The National Patient Safety Foundation is proud to partner with the American Hospital Association in sponsoring the AHA-NPSF Comprehensive Patient Safety Leadership Fellowship. This year-long program provides essential training in patient safety, quality, and performance improvement.

The fellowship consists of four in-person learning sessions, periodic teleconferences, webinars, various self and organizational assessments, and individual coaching.

This curriculum is based on the 2009 paper Transforming Healthcare: A Safety Imperative from the Lucien Leape Institute at NPSF. It prepares health care leaders to guide patient safety improvement initiatives and drive transformational change within their organizations.

The fellowship framework includes a focus on foundational elements of patient safety, such as leadership roles, culture and communication, and incorporates them into four pillars of patient safety:

• Care coordination
• Patient centeredness
• Organizational culture
• Transparency and learning organization

Fellows complete an action learning project to bring real change within their organizations and demonstrate their ability to apply the concepts learned. This rigorous approach ensures that Fellows can translate knowledge and best practices learned into action within their own organizations.

Applications for the 2013-2014 are being accepted through March 15, 2013. Please visit the fellowship website for more information.

The AHA and the National Patient Safety Foundation are sponsors of this program.

Partners include: The Health Education & Research Trust, Health Forum, the American Society for Healthcare Risk Management, the American Organization of Nurse Executives and the Society of Hospital Medicine.

Table of Contents

1. Colorectal Surgery Surgical Site Infection Reduction Program: A National Surgical Quality Improvement–Driven Multidisciplinary Single-Institution Experience
2. Computer Screen Saver Hand Hygiene Information Curbs a Negative Trend in Hand Hygiene Behavior
3. Context, Culture and (Non-Verbal) Communication Affect Handover Quality
4. Effect of an Office-Based Surgical Safety System on Patient Outcomes
5. Global Patient Safety and Antiretroviral Drug–Drug Interactions in the Resource-Limited Setting
6. Improving Patient Safety in the Operating Theatre and Perioperative Care: Obstacles, Interventions, and Priorities for Accelerating Progress
7. “It’s Like Two Worlds Apart”: An Analysis of Vulnerable Patient Handover Practices at Discharge from Hospital
8. The KIDS SAFE Checklist for Pediatric Intensive Care Units
9. Managing the After Effects of Serious Patient Safety Incidents in the NHS: An Online Survey Study
10. Measure, Promote, and Reward Mobility to Prevent Falls in Older Patients
11. A Mixed-Methods Analysis of Patient Reviews of Hospital Care in England: Implications for Public Reporting of Health Care Quality Data in the United States
12. Patient Safety Culture and the Association with Safe Resident Care in Nursing Homes
13. Patient Safety in Midwifery-Led Care in the Netherlands
14. Post-Hospital Syndrome—An Acquired, Transient Condition of Generalized Risk
15. Pressures to “Measure Up” in Surgery: Managing Your Image and Managing Your Patient
16. Preventable Hospital Mortality: Learning from Retrospective Case Record Review
17. Promoting Appropriate Use of Physicians’ Non-English Language Skills in Clinical Care: Recommendations for Policymakers, Organizations and Clinicians
18. Quality in Practice: Implementation of Hospital Guidelines for Patient Identification in Malawi
19. Standardized Patient Identification and Specimen Labeling: A Retrospective Analysis on Improving Patient Safety
20. Successful Implementation of Policies Addressing Lateral Violence

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Table of Contents

1. Anesthesiology Leadership Rounding: Identifying Opportunities for Improvement
2. Changes to Medication-Use Processes after Overdose of U-500 Regular Insulin
3. Disclosure-and-Resolution Programs That Include Generous Compensation Offers May Prompt a Complex Patient Response
4. Errors of Medical Interpretation and Their Potential Clinical Consequences: A Comparison of Professional versus Ad Hoc versus No Interpreters
5. Healing Environment: A Review of the Impact of Physical Environmental Factors on Users
6. Integrating Human Factors Research and Surgery: A Review
7. Learning from Business: Incorporating the Toyota Production System into Nursing Curricula
8. Learning from Taiwan Patient-Safety Reporting System
9. Mapping Out the Emergency Department Disposition Decision for High-Acuity Patients
10. A Multicenter, Phased, Cluster-Randomized Controlled Trial to Reduce Central Line-Associated Bloodstream Infections in Intensive Care Units
11. Patient Involvement in Patient Safety: The Health-Care Professional’s Perspective
12. Poor Communication on Patients’ Medication across Health Care Levels Leads to Potentially Harmful Medication Errors
13. Professionalism in the Era of Duty Hours: Time for a Shift Change?
14. Reasons for Not Reporting Patient Safety Incidents in General Practice: A Qualitative Study
15. Residents’ Duty Hours—Toward an Empirical Narrative
16. Results of an Effort to Integrate Quality and Safety into Medical and Nursing School Curricula and Foster Joint Learning
17. Seven Years of Zero Central-Line-Associated Bloodstream Infections
18. Technology-Related Medication Errors in a Tertiary Hospital: A 5-Year Analysis of Reported Medication Incidents
19. Use of FMEA Analysis to Reduce Risk of Errors in Prescribing and Administering Drugs in Paediatric Wards: A Quality Improvement Report
20. Waking Up the Next Morning: Surgeons’ Emotional Reactions to Adverse Events

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Table of Contents

1. Application of an Aviation Model of Incident Reporting and Investigation to the Neurosurgical Scenario: Method and Preliminary Data
2. As She Lay Dying: How I Fought to Stop Medical Errors from Killing My Mom
3. Counting Matters: Lessons from the Root Cause Analysis of a Retained Surgical Item
4. Duplication of Surgical Site Marking
5. Effects of Nursing Unit Spatial Layout on Nursing Team Communication Patterns, Quality of Care, and Patient Safety
6. A Framework for Encouraging Patient Engagement in Medical Decision Making
7. The Heart of Health Care: Parents’ Perspectives on Patient Safety
8. How-To Guide: Prevent Obstetrical Adverse Events
9. Impact of a Hospital-Wide Hand Hygiene Initiative on Healthcare-Associated Infections: Results of an Interrupted Time Series
10. The Impact of Medication Reconciliation Program at Admission in an Internal Medicine Department
11. Improving Patient Safety through the Systematic Evaluation of Patient Outcomes
12. Online, Direct-to-Consumer Access to Insulin: Patient Safety Considerations and Reform
13. Pediatric Medical Line Safety: The Prevalence and Severity of Medical Line Entanglements
14. Pharmacy Dispensing of Electronically Discontinued Medications
15. The Role of the Electronic Health Record in Patient Safety Events
16. A Study of the Prevalence of Adverse Events in Primary Healthcare in Spain
17. Surgical Fires: Trends Associated with Prevention Efforts
18. A Systematic Approach to the Identification and Classification of Near-Miss Events on Labor and Delivery in a Large, National Health Care System
19. “Team Time-Out” and Surgical Safety—Experiences in 12,390 Neurosurgical Patients
20. Thirty-Day Outcomes Support Implementation of a Surgical Safety Checklist

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• Members in the News
  • ASPPS member Tim Morgenthaler, MD, publishes on Zolpidem as a fall risk for inpatients, in the Journal of Hospital Medicine
• NPSF News
  • The National Patient Safety Foundation’s interim president, Patricia McGaffigan, recently participated in a Congressional briefing on the issue of patient safety and cancer care
• Patient Safety in the News
  • The Joint Commission issues Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation
  • Nurse Burnout and Long Shifts
  • A recent article in the New England Journal of Medicine proposes EHR-specific safety goals
• Save the date for the 15th annual NPSF Patient Safety Congress, May 8-10, 2013, in New Orleans. Keynote Speaker: Suzanne Gordon

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Table of Contents

1. Cognitive Errors and Logistical Breakdowns Contributing to Missed and Delayed Diagnoses of Breast and Colorectal Cancers: A Process Analysis of Closed Malpractice Claims
2. A Collaborative, Systems-Level Approach to Eliminating Healthcare-Associated MRSA, Central-Line–Associated Bloodstream Infections, Ventilator-Associated Pneumonia, and Respiratory Virus Infections
3. Diagnostic Errors and Flaws in Clinical Reasoning: Mechanisms and Prevention in Practice
4. Error Reporting in Transfusion Medicine at a Tertiary Care Centre: A Patient Safety Initiative
5. Errors and Near Misses in Digestive Endoscopy Units
6. The Feedback Intervention Trial (FIT)—Improving Hand-Hygiene Compliance in UK Healthcare Workers: A Stepped Wedge Cluster Randomised Controlled Trial
7. Impact of Automated Alerts on Follow-Up of Post-Discharge Microbiology Results: A Cluster Randomized Controlled Trial
8. Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation
9. Interruption Handling Strategies during Paediatric Medication Administration
10. Intravascular Retained Surgical Items: A Multicenter Study of Risk Factors
11. Medication Problems Are Frequent and Often Serious in a Danish Emergency Department and May Be Discovered by Clinical Pharmacists
12. Non-Technical Skills Training to Enhance Patient Safety: A Systematic Review
13. Partnering with Family Members to Improve the Intensive Care Unit Experience
14. Patterns in Neurosurgical Adverse Events and Proposed Strategies for Reduction
15. Preventing Wrong-Site Surgery in Minnesota: A 5-Year Journey
16. Restructuring the Morbidity and Mortality Conference in a Department of Pediatrics to Serve as a Vehicle for System Changes
17. Safety Climate and Medical Errors in 62 US Emergency Departments
18. Sharing Lessons Learned to Prevent Incorrect Surgery
19. Surgical Debriefing: A Reliable Roadmap to Completing the Patient Safety Cycle
20. Ultrasound to Reduce Cognitive Errors in the ED

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Webcast held November 15, 2012

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

Featured Faculty:

Matthew K. Wynia, MD, MPH, FACP
Director
The Institute for Ethics and Center for Patient Safety
American Medical Association
Clinical Assistant Professor for Infectious Diseases
University of Chicago

Learning Objectives

Attendees of this webcast will be able to:

1. Describe the frequency of and harms associated with errors in the outpatient setting
2. List the most common types of errors in outpatient care
3. Explain at least 3 factors that make care in the ambulatory setting different from care in the hospital in regard to potential for errors and harm
4. Challenge conventional thinking about the roles of patients in safety
5. Formulate plans for how to incorporate ambulatory issues in future quality and safety work

...

Table of Contents

1. Adjusting Team Involvement: A Grounded Theory Study of Challenges in Utilizing a Surgical Safety Checklist as Experienced by Nurses in the Operating Room
2. Adverse Drug Events Caused by Serious Medication Errors
3. Certain Uncertainties: Modes of Patient Safety in Healthcare
4. Designing for Distractions: A Human Factors Approach to Decreasing Interruptions at a Centralised Medication Station
5. Designing for Patient Safety: Developing Methods to Integrate Patient Safety Concerns in the Design Process
6. The Effect of the WHO Surgical Safety Checklist on Complication Rate and Communication
7. Electronic Health Records and National Patient-Safety Goals
8. More Quality Measures versus Measuring What Matters: A Call for Balance and Parsimony
9. Multiple Patient Safety Events within a Single Hospitalization: A National Profile in US Hospitals
10. A Nurse Learns Firsthand That You May Fend for Yourself after a Hospital Stay
11. Patient Safety Culture in Home Care: Experiences of Home-Care Nurses
12. Procedural Safety in Emergency Care: A Conceptual Model and Recommendations
13. Reduced Mortality with Hospital Pay for Performance in England
14. Rethinking Opioid Prescribing to Protect Patient Safety and Public Health
15. Serious Safety Events: Getting to Zero™
16. A Systematic Review of Hand Hygiene Improvement Strategies: A Behavioural Approach
17. TeamSTEPPS®: The Patient Safety Tool That Needs to Be Implemented
18. Top 10 Health Technology Hazards for 2013
19. Utah Tenth Anniversary (2001-2011) Patient Safety Report: Identifying Opportunities for Improvement
20. What Keeps Facilities from Implementing Best Practices to Prevent Wrong-Site Surgery? Barriers and Strategies for Overcoming Them

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ASPPS member Tim Morgenthaler, MD, chief patient safety officer at Mayo Clinic in Rochester, MN, is among the authors of a study that found the rate of falls was four times higher among inpatients who took Ambien than among other patients.

Read the abstract in the Journal of Hospital Medicine.

Read a summary article from the Philadelphia Inquirer.

Cancer services cover a wide range of activities, from health promotion and screenings to diagnosis, surgery, medical or radiotherapy, palliative care, and disease management. Likewise, the safety risks and opportunities for error are broad and far-reaching in consequence, and include adverse drug interactions, patient misidentification and cross-contamination of laboratory specimens. The risk of error grows with the introduction of new therapies and the advance of personalized medicine.

In written comments to his colleagues prior to the meeting, Rep. Barber said, “As Congress continues to address health issues, a concise overview of some of the key issues, challenges, and solutions related to cancer and patient safety should help guide the institution’s analysis, debate, and action.”

Patricia McGaffigan, RN, MS, interim president of NPSF, represented the Foundation’s commitment to supporting health systems in their efforts to improve safety in cancer care. She also recounted personal experience with the health care system that served to illustrate some of the very issues under discussion.

Joining Ms. McGaffigan on the expert panel were Mara Aspinall, president and CEO, Ventana Medical Systems, Inc., and global head, Roche Tissue Diagnostics; Maurie Markman, MD, senior vice president of clinical affairs and national director of medical oncology, Cancer Treatment Centers of America; and Eric Walk, MD, FCAP, senior vice president, medical and scientific affairs, Ventana Medical Systems.

Ms. McGaffigan also answered questions informally after the session. View the video below.

Part I

Part II