facing this population?

“Many very young, often single parents, with severely disabled children, as well as very elderly patients, are desperately trying to navigate a very complex and disconnected health care system. Often these patients are seeing multiple health care providers at the same time, but each without any communication with one another, or awareness of what treatments the other had prescribed or recommended. 


One young mother I worked with had a severely disabled child. She came to our office beside herself with guilt for not being able to afford all of the drugs her daughter had been prescribed. I’ll never forget her gratitude when, by fostering communication among her daughter’s multiple providers, we determined not only did she not need the additional drugs, but taking all of them together may very likely have killed her.”


Why did you join ASPPS?

“Through my work as an associate director of medical/health administration for the University of Florida Health Science Center since 2002, I witnessed the impact of increasing financial pressures. I started asking myself: how do we shift the focus to be on health care quality and patient safety first?  In seeking to answer this question, I came to learn of ASPPS and welcomed the opportunity to be a part of an organization full of like-minded individuals, many of them clinicians, and with the same important focus on patient safety.  


The goal of becoming a Certified Professional in Patient Safety was an opportunity to become much more knowledgeable in the actual how of patient safety by immersing myself in understanding the clinical side of health care operations and patient safety activities that help clinicians and patients alike in achieving higher quality health care.”


How does your law firm help clinicians and patients?

“My role at Dell Graham as a legal advocate and risk manager for clinicians and others in the health care industry is to proactively address, standardize, and simplify the business and regulatory side of health care so that they can give their 100% to providing high quality health care. The work I have the opportunity to be involved in now is the most fulfilling of my professional career.”


You said that clinicians are at risk due to a broken health care system. In your opinion, what improvements should be made to make the system better for everyone?

“Two things are crucial for improvement. The first is better coordination and communication among all the fragmented pieces. The second is developing and fostering a just culture within organizations where there is no finger-pointing, shaming, or disproportionate disciplinary actions. This is the key to an environment where every medical error becomes an opportunity to learn and improve upon the quality of health care within the system.”


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


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Evidence As a Seed for Collaboration: Separating the Wheat from the Chaff

Posted By Administration, Wednesday, July 06, 2016
Updated: Tuesday, July 05, 2016

Organizations should have individuals who monitor published research in order to help their clinicians and executives apply findings to address local gaps.

by Lorri Zipperer, MA


I have been monitoring the patient safety literature for more than two decades now, first as the information project manager at the National Patient Safety Foundation, and for more than a decade as the development editor for AHRQ Patient Safety Network. As those in patient safety might attest and applaud, the evidence base has gotten more robust over the years, spurred by increased funding for research and public interest in the topic.


This expanding wealth of literature creates a challenge for organizations and individual practitioners. The unintended consequence of this explosion is that there is more wheat to sift through. The growing set of materials makes tracking useful evidence more cumbersome while in turn increasing the messiness of translating existing research results into actions that make sense and conclusions that are credible. We know that just because it’s science doesn’t necessarily mean it’s good science. We know that just because it’s published, identified, and shared within an organization, community, or team that evidence derived from science is not necessarily applied or able to be translated for use on the front line.(Zipperer 2016)


While somewhat editorial in nature,
Dr. Shojania’s presentation brought nuance
to seeing how the evidence exploring these areas
can play a part in our understanding of them.

There are tools out there to help with creating awareness of materials, such as AHRQ Patient Safety Net and the NPSF Current Awareness subscription service. However, not only should organizations have individuals trained to monitor these resources, also the search for particular evidence needs to address local gaps in understanding and effectively disseminate the literature to decision makers. Someone in the organization should navigate this output in order to help their clinicians and executives apply it if it is going to enrich the design of interventions and implementation of programs and contribute to enhancing the reliability of their patient safety work.


We could all use someone like Dr. Kaveh Shojania to help translate what is written to help create actionable knowledge in health care.


Dr. Shojania—with whom I work in my role at AHRQ Patient Safety Network, as he is on the editorial team—has for three consecutive NPSF Congresses provided a thoughtful and provocative analysis of key articles and the trends they indicate for conference attendees. This year’s session, entitled “Hot Topics in Patient Safety: Selected Papers Advancing the Field in the Past Year,” did not disappoint. Dr. Shojania covered literature on 6 important topics:

  • Diagnostic errors
  • Rudeness’ impact on team performance
  • Trends in adverse events over time
  • Incident reporting
  • Fall prevention
  • Reducing high-risk prescribing in primary care, with a focus on the current opioid abuse/misuse epidemic in the US

These themes should be no surprise to those in the patient safety community. While somewhat editorial in nature, Dr. Shojania’s presentation brought nuance to seeing how the evidence exploring these areas can play a part in our understanding of them. While some analysis of research design was applied, and the value of results was discussed, Dr. Shojania’s insights should enhance our ability to be more critical of what is published and by whom.


Imagine the opportunity that the sort of dialogue generated by this type of expert assessment could provide in an organization. The exercise could be brought to our care environments as more than a social or intellectually opportunity. If positioned as a patient safety improvement tactic, it could serve a more impactful role.


Dr. Shojania was challenged by an attendee, and his response provided thoughtful seeds for all of us who seek to partner to “plant” evidence-based solutions in the patient safety community garden. Imagine the learning and collaboration that could be generated in organizations if teams had these types of conversations on a regular basis, with accountability assigned to do something with the issues raised. Could the dialogues support increasing the transparency around sharing of ideas, forming of shared mental models, leveling of hierarchy, and engaging of individuals to form multidisciplinary teams to do research to reflect the frontline needs of improvers? Could be.

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What tools, techniques, and team members do you use to identify, analyze, and infuse the most relevant literature to innovate and anchor patient safety efforts throughout your organization? Comment on this post below. Note: to post a comment you must be logged in. Register or log in.


Zipperer L. Jones BB, Esparza JM, Wahr J. Evidence, information, and knowledge as elements of safe surgical care. In: Stahel P, ed. Surgical Patient Safety. New York: McGraw-Hill Education; in press.


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Lorri Zipperer, MA, is the principal at Zipperer Project Management in Albuquerque, NM, specializing in patient safety and knowledge management efforts and bringing multidisciplinary teams together to envision, design, and implement knowledge sharing initiatives. Her latest collaboration was with The Risk Authority Stanford as a co-editor and contributing author of their 2016 publication Inside Looking Up. Contact her at

Tags:  2016 NPSF Congress  patient safety research 

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Member Spotlight: Shelley Castellino

Posted By Administration, Wednesday, June 22, 2016
Updated: Tuesday, June 21, 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 

Shelley Castellino is a member of ASPPS.


Shelley Castellino, BSN, RN, Providence Regional Medical Center, Colby Campus


Tell us why you chose to get into the field of nursing.

I used to ride horses all the time and on one particular day when I was 22, my horse and I had an argument. He jumped and I was thrown 30 feet up into the air. When the ambulance arrived, I was in a coma. I came out of it nine days later, but was completely paralyzed, and so I thought my life was over. In the hospital, the nurses were fabulous and their positivity was so important to my recovery. Because of that, I wanted to be a nurse and facilitate patients' healing.


What brought you to join the ASPPS?

“When I saw what the ASPPS does for patient safety, it really spoke to me. ASPPS allows people to become proactively involved in patient safety. This is necessary as we have a medical system that results in too many medical errors. I feel membership is the first step towards involvement and making a difference for reducing their occurrence. Through patient safety involvement we provide better outcomes for our patients, which, I believe, in turn improves our job satisfaction.”


In your opinion, how do you move forward to promote a culture of safety?

“Awareness promotes safety. Awareness of your own self, of your actions, as well as an awareness of the patient, and their response to care matters. As a nurse, I feel that if the staff doesn’t take care of themselves, along with the support of hospital management, we will not have the where-with-all to take care of our patients. I love being part of a team culture where I can stand up and say, I don’t understand or I need help and receive the assistance that I need so I can support my patients.”


What is an example of something you (or anyone) can do to keep safety standards high?

“Two things:


Listen to the patient. Every body is different. You have to listen because a patient is an expert in his or her own body. If a patient is telling you something is off, perk up your ears and poke around to see if you can find out what the problem may be.


Take care of yourself. If you are well rested and alert, you can be your best possible self and the best possible nurse for your patients.”


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


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