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Human Factors and Ergonomics Society: Call for Proposals 0 J. Carmona The Human Factors and Ergonomics Society welcomes proposals for the 2017 International Annual Meeting, to be held October 9-13 at the JW Marriott in Austin, Texas. HFES particularly invites submissions on work related to topics such as patient safety, medical devices and systems, workplace safety and health, handoff practices/protocols, environmental/facility design, simulation and training, and health-care information technology. Share your work and network with an international group of about 1,200 human factors/ergonomics professionals to improve patient safety. The deadline to submit your proposals is Monday, March 6.   Detailed instructions for submitting your work may be found in the Call for Proposals, now available at https://www.hfes.org//Web/HFESMeetings/2017AMcallforproposals.html.   For more information about attending this year’s Annual Meeting, visit https://www.hfes.org//Web/HFESMeetings/2017annualmeeting.html.
by J. Carmona
Wednesday, February 8, 2017
Partnered Hotels 0 W. Hyman The partnering of hotels with nearby hospitals (with co-located facilities in some cases) may present the problem of extending hospital safety issues into the hotel. Sharps and bloodborne/fluid pathogens are one area of concern. Are hospital's paying attention to such issues, and helping protect hotel workers, notably housekeeping? Or are they ignoring them? One such partnered hospital has been fined by OSHA for the second time.   http://www.oshatoday.com/news-digest-item/bostons-wyndham-hotel-fined-unsafe-working-conditions/
by W. Hyman
Monday, February 6, 2017
NPSF Joins Consumer Partnership for eHealth 0 J. Carmona   The National Patient Safety Foundation (NPSF), a central voice for patient safety since 1997, has joined the Consumer Partnership for eHealth (CPeH).   Led by the National Partnership for Women & Families, CPeH is a coalition of more than 50 consumer, patient, and labor organizations working to advance health information technology to meet the needs of patients and families. Through its initiatives, CPeH seeks to shape the policy landscape, amplify the consumer voice, and enhance access to and use of health information.   “The goals of CPeH are in parallel with recommendations of the National Patient Safety Foundation’s Free from Harm report,” said Tejal K. Gandhi, MD, MPH, CPPS, president and chief executive officer of NPSF. “Ensuring that that technology is safe and partnering with patients and families are two keys to advancing patient safety, and we look forward to working with the Partnership.”   CPeH’s members collectively represent 127 million people.  The Partnership aims to measurably improve lives through health IT and digital health tools.   “The ability for consumers and providers to easily and efficiently share critical health care information with each other is paramount to facilitating patient-centered care and promoting shared decision making,” said Erin Mackay, associate director, Health Information Technology Policy and Program, National Partnership for Women & Families. “We look forward to input and support of NPSF as a new member.”   To learn more about the Consumer Partnership for eHealth, visit http://www.nationalpartnership.org/issues/health/HIT/about-cpeh.html.
by J. Carmona
Thursday, February 2, 2017
Safety Leadership Errors 0 W. Hyman UL has a nice post entitled 5 Things Safety Leaders Do to Make Employees Mock Safety. (https://www.ulehssustainability.com/blog/)   I will paraphrase: 1. Forget that exposures effect real people 2. Talking change without attention to buy-in 3. Know-it-all and demanding leadership attitude that automatically generates resistance 4. Turning safety breaches into opportunities for blame and punitive actions 5. Mocking safety, eg The XXX is making you wash your hands and glove, not me   Are you guilty of any? Are there others?
by W. Hyman
Tuesday, January 31, 2017
Nominations Open: 2017 Sherman Award for Excellence in Patient Engagement 0 P. McTiernan Nominations now open for 2017 Sherman Award for Excellence in Patient Engagement EngagingPatients.org opened nominations today for the John Q. Sherman Award for Excellence in Patient Engagement. The Sherman Award, a partnership between EngagingPatients.org, the National Patient Safety Foundation, and Taylor Healthcare, recognizes outstanding programs focused on engaging patients and families in care to improve patient safety and boost outcomes.   Nominations will be open through Friday, March 3. Download this year’s newly streamlined nomination form.   Questions? Contact Arundi Venkayya, curator of EngagingPatients.org and Sherman Award administrator or call 937-221-4482.
by P. McTiernan
Monday, January 30, 2017
Workarounds 3 W. Hyman am new to safety field,background is in PT...seems like work arounds become normalized deviance and this suggests something needs to be changed in the system and/or workflow...Unfortunately humans make mistakes and we don't always choose to do the"right "thing but sometimes choose to do the "quick" thing.
by L. Kahan
Wednesday, January 18, 2017
WHO Technical Series on Safe Primary Care 0 P. McTiernan In case you missed it, in December, the World Health Organization published a technical series on Safer Primary Care. The series consists of nine monographs on topics such as patient engagement, human factors, and diagnostic error. Access it at http://www.who.int/patientsafety/topics/primary-care/technical_series/en/
by P. McTiernan
Thursday, January 12, 2017
"A View from the Edge" (N Engl J Med)-Perspective on Organizational Culture 1 A. Spielman I have had a related question. If you were to become a patient in your own institution are there staff that you would prefer be taking care of you, and staff that you definitely wouldn't want to be taking care of you, based on their skills and delivery of those skills? If the latter group exists then patients are being exposed to people we wouldn't want taking care of ourselves. Is this ethical? How can it be addressed?
by W. Hyman
Wednesday, January 11, 2017
Patient Safety Priorities 0 P. McTiernan What are your patient safety priorities for 2017? We'd love to hear from you and what you are working on.
by P. McTiernan
Monday, January 9, 2017
Support for Family Caregivers (commentary in New Engl J Med) 0 A. Spielman A commentary published in the December 29, 2016 issue of New England Journal of Medicine might be of interest to readers of this forum. It talks about the need to provide better support for unpaid family caregivers, who play a major part in managing the health care of millions of older Americans, but whose role often goes unrecognized by the health care professionals treating these patients.   The commentary references a 2016 report from the National Academies of Sciences, Engineering, and Medicine that examined the issue of family caregiving.   Free full text of the commentary: http://www.nejm.org/doi/full/10.1056/NEJMp1612351   National Academies report: https://www.nap.edu/catalog/23606/families-caring-for-an-aging-america
by A. Spielman
Thursday, January 5, 2017
"Ask Yourself..." Campaign 1 W. Hyman Great idea, and thanks for your kind offer to share the resources you created. The “Ask Yourself” theme made me think of some studies that suggest that training health care professionals to examine their practices through a process of regular self-reflection (not just admonishing them to “be more careful” after an accident occurs) could increase awareness of safety issues, which could help prevent potential future errors from actually happening.         Here is one example of such a study: Hoke LM, Guarracino D. Beyond Socks, Signs, and Alarms: A Reflective Accountability Model for Fall Prevention. Am J Nurs. 2016 Jan;116(1):42-7. https://www.ncbi.nlm.nih.gov/pubmed/26710147
by A. Spielman
Wednesday, January 4, 2017
December 2016 e-newsletter 0 J. Carmona IN THIS ISSUE NPSF News NPSF In the News Upcoming NPSF Events Patient Safety News & Resources Thank you for your interest. If you are not already on our mailing list, join now to receive e-News every month. December 2016 Take a look at our year-end blog post with 12 special NPSF moments you may have missed this year. NPSF News President's Corner Dr. Gandhi talks about notable developments in patient safety this year that reflect recommendations presented in the NPSF report Free from Harm. Read her column.        Tejal K. Gandhi         Patient Safety Awareness Week Is March 12-18, 2017 There are lots of ways to get involved in the months leading up to Patient Safety Awareness Week, a highlight of the United for Patient Safety Campaign.   Here’s how:   -  Download Free Campaign Materials   -  Visit the Online Store   -  Help Us Spread Awareness by Donating to the Cause   -  Join the Discussion   -  Share Your Plans NPSF salutes Mallinckrodt Pharmaceuticals for their generous support of the 2017 Patient Safety Awareness Week activities. NPSF Launches Career Center We are excited to introduce the new NPSF Career Center. We are bringing together job seekers and hiring organizations who share our vision of creating a world where patients and those who care for them are free from harm. Visit the Career Center.       19th Annual NPSF Patient Safety Congress Is May 17-19, 2017 Join us in Orlando, Florida, at the one and only globally relevant conference with a sole focus on patient safety. Visit the Congress website to learn more. Register online now and you’ll save $200. Continuing Education Credit Opportunities Looking for last-minute continuing education credits before the year is over? The 2016 NPSF Patient Safety Congress Keynote Speaker presentations have been discounted to $29 each. Each session earns one credit. Learn more. NPSF Welcomes New Stand Up Members The National Patient Safety Foundation is pleased to welcome five new members who recently joined our Stand Up for Patient Safety organizational membership program. Read about them here.   From the P.S. Blog — Addressing Workplace Violence in Health Care Ann Scott Blouin, PhD, RN, FACHE, NPSF Board of Directors, lifetime member of ASPPS, wrote a guest post this month discussing workplace violence and the Joint Commission’s virtual workforce violence resource center. Read it here. Visit the blog home page for more.   Our Members in the News Daniel L. Cohen, MD, FRCPCH, FAAP, published an article in Patient Safety & Quality Healthcare, “Unraveling Diagnostic Error: Delving Deeply to Identify Hidden Human Factors.”       Sheri Herner   Meet Sheri Herner, PharmD, CPPS, the ASPPS member featured this month in our latest Member Spotlight series blog post. Go here to find more ASPPS member news.   Certification News Certification Board Announces Certifications Awarded NPSF congratulates all who achieved the CPPS credential during the month of November 2016. Find out who they are. NPSF In the News   Profile of Dr. Tejal Gandhi NPSF President and CEO Dr. Tejal Gandhi was recently interviewed by Medical Training magazine on workforce safety, top patient safety challenges, simulation, and more. Read the full interview.   A Conversation on Root Cause Analysis James P. Bagian, MD, PE, NPSF Board of Advisors, spoke with Robert M. Wachter, MD, member of the NPSF Lucian Leape Institute, about the NPSF report RCA2: Improving Root Cause Analyses and Actions to Prevent Harm and the key recommendations in the report. Listen or read here. Upcoming NPSF Events   Two-Part Webinar Series Ways to Improve the Effectiveness and Impact of Health Information Technology on Patient Safety and Quality and the Value of Health IT   Part 2: Organizational Best Practices for Optimizing Health IT Tuesday, January 10, 2017 | 2:00 pm ET   Featured Speaker: Amy Feaster Vice President of Information Technology, Centura Health   This complimentary webinar series is jointly sponsored by the Health Information Management Systems Society (HIMSS) and NPSF. Learn more and register. ---------------------------------------------------------------------   To view all our events, visit our online event calendar. Patient Safety News & Resources   National Academy of Medicine Action Collaborative NPSF is supporting the National Academy of Medicine's collaborative of organizations working to help promote clinician well-being and resilience. Every year in the United States, 400 physicians take their own lives — a rate more than double that of the general population. In response to these alarming rates of burnout, depression, and suicide among U.S. health care workers, the National Academy of Medicine is launching an action collaborative. Read more here. 6 Patient Safety New Year's Resolutions A Hospitals & Health Networks (H&HN) article discusses six patient safety items that Derek Feeley, IHI president and CEO, believes we should tackle in 2017. Find out what they are.   HIMSS17 Annual Conference & Exhibition February 19–23, 2017, in Orlando, the Healthcare Information and Management Systems Society brings together health IT professionals, clinicians, executives, and vendors from around the world. More than 300 education programs feature keynotes, thought leader sessions, roundtable discussions and workshops, plus a full day of preconference symposia.   Patient Safety Efforts Save Lives A recently released report by the U.S. Department of Health and Human Services provides evidence that “125,000 fewer patients died due to hospital-acquired conditions and more than $28 billion in health care costs were saved from 2010 through 2015.” See the AHRQ press release for more.   Bar Code Rx Administration Compliance Rolling Out Slowly Health Leaders Media reports on efforts by the Leapfrog Group to collect data on the use of barcodes for drug administration in hospitals. Take a look at the preliminary results.   Zero Tolerance for Deadly Hospital-Acquired Infections Consumer Reports takes on hospital-acquired infections in this piece which includes lists of the lowest and highest performing teaching hospitals in the U.S.   ASHP Publishes Controlled Substances Diversion Prevention Guidelines The American Journal of Health-System Pharmacy (AJHP) has released guidelines to help health care organizations improve the management of controlled substances. Download the guidelines.   3 Ways to Incorporate Patient Preferences into Healthcare PatientEngagementHIT offers three ways to incorporate patients into their care including surveys, patient advisory boards, and tips for meeting patient expectations. Read more.   Principles of Quality and Patient Safety Don't Change Under a Trump Administration Take a look at this video interview from Hospitals & Health Networks (H&HN) with Don Berwick on the future of patient safety.   Senate Committee Calls For Ban on Surgeons Conducting Simultaneous Operations The Boston Globe reports on a recent Finance Committee report that urges hospitals to prohibit concurrent surgeries. Read more.   Prevalence of Depression, Depressive Symptoms, and Suicidal Ideation among Medical Students A study published in JAMA asks the question “Are medical students at high risk for depression and suicidal ideation”? Read about the results.   Consumer Focus — What to Expect When Your Loved One Is in the ICU U.S. News & World Report answers common questions like "Why intensive care?" and "Can I give them a hug?" along with tips for what to expect and how to communicate with health care staff in the ICU. Read more. Thinking about membership? As 2017 fast approaches, joining one of our programs would be a great way to jump start the New Year. NPSF offers membership programs — for individuals and organizations — that provide valuable benefits to help you stay on top of developments in patient safety, achieve your professional goals, and help grow or sustain your organization’s patient safety program. Learn how membership can help you.   Help support the patient safety mission As you consider your gifts for this holiday season, keep in mind that Amazon will donate a percentage of your total dollars spent to support NPSF and the patient safety mission. Use this link when shopping — https://smile.amazon.com/ch/36-7166993. And thank you!
by J. Carmona
Thursday, December 22, 2016
Registration Open: 19th Annual NPSF Patient Safety Congress 0 P. McTiernan   19th Annual NPSF Patient Safety Congress Wednesday, May 17–Friday, May 19, 2017 Orlando, FL Visit the Congress Website Register Online Now and Save $200 Join us at the one and only globally relevant conference with a sole focus on patient safety. The 2017 NPSF Patient Safety Congress will offer inspiring keynote sessions with renowned thought leaders, hands-on educational breakout sessions led by get-it-done experts, and an engaging and interactive Learning & Simulation Center. The additional, optional Immersion Workshops provide in-depth full-day sessions on specific areas and issues in workforce and health care safety. In addition, we'll also have More than 100 posters Live and interactive medical simulation 80 solutions providers 2 networking receptions, daily breakfast and lunch — and more. Who Should Attend Patient safety, quality, and risk professionals Hospital executives and board members Frontline clinicians, including nurses, physicians, and pharmacists Patient advocates, payors, researchers, and policy setters All those dedicated to patient safety — Across the continuum | Across all ages | Across all specialties         Breakout Sessions Choose from 30 informative sessions in the following six educational tracks: Advancing Safety Science Implementation. Addressing the successful application of safety and improvement science to health care. Caring for the Caregiver. Addressing the issues that affect front-line workers including workplace violence and burnout. Culture of Safety in the Workplace. Addressing cultural and leadership imperatives and programs that improve joy and meaning of work and workforce safety. Innovative Technology. Addressing safety considerations and innovations related to technology, including HIT. Medication Safety Across the Continuum. Addressing medication safety best practices, new innovations and emerging issues. Patient Safety Beyond the Walls of the Hospital. Addressing safety issues and solutions in settings outside of the acute care hospital. Announcing Keynote Sessions Among others —  ZDoggMD       Dr. Zubin Damania, MD, is an internist and the founder of Turntable Health, an innovative health care startup that’s part of an ambitious urban revitalization movement spearheaded by Zappos.com CEO Tony Hsieh. During a 10-year hospitalist career at Stanford, Dr. Damania somehow won clinical teaching awards while simultaneously maintaining a shadow career performing stand-up comedy for medical audiences worldwide. His videos, created under the pseudonym ZDoggMD, have gone epidemically viral, educating patients and providers while mercilessly satirizing our dysfunctional health care system. Immersion Workshops Make the most of your Congress experience by participating in our Immersion Workshops (additional day, separate registration). Select one of these full-day programs that take deep dives into compelling areas of patient safety. Leadership Day: Business Case for Patient Safety Certified Professional in Patient Safety Review Course Patient Safety 101 Emotional Harm and Peer Support NEW THIS YEAR! Hotel Information Attendees can book accommodations by going online to https://aws.passkey.com/go/nps2017 or by calling the hotel directly at 1-800- 266-9432. Please indicate that you are with the National Patient Safety Foundation. Sleeping rooms are available on a first-come, first-served basis within the designated NPSF block. Rates are $189 per night, exclusive of state and local taxes. REGISTER for Congress Today Stand Up for Patient Safety members receive a 20% discount on Congress registration. Check the member pages of www.npsf.org for details. Members of the American Society of Professionals in Patient Safety (ASPPS) receive a 10% discount on Congress registration. Check the member pagesof www.npsf.org for details. Supporters, Exhibitors Learn more about supporting or exhibiting at the Annual NPSF Congress. Special Discount NPSF Patient Safety Congress Keynote Speaker Series Couldn't make it to the last Annual NPSF Congress? We’ve got you covered: Watch three of the Keynotes and earn continuing education credits at the same time. You can now purchase the Keynotes for the discounted rate of $29 each. Learn more here. National Patient Safety Foundation® 280 Summer Street, Ninth floor, Boston, MA 02210 • 617.391.9900 npsf.org • info@npsf.org • contact us
by P. McTiernan
Friday, December 16, 2016
Staff and Unit Recognition 0 C. Blalock Can you share ideas you use to reward staff and units for being patient safety advocates. Here are some thoughts I have below. - Golden urinal award for unit that reduces Foley utilization - Recognizing Patient Safety Staff Member of the Month (someone who's really engaged, asks questions, speaks up, and perform at high level)- gift card or lunch with Chief of Quality and Pt. Safety or RN balloon with photo and recognized in newsletter - Recognizing units that hit 100% bundle compliance for CAUTI and CLABSI - We did a 5 for 5 Hand Hygiene campaign; if staff collected 5 business cards for compliant hand hygiene observations, they received a $5 coffee gift card - Banner for unit that improved the most   Do you have any fun or unique ways you celebrate patient safety initiatives? What about falls, pressure injuries, medication safety, hand hygiene...
by C. Blalock
Monday, December 12, 2016
Patient Safety News Roundup, December 5 0 J. Carmona   Stories and articles that caught our attention this week:   3 Ways to Incorporate Patient Preferences Into Healthcare HealthIT Analytics| December 1, 2016 http://patientengagementhit.com/news/3-ways-to-incorporate-patient-preferences-into-healthcare   Principles of Quality and Patient Safety Don't Change Under a Trump Administration, Says Don Berwick H&HN| December 6, 2016 http://www.hhnmag.com/articles/7897-principles-of-quality-and-patient-safety-dont-change-under-a-trump-administration-don-berwick?   Senate Committee Calls For Ban on Surgeons Conducting Simultaneous Operations The Boston Globe| December 6, 2016 http://www.bostonglobe.com/metro/2016/12/05/senate-committee-calls-for-ban-surgeons-doing-simultaneous-operations/EYjO9jiAfLYJsliIrdY4LO/story.html?event=event25   Prevalence of Depression, Depressive Symptoms, and Suicidal Ideation Among Medical Students JAMA| December 6, 2016 http://jamanetwork.com/journals/jama/article-abstract/2589340   6 Patient Safety New Year's Resolutions H&HN| December 8, 2016 http://www.hhnmag.com/articles/7903-patient-safety-news-years-resolutions?   Complimentary Webinar: Leveraging Health IT to Improve Safety and Reduce Harm http://www.himss.org/event/ways-improve-effectiveness-and-impact-health-information-technology-patient-safety-and-quality-and
by J. Carmona
Thursday, December 8, 2016
Ticket to Ride -- Transportation to Procedure Areas 0 L. Baker What are your hospitals doing related to hand-off/communication when a patient leaves a nursing unit and goes to a procedure area?   We have a "ticket to ride" process, but are finding it is not well utilized.  Do you do a face to face hand-off?  use a ticket to ride?  Thanks for any help you can offer!
by L. Baker
Tuesday, December 6, 2016
Up Campaign 0 C. Blalock Hello,   I am wondering if any of your institutions have implemented the Up Campaign from HRET/AHA and if you can share ideas about how you rolled it out. We are thinking of doing a soft roll out so staff don't feel like there is a big push around a new campaign. We're thinking about messaging it something like, "The next big thing that's not really new at all," because it focuses on safety behaviors staff should be doing already.     http://www.hret-hen.org/topics/up-campaign.shtml   Thanks, Casey   casey.blalock@asante.org  
by C. Blalock
Friday, December 2, 2016
Support the Patient Safety Mission 0 P. McTiernan We want to let our friends know that if you shop Amazon, use this link and the Amazon Smile program will donate a percentage of your total spend to the nonprofit National Patient Safety Foundation to support our patient safety mission. And thank you. https://smile.amazon.com/ch/36-7166993
by P. McTiernan
Sunday, November 27, 2016
NPSF Thank You 0 P. McTiernan Our thanks this season to all who helped advance patient safety in 2016
by P. McTiernan
Thursday, November 24, 2016
Patient Safety News Roundup, November 23 0 P. McTiernan Stories and articles that caught our attention this week:   Nine Organizational Strategies to Promote Engagement and Reduce Burnout Mayo Clinic Proceedings | November 18, 2016 http://www.mayoclinicproceedings.org/article/S0025-6196(16)30625-5/fulltext Read a summary article from Fierce Healthcare, http://www.fiercehealthcare.com/healthcare/mayo-clinic-9-strategies-to-boost-physician-engagement-prevent-burnout   Patient safety benefits when hospitals provide feedback to staff who report errors Science Daily | November 1 https://www.sciencedaily.com/releases/2016/11/161101133246.htm AHRQ's Low Profile Threatens work on Healthcare Best Practices Modern Healthcare | November 19, 2016 http://www.modernhealthcare.com/article/20161119/MAGAZINE/311199946/how-ahrqs-low-profile-threatens-work-on-healthcare-best-practices   6 EHR Patient Safety Strategies for Medication Orders, CPOE "The ONC is hoping that providers optimize their electronic health records to avoid patient safety risks tied to inefficient or confusing medication ordering procedures." Health IT Analytics | November 21, 2016 http://www.healthitanalytics.com/news/6-ehr-patient-safety-strategies-for-medication-orders-cpoe November Is National Family Caregiver Month Learn more at the Caregiver Action Network, http://ow.ly/RLXf306qiGf
by P. McTiernan
Wednesday, November 23, 2016
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