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What Does Patient Safety Mean to You?

Posted By Administration, Friday, September 2, 2016
Updated: Friday, September 2, 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 pmctiernan@npsf.org.

 

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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.

 

 

 

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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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Joanna Carmona is communications coordinator at the National Patient Safety Foundation. Contact her at jcarmona@npsf.org.

 

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Tags:  2016 NPSF Congress  specimen management  Stand Up for Patient Safety 

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Member Spotlight: Sunil K. Sinha

Posted By Administration, Tuesday, August 2, 2016
Updated: Tuesday, August 2, 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 jcarmona@npsf.org.

 

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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 jcarmona@npsf.org.

 

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