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New way to survey culture? 4 C. Rebouche I have probably asked this before. What do you do with the results? Does what is that you do results matter?
by W. Hyman
Saturday, November 19, 2016
November 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. November 2016  NPSF News   President's Corner Medication adherence is a major challenge in outpatient settings. In this month's column. Dr. Gandhi discusses why a multipronged approach is needed for improvement.   Read her column.        Tejal K. Gandhi   Take the Healthcare Simulation Survey We want to better understand your individual and organizational needs surrounding healthcare simulation. Please take our five-question survey. Deadline is November 23, 2016.         NPSF Patient Safety Congress: Last Call for Posters There are still a few days left! Don’t forget to submit an abstract for consideration by the Congress Planning Committee.   Learn more and submit your poster by November 18: http://www.npsf.org/page/callforposters   Tell Your Friends to Support the NPSF Mission NPSF is asking you to share this post with anyone you know who is a military or federal employee. Federal and Military employees can easily pledge to NPSF by visiting http://rimactcfc.org/pledge-options/ and choosing: National Patient Safety Foundation, #24411 From the P.S. Blog —   Five Ways to Take Action Against Antibiotic Resistance Antibiotic resistance is among the most pressing threats to public health today, according to the Centers for Disease Control and Prevention (CDC). This post offers five ways to take action.    Marian Hoy   The Patient’s Voice in Action “He thoughtfully used my own words, so as to not frighten me.” This is Marian Hoy’s good news story. Read more. Visit the blog home page for more.   Our Members in the News   ASPPS member Susan Morris, MPH, MLS(ASCP)CM, patient safety officer at St. Luke’s Magic Valley Medical Center in Idaho, discusses how St. Luke’s was able to improve their Leapfrog Hospital Safety ranking over the past few years. Read more here.   Member Chenel Trevellini, MSN, RN, CWOCN, presented her poster on the tracking and prevalence of incontinence associated skin damage at the NPUAP Research Symposium in Las Vegas, Nevada.   Member Linda Waddell, RN, MSN, CPPS, CJCP, co-authored this article published in the Journal of the American Medical Association on performing the wrong procedure on a patient.   Go here to find more ASPPS member news and news about our Stand Up for Patient Safety members. Certification News Niki Griffith, patient safety officer at Pratt Regional Medical Center, was featured in this post in the Pratt Tribune for earning the Certified Professional in Patient Safety (CPPS) credential. Certification Board Announces October Certifications Awarded NPSF congratulates all who achieved the CPPS credential during the month of October 2016. Find out who they are.  NPSF In the News   Safety Lessons From the NIH Clinical Center A perspective piece by NPSF President and CEO Dr. Tejal Gandhi was published in the New England Journal of Medicine on lessons learned from recent events at the National Institutes of Health Clinical Center. Five Hospital   Practices That may Soon Look Outdated A recent piece in STAT expands upon a presentation by Dana Siegal, RN, CPHRM, CPPS, director, patient safety services at CRICO Strategies, from the 9th Annual Lucian Leape Institute Forum & Keynote Dinner. What are the five practices? Read more.   New Focus on Hospital Errors Aims to Correct Problems In this recent article in the Roanoke Times, Dr. Gandhi states that NPSF would like to see more research dollars going to ambulatory settings.   Dr. Tejal Gandhi Joins Aurora Health Care Board of Directors Aurora Health Care has recently announced the appointment of Dr. Gandhi as one of two new board members to join 11 other health care leaders. Read more here. Upcoming NPSF Events   Professional Learning Series Webcast The Overlap between Organizational Contributions to Burnout and Workplace Violence….  Is There Overlap of Solutions? Wednesday, December 7 | 2:00pm - 3:00pm ET        Michael Privitera   Featured Speaker: Michael R. Privitera, MD, MS Professor of Psychiatry, University of Rochester Medical Director, Medical Faculty and Clinician Wellness Program University of Rochester Medical Center Chair, MSSNY Task Force on Physician Stress and Burnout   Learn more and register. Want a discount on Professional Learning Series Webcasts? Join one of our membership programs. Details here.   ---------------------------------------------------------------------   To view all our events, visit our online event calendar. Patient Safety News & Resources   Focus on Safe Use of Antibiotics —       November 14-20 Is Get Smart About Antibiotics Week 2016 The Centers for Disease Control and Prevention’s Get Smart About Antibiotics Week is finally here! During this week, join the CDC in raising awareness about antibiotic resistance. Antibiotic-Resistant Bacteria Can Hitch a Ride on Hospital Scrubs LiveScience.com provides a summary of a study on the spread of germs in hospitals through bacteria on scrubs. Read it here. Nursing Home Antimicrobial Stewardship Guide The Agency for Healthcare Research and Quality is offering research-based materials and step-by-step instructions for nursing homes in an effort to reduce harm associated with antibiotic use.   Applying Best Practices from Hospitals to the Ambulatory Care Setting The Agency for Healthcare Research and Quality has released a technical brief on evidence-based practices from hospitals that could be implemented in ambulatory care settings. 12 Hospitals Receive FDA Violations for Failing to Disclose Injuries Kaiser Health News reported on 12 US hospitals who failed to report patient deaths or injuries linked to medical devices within the 10-day reporting period. Read more here. Top 10 Health Technology Hazards for 2017 Download the ECRI Institute report for free to find out about technology hazards that could affect patients and what to do about it. A Way to Improve Staff Vaccination Rates Some hospitals in California found that rates in health care staff receiving the flu shot rose after instituting a mandate about protective masks. Take a look at the data. Instruction Sheet Helps Patients Before Surgery The American Society of Anesthesiologists (ASA) October press release details how instruction sheets can help patients take their regularly prescribed medications correctly before surgery. Find out more. Consumer Focus — Two Myths About the Flu Shot That People Should Stop Spreading Are you confusing flu shot myths for facts? Read this post and find out. Get Inspired —     by the NPSF Health Care Safety Speakers Patient safety leaders from the NPSF governing boards and the NPSF Lucian Leape Institute will provide inspiration to energize your next event. Find out who they are and how it works.
by J. Carmona
Wednesday, November 16, 2016
Health Information Technology unintended consequences: IMIA Yearbook 2016 0 A. Spielman The 2016 issue of the Yearbook of Medical Informatics (published by the International Medical Informatics Association) focuses on the topic of unintended consequences of health IT. Several sections within the issue are particularly relevant to patient safety, including Special Section: Unintended Consequences: New Problems and New Solutions, Section 2: Human Factors and Organizational Issues, Section 3: Clinical Information Systems, and Section 5: Decision Support.   The entire publication is open-access.   Link: http://imia.schattauer.de/contents/archive/issue/2422.html
by A. Spielman
Wednesday, November 16, 2016
Top Ten Health Technology Hazards for 2017 from ECRI Institute 0 A. Spielman The ECRI Institute’s Top Ten Health Technology Hazards for 2017 has been published. The executive summary can be downloaded for free at www.ecri.org/2017hazards
by A. Spielman
Wednesday, November 16, 2016
11/14 Webcast: Taking Action to Combat Antibiotic Resistance 0 K. Rowbotham Thank you to those that attended today’s webcast titled Taking Action to Combat Antibiotic Resistance and Improve Antibiotic Use with Arjun Srinivasan, MD (CAPT, USPHS) of the Centers for Disease Control and Prevention and Deborah A. Pasko, Pharm.D, MHA of the American Society of Health-System Pharmacists.   November 14-20, 2016 is Get Smart About Antibiotics Week. Please see below for additional resources. Visit the Centers for Disease Control and Prevention website for more information about Get Smart About Antibiotics Week. Read the recent NPSF blog post on the topic here. We also encourage you to continue the discussion on antibiotic resistance and stewardship by adding your comments or questions below.    
by K. Rowbotham
Monday, November 14, 2016
Reminder: Call for Posters, NPSF Patient Safety Congress 0 P. McTiernan REMINDER 19th Annual NPSF Patient Safety Congress May 17–19, 2017 | Orlando, Florida CALL FOR POSTERS Do you have a poster to share that demonstrates a successful patient safety initiative in your organization? We are now building our roster of expert poster presenters and invite you to submit an abstract for consideration by the NPSF Congress Planning Committee. The NPSF Patient Safety Congress is the only annual meeting with global reach and a singular focus on patient safety. Don't miss this opportunity to share your expertise and successes with those on the leading edge of patient safety. Posters should highlight cutting-edge patient safety research or the utilization of patient safety approaches, methods, and tools that result in demonstrated reductions in harm or improved patient outcomes. Showcase your organization's work by submitting a poster to be displayed in the Learning & Simulation Center. A detailed list of criteria for poster submissions is outlined in the online form.   Use our online form, http://www.npsf.org/page/callforposters and submit your poster by  11:59 pm Eastern Time on Friday, November 18, 2016.   All those submitting will be notified by e-mail indicating the status of their proposal as a poster presenter. ________________________________________________ Supporters and Exhibitors The NPSF Patient Safety Congress provides high-visibility supporter and exhibitor opportunities. To learn more, contact David Coletta at 617.391.9908 or dcoletta@npsf.org.
by P. McTiernan
Tuesday, November 8, 2016
Serious Safety Events and Safety Culture Survey Domains 0 L. Baker Hello all, I am currently reviewing our Safety Culture Survey results and preparing an executive summary for our leadership team.  As I prepare to discuss with my colleagues the 12 domains of the SCS and needing to improve our safety culture to reduce error and increase patient safety, I wondered if any of you with a high number of days since serious safety events/low SSER's could comment on which domains of the 12 are your highest scoring areas on the Safety Culture Survey.  I'm trying to figure out if there is a correlation between just a few of the domains and decreased SSER's or if improvement of all 12 is required.  I have compared our scores to national benchmarks and my gut reaction is to work on the things that are significantly below national benchmarks, but I'm interested in what highly reliable/high safety preforming organizations are doing as well.  If anyone has experience with this or could point me to specific articles in the literature related to this, I would really appreciate it! Thank you, Laura Baker, MSN, RN, CPN, CPPS
by L. Baker
Monday, November 7, 2016
N Engl J Med: Safety Lessons from the NIHCC--by NPSF President Tejal Gandhi 0 A. Spielman A perspective article by NPSF President Tejal Gandhi published in the November 3 issue of New England Journal of Medicine looks at what can be learned from recent events at the NIH Clinical Center about the critical need for health care organizations to make safe delivery of care a top priority – and to establish the forms of organizational culture, oversight, structures, and processes that support this objective.   Read the article at http://www.nejm.org/doi/full/10.1056/NEJMp1609208
by A. Spielman
Thursday, November 3, 2016
Career website - which one is best for safety positions? 1 A. White Thank you for your inquiry related to patient safety career websites.   We recently launched the NPSF Career Center to bring together job seekers and organizations who share in our vision of creating a world where patients and those who care for them are free from harm. The NPSF Career Center is available for anyone to use. Individuals can post their resumes in the resume bank at no cost for employers to peruse. Resumes of individuals who have shown interest and commitment to patient and workforce safety by becoming members of the American Society of Professionals in Patient Safety (ASPPS) or by becoming Certified Professionals in Patient Safety (CPPS) are highlighted. Additionally, organizations who have committed to patient and workforce safety by becoming organizational members (Stand Up for Patient Safety or NPSF Patient Safety Coalition) receive incentivized pricing on job postings.   Further information about the NPSF Career Center will be distributed in the near future. We encourage you to visit the NPSF Career Center at http://jobs.npsf.org/ and post safety related jobs here.   Feel free to contact me for more information or questions about the NPSF Career Center at jwalker@npsf.org or 617-391-9901.     Regards,     Jennifer Walker VP Administration National Patient Safety Foundation
by J. Walker
Thursday, November 3, 2016
Patient Safety Committee Charter 1 C. Blalock Hey Casey. Happy to chat. 214.648.2118
by A. White
Thursday, November 3, 2016
Patient Safety News Roundup, October 27 0 P. McTiernan Sharing some stories and articles that caught our attention this week:   NPSF In the News Aurora Health Care Announces Two National Leaders to the Organization's Board of Directors Marketwired – Online | 10/25/2016 ...on the board is Dr. Gandhi, president and chief executive officer of the National Patient Safety Foundation, the NPSF... Link: http://www.marketwired.com/mw/release.do?id=2169279&sourceType=3 Industry News Johns Hopkins partners with consulting firm to share safety and quality practices Modern Healthcare Online | 10/25/2016 Johns Hopkins Medicine's Armstrong Institute for Patient Safety and Quality has entered into a strategic... Link: http://www.modernhealthcare.com/article/20161025/NEWS/161029954/johns-hopkins-partners-with-consulting-firm-to-share-safety-and Drug Maker Thwarted Plan to Limit OxyContin Prescriptions at Dawn of Opioid Epidemic STAT News | 10/26/16 The warning signs of what would become a deadly opioid epidemic emerged in early 2001. (Story about Purdue Pharma) https://www.statnews.com/2016/10/26/oxycontin-maker-thwarted-limits/ Mask Policies Drive Higher Flu Vax Rates HealthLeaders Media | 10/24/16 Some CA hospitals expect staff vaccination rates as high as 95% for the coming flu season, well above the national average. http://www.healthleadersmedia.com/leadership/mask-policies-drive-higher-flu-vax-rates# Simple instruction sheet helps patients correctly take regular medications before surgery Science Daily | 10/24/16 American Society of Anesthesiologists https://www.sciencedaily.com/releases/2016/10/161024170619.htm
by P. McTiernan
Thursday, October 27, 2016
Vital Directions for Health and Health Care publications 0 A. Spielman The Journal of the American Medical Association recently published a collection of 19 viewpoint articles summarizing content from a series of discussion papers presented by the National Academy of Medicine as part of the Vital Directions for Health and Health Care initiative. The initiative brings together a large group of researchers and scientists in an effort to provide direction and recommendations for health care policy in the US. https://nam.edu/initiatives/vital-directions-for-health-and-health-care/ The articles in JAMA are open access and can be found at http://jamanetwork.com/journals/jama/newonline/2016/9/26. The editorial at the following link introduces the collection: http://jamanetwork.com/journals/jama/fullarticle/2557167
by A. Spielman
Thursday, October 20, 2016
Patient Safety News Roundup, October 14 0 P. McTiernan International Infection Prevention Week, October 16-22 What does zero infections mean? In advance of International Infection Prevention Week, read this post on the CDC Safe Healthcare Blog by the president of APIC, Susan Dolan, https://blogs.cdc.gov/safehealthcare/the-faces-of-zero-infections/   Right Care Action Week, October 16-22 Information about activities throughout the week and the Right Care Alliance can be found at: http://rightcarealliance.org/right-care-action-week/   National Pharmacy Week, October 16-22 Pharmacy Week acknowledges the invaluable contributions that pharmacists and technicians make to patient care in hospitals, ambulatory care clinics, and other healthcare settings.The American Society of Health-System Pharmacists has developed a consumer website and has tips for how to recognize the week: http://www.ashp.org/pharmacyweek   Spotlight Series on RCA2 Continues Thank you to everyone who attended this week’s webcast on RCA2: Lessons from the Trenches with our excellent team from Abington-Jefferson Health. Be sure to tune in for the next complimentary webinar on October 18 with speakers from Ochsner Clinic/Health System. If you missed the first two programs, we have two still to come.   Details here, http://bit.ly/RCA2spot. And be sure to download the report at http://www.npsf.org/rca2.   Drug Take-Back Day Oct. 22 October 22 is National Prescription Drug Take-Back Day. Read this post from the P.S. Blog on how the DEA is helping health professionals mitigate harm from opioids and other unused medications, http://bit.ly/2dIGY2i How 5 Hospitals Reduced Falls Read this summary article of a new report from HRET, http://www.hhnmag.com/articles/7709-contributing-factors-for-patient-falls-and-how-5-hospitals-were-able-to-address-them   We are especially proud to recognize two of the organizations noted in the report, Memorial Hermann and Baylor Scott & White Health, both members of the NPSF Stand Up for Patient Safety program.
by P. McTiernan
Friday, October 14, 2016
Clinical Alert from CDC: Heater/Cooler Devices 0 P. McTiernan CDC ALERT: Have you or a loved one had open-heart surgery, such as valve replacement, in the last few years? If so, this important safety information is for you. https://www.cdc.gov/HAI/outbreaks/heater-cooler.html
by P. McTiernan
Friday, October 14, 2016
What are your top 3 safety concerns? 3 P. McTiernan My biggest safety concern is at the moment that not all practitioners are ethical. If patient is victim of a malpractice in for example  plastic surgery, they can have very hard time finding justice for their case. There needs to be laws that prevent practitioners from doing procedures to patients that are not agreed. I have read Realself community on internet and there are lot of horror stories. Even the top surgeons have botched people on purpose. There need to be laws and regulations that this does not happen anymore. According to some sources the malpractice listings are biased. According to a source a top San Francisco plastic surgeon who teaches his techniques all over the world does unagreed surgeries to his patients. He is respected among his peers but very unethical in his choices while people are under anestesia. Imagine going to a surgery for the eyelids and waking up with botched nose.   I very much want strict laws to this and all other fields. Medical personnel who do not follow code of ethics need to be stopped. Too many horror stories out there. And the review sites are like wild west, full of lies and bad reviews are deleted.
by B. Bella
Sunday, October 9, 2016
Reviewing & Classifying Patient Safety Events 0 K. Johnson Does anyone have a job description or information regarding a position where the primary responsibilities are to review, edit, classify and route patient safety events that were entered by front line caregivers into an electronic system?
by K. Johnson
Thursday, October 6, 2016
Video Monitoring for Fall Prevention 1 J. Schreiber You may already be familiar with examples from the literature, but in case this would be of help to anyone interested in this topic, here is the citation and abstract (pasted from https://www.ncbi.nlm.nih.gov/pubmed/26513398) from a recent study that looked at one institution's implementation of centralized video monitoring as part of a fall reduction program.   J Nurs Care Qual. 2016 Apr-Jun;31(2):131-8. doi: 10.1097/NCQ.0000000000000163. Protecting Patient Safety: Can Video Monitoring Prevent Falls in High-Risk Patient Populations? Sand-Jecklin K(1), Johnson JR, Tylka S. Author information: (1)West Virginia University School of Nursing, Morgantown (Dr Sand-Jecklin); and Neurosciences Unit (Ms Johnson) and Trauma/General Surgery Unit (Ms Tylka), West Virginia University Healthcare, Morgantown. Abstract: Despite implementation of many prevention strategies, patient falls in hospitals continue to be a significant safety problem, causing nursing staff and administrators to seek innovative means to further reduce falls among hospitalized patients. This article describes the feasibility and impact of implementing centralized video monitoring on the safety of patients identified as high risk for falls, as well as implications of video monitoring in the acute care setting.
by A. Spielman
Thursday, October 6, 2016
Reminder: Call for Speaker Abstracts, NPSF Patient Safety Congress 0 P. McTiernan The 19th Annual NPSF Patient Safety Congress will be held May 17 – 19, 2017, at the Renaissance Orlando at SeaWorld®, Orlando, Florida. The only meeting with a global reach and a singular focus on patient safety, the annual NPSF Congress brings together health practitioners, solutions providers, and others.   Share your success. Submit your speaker abstract by October 11. Get details at https://npsf.site-ym.com/page/callforabstracts
by P. McTiernan
Wednesday, October 5, 2016
October Is Health Literacy Month 0 P. McTiernan October Is Health Literacy Month Did you know… Health literacy is more than just the ability to read and understand information; it involves listening skills, communicating thoughts, facility with numbers, and judgment. By some estimates, only 12% of English-speaking adults in the U.S. are proficient in these skills. Studies have found health literacy to be a stronger predictor of an individual’s health status than income, employment status, education level, or racial or ethnic group. Read about Health Literacy and Patient Safety on the P.S. Blog. Resources for Health Professionals and Consumers       Use Ask Me 3® to Promote Clear Health Communication Developed by health literacy experts, the Ask Me 3 program encourages patients and families to ask the following key questions of their providers to better understand their health conditions and what they need to do to stay healthy: 1.  What is my main problem? 2.  What do I need to do? 3.  Why is it important for me to do this?   Patients and consumers: View the the Ask Me 3 video here.       Providers and health care organizations: NPSF encourages you to show the Ask Me 3 video and share Ask Me 3 materials with your patients to help promote clear health communication. And download the NPSF Health Literacy Training slide deck to share with your team. Learn About Health Literacy Read a recent advisory from the Pennsylvania Patient Safety Authority, Health Literacy and Patient Safety Events, and view the Authority’s interactive communication tool referenced in our recent webcast. The Centers for Disease Control and Prevention (CDC) hosts a resource-rich website that includes a list of state-level organizations working on the problem, as well as the CDC Clear Communication Index, to help health care professionals prepare patient materials that are more accessible. What will you do this month to improve health literacy in your organization or community? Tell us about it on the NPSF Online Forum.  
by P. McTiernan
Wednesday, October 5, 2016
Product Evaluation 1 C. Blalock Do you have a biomedical engineering/clinical engineering group? If so they should be involved in product evaluation. For products that are "medical devices" the FDA website has resources of interest including the MAUDE database of mandatory and voluntary adverse events reports (Medical Device Reports, or MDRs). I would also ask the vendor if the product is a medical device and if so the 510(k) clearance number for that specific product, or the FDA three letter product code for the generic type of product. If the vendor acts like they don't know what these are, that is not a good sign. With the product code you can look at a variety of information about the product and similar products including adverse events and recalls. Another general "shopping" tool is to have listed criteria and a side-by-side evaluation of each product against these criteria. In this way you might get better information about why they chose what they chose.
by W. Hyman
Wednesday, October 5, 2016
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