Read the full issue here.

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

From Kaiser Health News

Medicare’s first public effort to identify hospitals with patient safety problems has pinpointed many prestigious teaching institutions around the nation, raising concerns about quality at these places but also bolstering objections that the government’s measurements are skewed.  Read the full text article >>.

In recognition of the advancement of patient safety as an acknowledged and critical discipline across the care continuum, testing for the CPPS credential will be made available as Patient Safety Awareness Week kicks off globally on March 5, 2012.

Certification requires a combination of education and experience, as well as successful completion of the evidence-based certification exam, which tests candidates on six core patient safety domains: Culture, Leadership, Risk Identification and Analysis, Data Management System Design, Mitigating Risk through Systems Thinking and Design and Human Factors Analysis, and External Influences on Patient Safety.

“It is widely recognized that, in order to make our health care system safer and more effective, improve the patient experience, and lower the cost of care, we need to work differently than we have in the past and incorporate all that we have learned from safety science and human factors engineering into our process design and improvement work,” said Diane Pinakiewicz, president of the National Patient Safety Foundation (NPSF). “The Certification Board for Professionals in Patient Safety has responded to this critical need by creating the benchmarking CPPS patient safety credential, formally validating skills and competencies, and encouraging health care professionals from all disciplines to become the standard bearers for patient safety excellence, advancing the shared body of knowledge and practice that will make the health care system safer for all.”

The CPPS credential is recommended for nurses, physicians, pharmacists, other clinicians, health care leadership, patient safety professionals, risk/quality managers, nonclinical health care professionals, client-facing solutions providers, and all others committed to the delivery of safe patient care.

CBPPS has also developed an optional 50-question practice exam, which is parallel in content and difficulty to the actual Certified Professional in Patient Safety exam and is a diagnostic tool to assess candidates’ strengths and weaknesses.

Additional information is available at www.cbpps.org.

Contact:
Patricia McTiernan
617.391.9922
pmctiernan@npsf.org

About the Certification Board for Professionals in Patient Safety

The Certification Board for Professionals in Patient Safety (CBPPS) was established by, but is a separate organizational entity from, the National Patient Safety Foundation, and was created to advance, standardize, and promote patient safety knowledge competencies for health care professionals. To this end, successful completion of the rigorously-designed Certified Professional in Patient Safety (CPPS) exam attests to candidates’ knowledge of essential patient safety competencies, upon which time the board confers the CPPS credential. Those attaining the CPPS designation represent a group of committed professionals from across health care who are determined to advance the patient safety field and make the health care system safer for all. To learn more, go to www.cbpps.org.

About the National Patient Safety Foundation

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 multi-stakeholder approach in all that it does. NPSF is an independent, not-for-profit 501(c)(3) organization. To learn more about the work of the National Patient Safety Foundation visit: www.npsf.org.

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Physicians need excellent communication skills and appropriate tools for facilitating communication to more effectively incorporate patient preferences into care. Read the full text article >>

Read the full issue here.

Table of Contents

1. Adverse Health Events in Minnesota: Eighth Annual Public Report
2. Association between Implementation of a Medical Team Training Program and Surgical Morbidity
3. Changing Practice to Improve Patient Safety and Quality of Care in Perinatal Medicine
4.  Chemotherapeutic Errors in Hospitalised Cancer Patients: Attributable Damage and Extra Costs
5. Diabetes Medication Patient Safety Incident Reports to the National Reporting and Learning Service: The Care Home Setting
6. Getting Moving on Patient Safety—Harnessing Electronic Data for Safer Care
7. Hospital Quality and Patient Safety Competencies: Development, Description, and Recommendations for Use
8. Human Reliability Assessment of a Critical Nursing Task in a Radiotherapy Treatment Process
9. Increasing the Use of ‘Smart’ Pump Drug Libraries by Nurses: A Continuous Quality Improvement Project
10. Inpatient Insulin Orders: Are Patients Getting What Is Prescribed?
11. Measuring the Cost of Hospital Adverse Patient Safety Events
12. Medication Administration Errors for Older People in Long-Term Residential Care
13. Medication Safety in Neonates
14. Nurses’ Clinical Reasoning: Processes and Practices of Medication Safety
15. Preventing Wrong Site, Procedure, and Patient Events Using a Common Cause Analysis
16. Quality Improvement in Medical Education: Current State and Future Directions
17. Research in Ambulatory Patient Safety 2000–2010: A 10-Year Review
18. Unusual Spine Anatomy Contributing to Wrong Level Spine Surgery: A Case Report and Recommendations for Decreasing the Risk of Preventable ‘Never Events’
19. Vaccine Shortages and Suspect Online Pharmacy Sellers
20. What “Patient-Centered Care” Requires in Serious Cultural Conflict

Read the full issue here.

Table of Contents

1. Anticoagulation-Associated Adverse Drug Events
2. Chemotherapy in Home Care: One Team’s Performance Improvement Journey toward Reducing Medication Errors
3. A ‘Communication and Patient Safety’ Training Programme for All Healthcare Staff: Can It Make a Difference?
4. Designing Education to Improve Care
5.  Errors in the Administration of Intravenous Medications in Hospital and the Role of Correct Procedures and Nurse Experience
6. Exploring Situational Awareness in Diagnostic Errors in Primary Care
7. How Dangerous Is a Day in Hospital? A Model of Adverse Events and Length of Stay for Medical Inpatients
8. Improved Quality and Outcomes through Congruent Leadership, Teamwork and Life Choices
9. Improving Quality of Patient Care by Improving Daily Practice in Radiation Oncology
10. Interdisciplinary Team Training Identifies Discrepancies in Institutional Policies and Practices
11. It’s Not All about Me: Motivating Hand Hygiene among Health Care Professionals by Focusing on Patients
12. Patient Safety in Primary Allied Health Care: What Can We Learn from Incidents in a Dutch Exploratory Cohort Study?
13. Patient Safety Instruction in US Health Professions Education
14. Patient Safety Problems Associated with Healthcare Information Technology: An Analysis of Adverse Events Reported to the US Food and Drug Administration
15. Patients’ and Healthcare Workers’ Perceptions of a Patient Safety Advisory
16. Patients Count on It: An Initiative to Reduce Incorrect Counts and Prevent Retained Surgical Items
17. Prevalence of Adverse Events in the Hospitals of Five Latin American Countries: Results of the ‘Iberoamerican Study of Adverse Events’ (IBEAS)
18. Safety of Telephone Triage in Out-of-Hours Care: A Systematic Review
19. Seek and Ye Shall Find: Consumer Search for Objective Health Care Cost and Quality Information
20. A Successful, Voluntary, Multicomponent Statewide Effort to Reduce Health Care–Associated Infections

Who is responsible for patient safety in your organization? The obvious answer may be the chief patient safety officer or the director of quality and safety. But that’s only partly right.

Patient safety has grown to become a distinct discipline involving practitioners from diverse areas of the health care spectrum who work under engaged and involved leaders. It involves representatives of nursing, medicine, environmental services, pharmacy, and other areas, none more important than the leadership team. Last January, the National Patient Safety Foundation established the American Society of Professionals in Patient Safety (ASPPS) as a multidisciplinary community of individuals committed to advancing patient safety best practices.

“ASPPS was created as a ‘home’ for what had previously been a fragmented community,” says Diane C. Pinakiewicz, MBA, president of NPSF and of ASPPS. “In unifying the broad base of people working to improve health care safety, our goal has been to promote consistency and standard practices to help health care professionals at all levels pursue the patient safety agenda.”

Because of their influence within their organizations, health care executives play a particularly vital role in advancing patient safety.

“There is no single strategic priority more critically important to a health care leader today than to relentlessly improve patient safety and health care quality,” says Susan T. Goodwin, RN, MSN, CPHQ, FNAHQ, FACHE.   “Doing this effectively means involving people with the requisite skills and education who employ evidence-based methods to achieve measurable goals, and who stay up-to-date on latest advances.”

Goodwin, immediate past president of the National Association for Healthcare Quality and assistant VP in the Clinical Services Group at Hospital Corporation of America, joined ASPPS last year. “The profession of patient safety has emerged as a discipline that engages many from diverse backgrounds,” she says. “ASPPS provides exceptional opportunities to bring disciplinary rigor to patient safety.”

ASPPS is marking its first anniversary this month with a number of events and activities, highlighted by an audio conference on January 24 with renowned patient safety pioneer, Lucian Leape, MD, adjunct professor of health policy at Harvard School of Public Health and chairman of the Lucian Leape Institute at NPSF.

Learn more about ASPPS and how you can benefit from membership.

WASHINGTON — Hospital employees recognize and report only one out of seven errors, accidents and other events that harm Medicare patients while they are hospitalized, federal investigators say in a new report.

Yet even after hospitals investigate preventable injuries and infections that have been reported, they rarely change their practices to prevent repetition of the “adverse events,” according to the study, from Daniel R. Levinson, inspector general of the Department of Health and Human Services.

Click to read the full article.

ASPPS Audio Conference: The Past, Present, and Future of Patient Safety

The American Society of Professionals in Patient Safety (ASPPS) marked its first anniversary on January 24, 2012. To celebrate this important milestone, members participated in a special members-only audio conference on the past, present, and future of the patient safety field.

The conference was led by patient safety pioneer and fellow ASPPS member Lucian Leape, MD. Dr. Leape shared his insights into the evolution and ongoing development of the patient safety profession. His remarks were followed by an interactive question-and-answer period highlighting audience participation.

If you weren’t able to participate in the call but would still like to hear Dr. Leape’s remarks, the event was recorded and is now available to members.

To download the audio file, click here.

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Last Updated: 1/27/12
ASPPSinfo@npsf.org

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.