Review an edited transcript (in reverse chronological order) [PDF format].

Communication

We shared a link to NPSF’s new video, which demonstrates the Ask Me 3 program in action, then asked, “What other questions can patients ask? Or what more can they do?” Among the suggestions:

• 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.

Health Literacy

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.

Raising Awareness

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.

• 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.

Table of Contents

1. Can Healthcare Go from Good to Great?
2. Confirmation Bias: Why Psychiatrists Stick to Wrong Preliminary Diagnoses
3. Detecting Delayed Microbiology Results after Hospital Discharge: Improving Patient Safety through an Automated Medical Informatics Tool
4. Diagnostic Errors in Primary Care: Lessons Learned
5. Effects of Two Commercial Electronic Prescribing Systems on Prescribing Error Rates in Hospital In-Patients: A Before and After Study
6. Hospital Incident Reporting Systems Do Not Capture Most Patient Harm
7. Human Factors and Ergonomics in Patient Safety Curriculum
8. Identification by Families of Pediatric Adverse Events and Near Misses Overlooked by Health Care Providers
9. Improving Hand Hygiene in a Paediatric Hospital: A Multimodal Quality Improvement Approach
10. Improving Patient Safety and Optimizing Nursing Teamwork Using Crew Resource Management Techniques
11. Leading for Quality in Healthcare: Development and Validation of a Competency Model
12. Making Sense of a Safety Reporting System’s Data with BI Software
13. Medication Errors in Patients with Severe Chronic Kidney Disease and Acute Coronary Syndrome: The Impact of Computer-Assisted Decision Support
14. New Federal Policy Initiatives to Boost Health Literacy Can Help the Nation Move beyond the Cycle of Costly ‘Crisis Care’
15. Reducing Health Care–Associated Infections (HAIs): Lessons Learned from a National Collaborative of Regional HAI Programs
16. Risks of Online Advertisement of Direct-to-Consumer Thermography for Breast Cancer Screening
17. A Road Map for Academic Departments to Promote Scholarship in Quality Improvement and Patient Safety
18. Spreading a Medication Administration Intervention Organizationwide in Six Hospitals
19. Synergy for Patient Safety and Quality: Academic and Service Partnerships to Promote Effective Nurse Education and Clinical Practice
20. What Can We Learn from Patient Claims? A Retrospective Analysis of Incidence and Patterns of Adverse Events after Orthopaedic Procedures in Sweden

...

Our redesigned site has been improved for better navigation and easy access to information about  membership programs, events, and resources for health care professionals and patients.

Visitors will also note handy drop-down menus to help find content quickly, news and important dates on the home page, and links to our social media sites.health professionals at computer

Attention ASPPS and Stand Up Members

You will be able to access members-only content on the site, such as Current Awareness Literature Alert and Focus on Patient Safety.

Members should have received an e-mail with the subject line [National Patient Safety Foundation] Your Username and Password. That e-mail message will contain your new username and a system-assigned password. You will need to visit the site and log in with those credentials to change your password.

ASPPS Members: View a short video on how to change your password.

Stand Up Members: View a short video on how to change your password.

 

 

If you have any questions about the new site, send an e-mail to info@npsf.org

Members who have not received their login information are asked to call us at 617-391-9900.

Visit the Society’s website for more information about the symposium and the meeting.

Take the Society’s survey on Interprofessional Education and Healthcare Simulation.

With an increasing demand for quality in health care, care providers must expand efforts to integrate patient safety concepts and deploy them in all areas, to all people in their organizations. They must be prepared to thrive in new delivery systems and care models across the continuum, while being responsive to public and private sector initiatives to broaden pay-for-performance programs.

The Lucian Leape Institute at the National Patient Safety Foundation outlined many of these challenges in its landmark 2009 paper, Transforming Healthcare: A Safety Imperative, in which it offers a new transformational model for patient safety improvement. The American Hospital Association (AHA) and the National Patient Safety Foundation (NPSF) have adapted the components of this transformational model to create a new curriculum, the Comprehensive Patient Safety Leadership Fellowship Framework.This new approach extends the program’s traditional focus on core patient safety knowledge to embrace new topics emerging from health care delivery system transformation.

Now entering its 11th year, the AHA-NPSF Comprehensive Patient Safety Leadership Fellowship, is designed to prepare the next generation of patient safety, quality, and performance improvement leaders.

The Fellowship consists of four in-person learning sessions, periodic teleconferences, various self and organizational assessment,s and individual coaching. The yearlong program culminates with the completion of an Action Learning Project (ALP) demonstrating the Fellow’s ability to apply the concepts learned.

Applications for the 2012-2013 class of the AHA-NPSF Comprehensive Patient Safety Leadership Fellowship are now being accepted. The deadline to apply is March 15, 2012.

Read more or download the brochure and application.

If you have any questions or need assistance, call Shawn Foster at AHA,  (312) 422-2933.

Read the full article in Take Care!

November was National Family Caregiver Month. This article is an excerpt from a recent issue of Take Care!, the newsletter of the National Family Caregivers Association. Read the full article online.

If you are caring for a family member or loved one, it’s important for to think of yourself as his or her advocate. Being engaged and asking questions are probably the most important things you can do to keep your loved one and yourself safe from medical errors.

In the Hospital

Earlier this year, the U.S. Department of Health and Human Services, in conjunction with the federal Centers for Medicare and Medicaid Services, launched the Partnership for Patients: Better Care, Lower Costs, with the goal of making hospital care “safer, more reliable and less costly.” Although this initiative seeks to reduce all causes of harm, the primary areas of focus include medication errors, hospital-acquired infections, surgical-site infections, pressure ulcers, falls, and obstetrical adverse events.

When the person you are caring for is hospitalized, here are some things you can do:

• Talk to your loved one about his or her wishes regarding communication with the clinical team. If he or she wants you to know everything that’s going on, be sure the doctors and nurses know that, so that you can be fully involved in the treatment plan.
• Make sure that hospital staff check your loved one’s identification before any treatment, tests, or procedures.
• Learn about hospital-acquired conditions and whether your loved one is at risk. Ask what protocols are followed to avoid these conditions.
• If your loved one is at risk of a fall, ask how that risk is communicated to different members of the team and what methods the hospital employs to minimize the risk.
• Find out if the hospital has a medical emergency team (MET) or a rapid response team, and when it is appropriate to seek their help. These teams respond when a patient’s condition appears to be deteriorating. Many hospitals empower families and patients to activate such teams if a medical condition is worsening.
• Never turn off an alarm on medical equipment in the assumption that “someone will be coming.” Let the medical team respond, and alert them if they do not respond quickly.
• Don’t be shy. Now is not the time to keep silent if you think something is not right — or even if you are simply confused. Speak up about safety practices, such as hand washing, if you don’t see them happening.
• Recognize that common safety practices apply to you, too. Wash your hands (or use alcohol-based hand sanitizer) before entering your loved one’s room. If you have a cough or cold, stay home so as not to spread it to others.
• Before your loved one is discharged from the hospital, be sure you understand what the next steps are for follow-up care.

At the Doctor’s Office or Pharmacy

Although the vast majority of healthcare is provided in outpatient settings, most of the research about patient safety has been done in hospitals. Some in the patient safety field consider outpatient care the “next frontier” in this work.

Here are some things to watch out for when visiting the doctor’s office or the pharmacy with your loved one:

• Help your loved one prepare in advance for a doctor’s appointment by updating his or her list of medications and writing down any questions.
• Make sure each medical or pharmacy staff member taking care of your loved one verifies his or her identification.
• Know what medications the doctor has prescribed, what they are for, and how they should be taken. Understand the treatment plan and what the patient needs to do.
• If lab tests or radiologic studies are ordered, be sure they are completed. Follow up to get the results. Don’t assume “no news is good news.”
• Make sure the members of your loved one’s clinical team know you and how to reach you.
• As with hospital care, don’t be shy about speaking up if you think something is not right. All the basic safety practices, such as hand washing, apply just as much in the outpatient setting as in the inpatient setting.

Excerpted from “Patient Safety: How to Protect Your Loved One From Medical Errors.” Reprinted from Take Care! (Summer 2011, Vol. 20. No. 2) by permission of the National Family Caregivers Association, Kensington, MD, the nation’s leading organization for all family caregivers, 1-800-896-3650, or http://www.thefamilycaregiver.org/.