In this issue
- ASPPS News
- Members in the News:
Gregg Meyer, MD, MSc, co-authors article on quality incentives for salaried physicians
Lucian Leape, MD, interviewed about disrespect in medicine
- Members in the News:
- NPSF News
- 16th Annual NPSF Patient Safety Congress: Check the website, npsfcongress.org, for updates
- Health Information Technology through the Lens of Patient Safety, CE/CME-accredited online educational module from NPSF, now available
- NPSF welcomes new Corporate Council members
- Upcoming Events & Conferences
- AAMI Foundation Webinar Series, Alarm Systems Management, December 3
- Professional Learning Series Webcasts: December 3 on preventing diagnostic error; January 7 on the quality, safety , and value movements
- Patient Safety News & Resources
- Save the Date: Patient Safety Awareness Week is March 2-8, 2014
- Doctors Company Foundation Young Physicians Patient Safety Award, deadline February 3
- Anesthesia Patient Safety Foundation calls for grant LOIs
- ISMP announces Cheers Awards
- ECRI Institute publishes top 10 health technology hazards
- Wall Street Journal article on misdiagnoses
- New resources from the Institute for Safe Medication Practices
Patient Safety Awareness Week, March 2-8, 2014, is fast approaching. Based on feedback from our members, NPSF will be highlighting the topic of diagnostic error during this week.
If you, or your organization, have materials on this topic that you would like to share or highlight during this week, please let us know. We are seeking publicly available resources that address the subject area of diagnostic error with patients and families, health care professionals, or health care organizations.
We also have a small number of volunteer opportunities available to assist with development, provide feedback on, or pilot test new materials.
As you may know, Patient Safety Awareness Week is held annually and is intended to raise awareness, promote the engagement of patients, families, and health care providers, and encourage a sustainable and conscientious collaboration between all parties. The week is intended to imprint an indelible statement that efforts to improve patient safety must be collaborative and that we must never be satisfied with the status quo.
Please send your name, contact information, and a summary of your potential interests and contributions to firstname.lastname@example.org by November 30, 2013.
September (1) 2013 | Volume 17, Issue 9:1
The National Patient Safety Foundation wants to hear from you.
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Take our website usability survey by July 31, 2013, and get a chance to be one of three winners who will be randomly chosen to receive a $50 Amazon gift card as our token of thanks.
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May 1, 2013, Boston, MA—The National Patient Safety Foundation (NPSF) has announced the winners of the 2013 Stand Up for Patient Safety Management Award. The award for a hospital-based project will go to JPS Health Network of Fort Worth, Texas. The award for ambulatory care will be given to the 97th Medical Group, Altus AFB, in Altus, Oklahoma.
The Stand Up for Patient Safety Management Awards will be conferred at the 15th Annual NPSF Patient Safety Congress to be held May 8-10, 2013, in New Orleans.
The Patient Safety Management Award is given in recognition of the successful implementation of an outstanding patient safety initiative led or created by mid-level management within a member organization of the NPSF Stand Up for Patient Safety program. The initiative must have demonstrated evidence of patient safety improvement, with involvement of staff at all levels of the organization.
JPS Health Network was chosen for an initiative designed to help prevent fires in the operating room (OR). Although OR fires are rare, a 2009 report by ECRI Institute cited them as among the top 10 technology hazards in health care. The JPS team adapted the Patient Fire Risk Assessment Tool (developed by the Association of periOperative Nurses) and trained the entire OR staff in how to use the tool and what to do to mitigate fire risk.
“Though we had not experienced a fire in the OR, everyone recognized that this initiative was a positive and important change to our standard of care to reduce the risk,” said Trudy Sanders, RN, vice president, patient services.
The 97th Medical Group, based at Altus Air Force Base in Oklahoma, provides care for 9,500 service people and their families in the surrounding communities. They are being recognized for a program designed to standardize pediatric visits through use of checklists that were developed in consultation with all stakeholders—clinical providers, ancillary medical staff, and parents.
“Our goal was to make sure that every parent could answer the question, ‘How do I know I am getting everything I need each time I bring my child to the doctor,’” said Mark H. Smithwick, MBA, patient safety program manager, 97th Medical Group. “Although we are still in the early stages, we have seen positive results in the form of increased immunization rates as well as parents characterizing the visits as ‘thorough.’”
This year marks the first time that two awards are being given. “Our Stand Up for Patient Safety program continues to be a highly valuable offering and continues to spread into the inpatient and ambulatory arenas,” said Patricia McGaffigan, RN, MS, interim president, NPSF. “Because we received numerous submissions from both settings, and because of our commitment to recognize excellence in mid-level management safety projects, we felt it was important to begin recognizing both an inpatient and ambulatory award this year and in the future.”
The awards will be conferred at the Stand Up for Patient Safety Member Breakfast on May 10, 2013. Mr. Smithwick will accept the award on behalf of his organization. Kami Walker, patient safety officer, will accept the award for JPS Health Network.
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, multistakeholder approach in all that it does. NPSF is an independent, not-for-profit 501(c)(3) organization.
About the NPSF Stand Up for Patient Safety Program The Stand Up for Patient Safety program at NPSF caters to hospitals, health systems, physician offices, and ambulatory facilities. Whether an organization is starting a new patient safety program or looking to enhance existing quality and safety efforts, membership provides the support and resources necessary to embed patient safety principles into organizational practice and align with national patient safety goals and critical regulatory requirements. Through participation, Stand Up members around the world gain access to field-tested tools and resources, expertly designed educational programs, and the invaluable support network created by the National Patient Safety Foundation. Visit npsf.org to learn more.
Boston, MA, April 16, 2013—The staff and leadership of the National Patient Safety Foundation offer our sympathy and prayers to the city of Boston and our marathon guests from around the world. We extend our appreciation and thoughts to the many first responders and health care providers who are, and will be, involved in the care of patients and families.
We share here an excerpt from an article in today’s Boston Globe.
Many were fleeing, but many were running to the wounded. They ripped down the metal barriers separating the runners from spectators. Unsure of whether there would be another explosion, these strangers risked their lives to help other strangers, performing CPR, comforting those in shock, and carrying the wounded to the nearby medical tent.
Alix Coletta, 26, a nurse in the medical tent, later told me she and others had treated dozens of people — including children — for severe trauma, massive bleeding, and heart problems.
The Boston Globe
Read the full issue here.
Table of Contents
- A Comprehensive Overview of Medical Error in Hospitals Using Incident-Reporting Systems, Patient Complaints and Chart Review of Inpatient Deaths
- Effects of the Introduction of the WHO “Surgical Safety Checklist” on In-Hospital Mortality: A Cohort Study
- Eradicating Central Line–Associated Bloodstream Infections Statewide: The Hawaii Experience
- An Examination of Opportunities for the Active Patient in Improving Patient Safety
- Faxed Arabic Prescriptions: A Medication Error Waiting to Happen?
- He Thought the “Lady in the Door” Was the “Lady in the Window”: A Qualitative Study of Patient Identification Practices
- Health Care System Vulnerabilities: Understanding the Root Causes of Patient Harm
- Health Professional Networks as a Vector for Improving Healthcare Quality and Safety: A Systematic Review
- How Should Medication Errors Be Defined? Development and Test of a Definition
- The Impact of Perioperative Catastrophes on Anesthesiologists: Results of a National Survey
- Implementation of Targeted Interventions to Decrease Antiretroviral-Related Errors in Hospitalized Patients
- IT-Enabled Systems Engineering Approach to Monitoring and Reducing ADEs
- Medication Errors: When Pharmacy Is Closed
- Moving in with Care: About Patient Safety as a Spatial Achievement
- Patient Safety in Developing Countries: Retrospective Estimation of Scale and Nature of Harm to Patients in Hospital
- The Senior Obstetrician Requesting Obstetric Privileges
- Surgical Checklists: A Detailed Review of Their Emergence, Development, and Relevance to Neurosurgical Practice
- System-Related Interventions to Reduce Diagnostic Errors: A Narrative Review
- Towards Safe Electronic Health Records: A Socio-Technical Perspective and the Need for Incident Reporting
- What Are Patients’ Concerns about Medical Errors in an Emergency Department?
This week, the National Patient Safety Foundation (also known as “@theNPSF”) held a Twitter chat in recognition of Patient Safety Awareness Week. Although our focus was patient engagement, the conversation took a few turns. In case you missed it, we’ve summarized some of the key points for you here.
Review an edited transcript (in reverse chronological order) [PDF format].
- Be sure to ask questions of all health providers, including pharmacists, infection control personnel, and others, not just your primary care providers.
- Be sure questions are asked and answered, so they are fully understood.
- Write questions down so you don’t forget them during the visit.
- Take notes
- Bring a “second set of ears”—a family member or friend who can help you remember everything.
One participant said, given how busy clinicians are, she is sometimes reluctant to ask too many question. That led to a discussion of time constraints in the modern health landscape. According to one participant, Jerome Groopman, MD, has estimated that doctors interrupt patients within the first 18 seconds of a visit.
We asked people to share some of their favorite videos or tools for patients. Not surprisingly, the AHRQ’s patient resource, Questions Are the Answer, was widely tweeted. Participants also shared information about medication safety and the safe disposal of prescription medication.
We asked if low health literacy may be a reason for a lack of engagement by some patients. One participant shared a source that says 53 percent of adults have only intermediate levels of health literacy. Participants shared links to health literacy resources:
Robert Wood Johnson Foundation resources: http://t.co/OXZAHyTA
NPSF, Words to Watch: http://www.npsf.org/wp-content/uploads/2011/12/AskMe3_WordsToWatch_English.pdf
Also recommended by one participant: follow @Hlth_Literacy on twitter.
Of course, one of the major goals of Patient Safety Awareness Week is to raise awareness of the issue. Someone we follow, @SusanCarr, asked what people are reading this week, and that yielded links to great articles sparked by PSAW:
Informing the Journey, Not Changing the Destination by Jim Conway on the Health Care For All blog, http://t.co/P97dB0WS
@ClaudiaNichols writing for Pilot Health Advocates, http://t.co/YDzSnzJV
@TrishaTorrey writing on why the word “celebrate” is the wrong word for Patient Safety Awareness Week, http://t.co/ZcPSAJIR
Trisha Torrey rightly points out that “celebrating” is not really what the week is about. “Recognizing” or “commemorating” Patient Safety Awareness Week are probably better ways to think about it.
With that in mind, we want to make sure that everyone saves the date for next year: Patient Safety Awareness Week will be March 3-9, 2013.
Patient engagement remains a critical untapped lever in the health care environment. In advance of Patient Safety Awareness Week, NPSF has released a new video derived from its Ask Me 3 program, a patient education program designed to promote communication between health care consumers and providers. The program encourages patients to ask, and understand the answers to, three questions:
- What is my main problem?
- What do I need to do?
- Why is it important for me to do this?
The video is available to the public at no cost. Watch below, or visit the Ask Me 3 section of the website.