To learn more about respect in the workplace from Virginia Mason Medical Center, read the full article from Hospital Impact.

Table of Contents

1. Achieving the Potential of Health Care Performance Measures
2. Building a Culture of Safety through Team Training and Engagement
3. Compendium of Resources for Radiation Safety in Medical Imaging Using Ionizing Radiation
4. Computerized Bar Code–Based Blood Identification Systems and Near-Miss Transfusion Episodes and Transfusion Errors
5. First Year Nursing Students’ Viewpoints about Compromised Clinical Safety
6. Impact of Multidisciplinary Simulation-Based Training on Patient Safety in a Paediatric Emergency Department
7. Impact of the World Health Organization’s Surgical Safety Checklist on Safety Culture in the Operating Theatre: A Controlled Intervention Study
8. Innovative Application of Bar Coding Technology to Breast Milk Administration
9. Is Detection of Adverse Events Affected by Record Review Methodology? An Evaluation of the “Harvard Medical Practice Study” Method and the “Global Trigger Tool”
10. Medical Error in Dermatology Practice: Development of a Classification System to Drive Priority Setting in Patient Safety Efforts
11. Medication Errors in Residential Aged Care Facilities: A Distributed Cognition Analysis of the Information Exchange Process
12. Medication Errors in the Home: A Multisite Study of Children with Cancer
13. Medication Errors in the Middle East Countries: A Systematic Review of the Literature
14. Medication Safety Practices in Hospitals: A National Survey in Saudi Arabia
15. National Efforts to Improve Health Information System Safety in Canada, the United States of America and England
16. Reduction in Medication Errors in Hospitals Due to Adoption of Computerized Provider Order Entry Systems
17. Supporting Involved Health Care Professionals (Second Victims) Following an Adverse Health Event: A Literature Review
18. Using Lean to Improve Medication Administration Safety: In Search of the “Perfect Dose”
19. Using “Teach-Back” to Promote a Safe Transition from Hospital to Home: An Evidence-Based Approach to Improving the Discharge Process
20. Wisdom through Adversity: Learning and Growing in the Wake of an Error

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Read full article.

1. To raise awareness of the need for a hospital-wide commitment to highly reliable, exceptional quality, patient-centered care.
   
2. Reward successful efforts to develop and promote a systems-based approach toward improvements in quality of care.
3. Inspire hospitals to systematically integrate and align their quality improvement efforts throughout the organization.
4. Communicate successful programs and strategies to the hospital field.

Applications are due by Sunday, October 13, 2013. For more information, read the full article on the American Hospital Association website.

Kami Walker, Patient Safety Officer, JPS Health Network (pictured with Gerald Hickson, MD, Chair, NPSF Board of Directors)

The highlight of the meeting was the conferring of the Stand Up for Patient Safety Management Awards. The Management Award is given each year to a Stand Up member organization in recognition of the successful implementation of an outstanding patient safety initiative that was led by, or created by, mid-level management.

This year, there were two awards given: one for an inpatient project and one for an ambulatory project. JPS Health Network, Fort Worth, Texas, received the inpatient award for a program to reduce the risk of fires in the OR. The 97^th Medical Group of Altus Air Force Base in Altus, Oklahoma, received the award for an ambulatory project designed to standardize pediatric visits through use of checklists that were developed in consultation with all stakeholders—clinical providers, ancillary medical staff, and parents.

Mark H. Smithwick, MBA, Patient Safety Program Manager, 97th Medical Group, Altus AFB (left, pictured with Gregg Meyer, MD, MSc, Vice Chair, NPSF Board of Directors)

In remarks to the members in attendance, Dr. Meyer lauded the Stand Up program as a “toolkit” for patient safety, but acknowledged some of the challenges facing health care professionals in a time of diminished budgets. He said that one goal for NPSF is make sure that members recognize and become familiar with the benefits of the program—and that they take advantage of, for example, the opportunity to earn continuing education or continuing medical education credits through some of the program’s offerings.

“We also recognize that the real power of the Stand Up program is not just what is provided to you from the Foundation, but also what you can learn from each other,” he said. A member directory is currently in development and will be available soon, enabling Stand Up members to seek advice or resources from their fellow members.

Mainly, though, Drs. Hickson and Meyer wanted to hear from the members present about what they wanted from the program and what they wanted to hear more about. Among the comments:

“I’d like to know more about how people do things, not necessarily what they do.”

In response to this comment, Dr. Meyer noted that one of the emerging things in the patient safety literature is investigation of the “things we know that will work.” He said that sometimes it’s not only the details of the initiative that lead to success—often it’s characteristics of the environment. “It’s not the seed, it’s the soil,” he said. Success is tied to context, and the patient safety field will be looking into this further in the coming years.

 “I would love to hear more about diagnostic error; it’s common, costly, hard to define and measure, but from the ambulatory side, would love some guidance.”

To this comment, Dr. Meyer pointed out a Stand Up member benefit that was introduced last year: All member organizations now have complimentary access to an online module offered by NPSF, called Reducing Diagnostic Errors. [To access this module, log on to the member pages at npsf.org, and go to the Online Learning Center.]

Other comments touched upon culture and lack of respect and, in the ambulatory setting, wrong-site surgery as an issue for dental professionals.

“We need your ideas to advance progress. We hope you are certified or working towards it. We need to listen—and take advantage of your ideas and suggestions,” said Dr. Hickson.

One of 31 Certified Professionals in Patient Safety in attendance receiving her CPPS pin from Dr. Hickson

Dr. Hickson opened the breakfast with words of appreciation and recognition for the inaugural group of CPPS certificants, the significance of the credential, the challenge of being among the first exam takers, and the measure of distinction becoming a certified professional in patient safety holds.

A number of new ASPPS members have joined the society via their affiliation with various Hospital Engagement Network (HEN) collaboratives, including the Illinois Hospital Association, Missouri Hospital Association, Michigan Hospital Association/Keystone Center, New Jersey Hospital Association, and Louisiana Hospital Association. These HEN organizations are enrolled in the NPSF Patient Safety Immersion Initiative, which combines ASPPS membership with access to the NPSF online Patient Safety Curriculum and the opportunity to pursue CPPS certification.

Ms. McGaffigan also recognized the strong support for certification by Kaiser Permanente. Dot Snow, MPH, CPPS, program lead, Patient Safety & KP HealthConnect, hosted an educational webinar as a means to drive more KP patient safety professionals to become certified, ensuring they benefit from critical patient safety competencies needed in today’s complex health care environment.

In an informal “pinning” ceremony, Ms. Rapala had the honor of announcing the names of the 31 certified professionals in attendance. One by one they were called to the front of the room to say where they are from and to receive their CPPS pin.

If you have become certified but couldn’t make it to the ceremony, your pin will be mailed to you. Future certificants will receive pins with their certificates upon passing the exam.

Table of Contents

1. ASHP Statement on the Role of the Medication Safety Leader
2. The Association between Frequency of Self-Reported Medical Errors and Anesthesia Trainee Supervision: A Survey of United States Anesthesiology Residents-in-Training
3. Associations of Patient Safety Outcomes with Models of Nursing Care Organization at Unit Level in Hospitals
4. Can We Quantify Harm in General Practice Records? An Assessment of Precision and Power Using Computer Simulation
5. Economic Measurement of Medical Errors Using a Hospital Claims Database
6. Engaging Patients in the Prevention of Health Care-Associated Infections: A Survey of Patients’ Awareness, Knowledge, and Perceptions Regarding the Risks and Consequences of Infection with Methicillin-Resistant Staphylococcus aureus and Clostridium difficile
7. Hand Hygiene among Patients: Attitudes, Perceptions, and Willingness to Participate
8. Human Cognition and the Dynamics of Failure to Rescue: The Lewis Blackman Case
9. Implementation of the World Health Organization Surgical Safety Checklist, Including Introduction of Pulse Oximetry, in a Resource-Limited Setting
10. Interdisciplinary Collaboration to Maintain a Culture of Safety in a Labor and Delivery Setting
11. The Measurement and Monitoring of Safety
12. Methodological Variations and Their Effects on Reported Medication Administration Error Rates
13. Nursing Student Medication Errors: A Case Study Using Root Cause Analysis
14. The Power of Video Recording: Taking Quality to the Next Level
15. Reducing Interruptions to Improve Medication Safety
16. Relationship between the Use of an Electronic Commercial Prescribing System and Medical Errors and Medication Errors in a Teaching Hospital
17. Surgical Never Events in the United States
18. A Survey-Based Study of Wrong-Level Lumbar Spine Surgery: The Scope of the Problem and Current Practices to Help Avoid These Errors
19. Variations in Risk Perceptions: A Qualitative Study of Why Unnecessary Urinary Catheter Use Continues to Be Problematic
20. ‘Why Is There Another Person’s Name on My Infusion Bag?’ Patient Safety in Chemotherapy Care — A Review of the Literature

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Webcast held May 22, 2013

Please note: Continuing education credits are not available for archived programs.

Faculty:

Theresa Famolaro, MPS
Senior Study Director
Westat

Suzanne Streagle, MA
Senior Study Director
Westat

Westat is under contract with AHRQ to support users of the Surveys on Patient Safety Culture and maintain the corresponding comparative databases.

Download the Presentation Slides [PDF}
Download the Audio File [.mp3]