Ambulatory Safety Reports from the AMA
Posted with permission of the American Medical Association.
AHA-NPSF Patient Safety Leadership Fellowship
Awarded through joint sponsorship by NPSF and the American Hospital Association to encourage leadership in the patient safety field by providing health care professionals an opportunity to integrate innovative strategies within their own organizations.
Please note: As of May 2015, the Patient Safety Leadership Fellowship has been suspended. The National Patient Safety Foundation is looking at suitable ways to support this fellowship in the future with the intention of adding a new venture to an already rich legacy.
If you would like your name to be added to a contact list for future opportunities and updates, please send an e-mail to Patricia McGaffigan.
Diagnostic Error Prevention
Improving Diagnosis in Health Care (2015)
Diagnostic errors persist throughout all settings of care and continue to harm an unacceptable number of patients. This report, part of the Quality Chasm series from the National Academies of Sciences, Engineering, and Medicine, concludes that improving the diagnostic process is not only possible, but also represents a moral, professional, and public health imperative.
Read or download the report.
Lab Safety: College of American Pathologists Guidelines
To ensure the accuracy of laboratory tests and reduce variation in laboratory practices, the College of American Pathologists has developed the first evidence-based guideline to validate all immunohistochemical (IHC) assays. The guideline, Principles of Analytic Validation of Immunohistochemical Assays, is available in the online edition of Archives of Pathology & Laboratory Medicine.
Diagnostic Error Prevention – General Resources
Diagnostic error prevention was the topic of Patient Safety Awareness Week 2014. Visit that page of the website for webcast replays and other downloadable materials. http://www.npsf.org/?page=psaw2014
The Office of the National Coordinator for Health Information Technology (ONC) sponsored the creation of the SAFER Guides, which offer information and recommendations to help health systems and organizations optimize their use of health IT. To access the SAFER Guides, visit http://www.healthit.gov/safer/
Health Literacy: Past, Present, and Future
The Institute of Medicine's Roundtable on Health Literacy convened a one-day public workshop (2015) to assess the progress made in the field of health literacy in the decade since the IOM published Health Literacy: A Prescription to End Confusion.
Purchase or view/download this workshop summary free of charge from the National Academies Press.
See also the Ask Me 3 program and the Health Literacy Resources page of our website.
The AHA’s Antimicrobial Stewardship Toolkit is provided to help health systems and hospitals create antimicrobial stewardship programs in their organizations to ensure more appropriate use of antibiotics. The toolkit includes helpful resources from a variety of organizations, including the Centers for Disease Control and Prevention, the Society of Hospital Medicine, and the American Society of Health-System Pharmacists. View or download the Antimicrobial Stewardship Toolkit.
CDC Health Care-Associated Infections Data
The latest data from the annual National and State Healthcare-associated Infection Progress Report were released in January 2015.
ANA CAUTI Prevention Tool
In summer 2015, the American Nurses Association (ANA) released an an innovative, streamlined, evidenced-based clinical tool developed by leading experts to help nurses prevent catheter-associated urinary tract infections (CAUTI). Read more and download the tool on the ANA website.
Hand Hygiene Compliance
Two open-access articles in the Joint Commission Journal on Quality and Patient Safety (January 2015) discuss targeted approaches to improving hand hygiene and spreading improvement to hospitals not in the initial study group. Visit the journal website to view or download the articles.
AHRQ Measurement Tools
The AHRQ Quality Indicators (AHRQ QIs) are four sets of evidence-based measures that include Patient Safety Indicators (PSIs) to help assess potential in-hospital complications and errors associated with surgery, specific procedures, and childbirth, and improve the quality and safety of health care. PSIs are used to help hospitals identify potential adverse events that might need further study; provide the opportunity to assess the incidence of adverse events and in-hospital complications; and as indicators for complications occurring in hospital that may represent patient safety events. Many private and public payers use the PSIs to promote and reward improved patient safety as part of their value-based purchasing programs.
Free software from AHRQ is available to calculate the AHRQ QI results for hospitals, using local inpatient hospital administrative data.
Center for Education and Research on Therapeutics
Tools for Optimizing Medication Safety (TOP-MEDS) is one of seven Centers for Education and Research on Therapeutics (CERTs) across the country. The CERT program, sponsored by the Agency for Healthcare Research and Quality, aims to increase drug knowledge and awareness, provide clinical information to patients and medical practitioners, and improve the quality of patient care while simultaneously cutting costs. NPSF is a dissemination partner to the TOP-MEDs CERT, which is focusing on medication safety. Read articles about their research.
ISMP Medication Error Reporting
The Institute for Safe Medication Practices (ISMP) operates two confidential, voluntary reporting databases, one for professionals and one for consumers. Visit the Medication Error reporting section of their website, https://www.ismp.org/errorReporting/reportErrortoISMP.aspx
GEDSA (Global Enteral Device Supplier Association) is managing the Stay Connected campaign, which is focusing on communications to health care providers and organizations about new standards in tubing connections. Starting with enteral devices in 2014, tubing connections will gradually be redesigned to prevent misconnections. Stay Connected will help introduce new standard connectors for specific delivery systems (neuraxial, limb cuff inflation, and respiratory). Visit http://stayconnected2014.org/.
Safety Alerts and Reporting
Global Patient Safety Alerts
Global Patient Safety Alerts is a publicly available, evidence informed online collection of patient safety alerts, advisories and recommendations from 26 international organizations around the world. Recognized by the World Health Organization and its member countries, Global Patient Safety Alerts contains more than 1,200 alerts and 6,100 recommendations from contributing organizations and acts as a centralized location for sharing and learning from patient safety incidents. Visit the site.
Reports from AHRQ
The AHRQ 2014 National Healthcare Quality and Disparities Report finds that hospital care was safer in 2013 than in 2010, with 17 percent fewer harms to patients and an estimated 1.3 million fewer hospital-acquired conditions, 50,000 fewer deaths, and $12 billion in cost savings over 3 years (2011, 2012, 2013).
The AHRQ Patient Safety Chartbook provides more detailed information and easy-to-understand slides that can be downloaded for presentations.
Health care organizations use the TeamSTEPPS curriculum to build the foundation for a culture of safety, making care safer and the implementation of other hospital safety initiatives easier. The curriculum is available online and in DVD format and includes PowerPoint presentations, teaching modules, and video vignettes that can be used to train staff. To access TeamSTEPPS 2.0 materials, please visit www.ahrq.gov/teamstepps. To order copies of the DVD, contact the AHRQ Publications Clearinghouse at AHRQPubs@ahrq.hhs.gov or call (800) 358-9295.
from the CDC
The CDC’s March Vital Signs report dives into the issue of health care-acquired infections and antibiotic resistance. It provides data on the incidence and scope of the problem as well as recommendation for improvement.
Read more on the CDC website.
Health IT Safe Practices
Toolkit for the Safe Use of Copy and Paste
The Partnership for Health IT Patient Safety recently released this toolkit, the first in a planned series of evidence-based recommendations designed to improve health IT safety.