A new module in the TeamSTEPPS program offers tools and resources to create a customized training plan with the goal of building teamwork skills as they relate to patients with LEP. The materials include a readiness assessment survey, training materials and guides, exercises, patient outcome surveys, and more.

In conjunction with the new TeamSTEPPS module, AHRQ has published an online guide, Improving Patient Safety Systems for Patients with Limited English Proficiency: A Guide for Hospitals. This text was developed to help hospital leaders learn how to identify, report, monitor, and prevent medical errors among patients with LEP.

These tools were developed by the Disparities Solutions Center at the Mongan Institute for Health Policy, based at Massachusetts General Hospital in Boston, and Abt Associates, a health care consulting organization.

Now, the Agency for Healthcare Research and Quality is offering a free toolkit to help acute care and post-acute care facilities evaluate and improve their current medication reconciliation process. The toolkit, Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation, can help facilities reduce patient harm due to adverse drug events or medication errors.

This toolkit is based on the Medications at Transitions and Clinical Handoffs (MATCH) Web site. It provides a framework to capture complete, accurate medication information through electronic health records (EHRs) and enables the development of a medication reconciliation process or the redesign an existing process.

For more information, visit the website, or contact AHRQ via e-mail AHRQpubs@ahrq.hhs.gov or by phone at 1-800-358-9295.

A recent post on a health care job website looked at patient safety as a career path for experienced nurses. The article quoted one patient safety specialist as noting that, “The unique element of this role is the relationship across disciplines.”

That’s a key point: That while many experienced nurses transition to patient safety manager or director roles, patient safety touches every area of health care. While a nursing background is certainly helpful, health professionals from other disciplines may also move into a role with a primary focus on patient safety.

The article noted that certification is now available for patient safety professionals.

What’s been your path to patient safety? Tell us via the comment box below or write to us at info@npsf.org.

Read the summary story online.

Pharmacy Practice News

August 2012 | Volume 30

A research project, funded by a National Patient Safety Foundation Research Grant, sheds new light on the types of errors that can occur with computerized physician order entry. This article summarizes finding of Gordon Schiff, MD, principal investigator.

Read the article from Pharmacy Practice News.

Health Day

A new study from the Center for Health Informatics at the Australian Institute of Health Innovation at the University of New South Wales finds that many test results ordered for patients in the hospital go unread by their physicians. Read a summary article from Health Day.

The College of American Pathologists estimates that 1 in 1,000 blood specimens ends up being labeled with the wrong patient identifiers. That type of error can potentially harm two patients—the patient whose blood was mislabeled as well as the patient who was incorrectly linked to that specimen. Both patients may end up with incorrect diagnoses, missed treatment, or treatment that they do not need.

Now, a collaboration between Palmetto Health Richland Hospital, the South Carolina Hospital Association, and Outcome Engenuity, LLC, has resulted in a simple intervention that hospitals can use to dramatically reduce the rate of mislabeled blood specimens. Called The Final Check, the intervention was used for the first time at Palmetto Health in 2011, resulting in a 90 percent decrease in mislabeled specimens in the first month it was used. Those results have since been validated at five other hospitals in South Carolina and sustained for five consecutive months to date.

Outcome Engenuity offers The Final Check Toolkit free of charge via the website, www.thefinalcheck.org.

David Marx, chief executive officer of Outcome Engenuity, described the intervention as being created through prospective risk modeling that looked at the various ways mislabeling can occur. Palmetto Health had previously tried to reduce the rate of mislabeled specimens through a highly rigorous Red Rule that required nurses and phlebotomists to ask the patient’s name and date of birth, and then to check both the 9-digit medical record number and the 10-digit patient account number.

After observing the staff at work, and realizing that few were actually following the Red Rule, Marx and his team turned that punitive routine upside down. “Instead of adding steps, we eliminated steps,” he said.

The Final Check still calls for the patient’s name and date of birth to be confirmed. But instead of checking the complete medical record number, the nurse or phlebotomist now reads only the last three digits of the medical record number on the label and on the patient’s wristband—and recites them out loud.

According to Marx, saying the numbers out loud ensures that the person is “on the task,” and also makes the staff accountable to the patient.

Marx, who was recently appointed to the National Patient Safety Foundation’s Board of Governors, is well known in the health care industry for his work around Just Culture principles, human factors engineering, and the design of socio-technical systems. The Final Check was designed with certain principles in mind—that people have free will, that effective systems make it easy for people to do the right thing, and that disciplining people for making errors does not necessarily stop errors from occurring.

View and download the Final Check Toolkit or visit www.thefinalcheck.org.

“Perspective: A Culture of Respect, Part 1: The Nature and Causes of Disrespectful Behavior by Physicians”

Leape LL, Shore MF, Dienstag JL, et al. Acad Med. 2012(Jul); 87(7):845–852.

The authors examine the phenomenon of disrespectful behavior by physicians in academic medical settings, arguing that disrespect extends beyond overtly disruptive actions to encompass myriad other forms of incivility and aggression toward nurses, medical trainees, and patients. In this first of a 2-part series, the authors describe ways in which disrespectful behavior is manifested, discuss factors that give rise to and perpetuate a “culture of disrespect,” and examine the destructive and sometimes insidious effects of such behavior on workplace morale, quality of care, and patient safety.

“Perspective: A Culture of Respect, Part 2: Creating a Culture of Respect”

Leape LL, Shore MF, Dienstag JL, et al. Acad Med. 2012(Jul); 87(7):853–858.

In this second of two articles, the authors argue that establishing a workplace culture characterized by mutual respect is a prerequisite for achieving high reliability and safety in the delivery of health care. Noting that health care organizational leaders hold the primary responsibility for effecting this change, the authors outline steps that CEOs must take to promote the development of such a culture and to address disrespectful behavior effectively when it occurs.

Read more on the ONC blog.