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It's Patient Safety Awareness Week

Posted By Admin, Sunday, March 8, 2015
Updated: Saturday, March 7, 2015

The National Patient Safety Foundation is proud to lead hospitals and health care organizations around the world in demonstrating their commitment to safer health care during Patient Safety Awareness Week.

This year’s theme is United in Safety, and our focus is on patient and family engagement. We will be emphasizing the importance of the relationship between clinicians and patients and their families. Enhanced communication begins with an informed and engaged patient and helps to lead to safer care.

We hope you will spend part of the week with us. See below for activities and ideas.

Wednesday, March 11, 8:30 pm Eastern Time

Join the Patient Safety Awareness Week Twitter Chat

@theNPSF will be hosting a special one-hour twitter chat to discuss barriers to patient and family engagement and how to overcome them. Use the hashtag #PSAWunited to participate.



Thursday, March 12 | 1:00-2:00 pm ET 

Complimentary Webcast
Patients and Families as Partners: United in Safety

Get the details or register at no charge.


Educational Resources

  • Use our Implementation Checklist for ideas on how to recognize the week with your patients and teams.
  • Download educational materials from NPSF and our partners.
  • Read the NPSF Lucian Leape Institute report Safety Is Personal: Partnering with Patients and Families for the Safest Care or listen to the webcast replay and share it with a colleague
  • Watch and share our Ask Me 3 video with your staff and patients.
    Watch our series of Safety Tips videos.
  • Visit the Patient Safety Awareness Week Facebook Event Page and post your photos, videos, plans, or ideas. 
  • Share our social media posts or create your own messages using the event hashtag #PSAW2015 to let everyone know what you are up to for the week.

The National Patient Safety Foundation gratefully acknowledges the generous support of the Gordon and Betty Moore Foundation for Patient Safety Awareness Week 2015.

The following organizations have generously donated content for Patient Safety Awareness Week 2015: College of American Pathologists; Institute for Patient- and Family-Centered Care; Lown Institute; Maine Patient Safety Academy at the Muskie School of Public Service, University of Southern Maine; Society to Improve Diagnosis in Medicine.


Thanks also to the MHA Keystone Center and The Joint Commission for their support.

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To Improve Patient Safety, Start With Avoiding Unnecessary Treatments

Posted By Administration, Wednesday, March 4, 2015
Updated: Wednesday, March 4, 2015

By Shannon Brownlee, MS

Every year, hundreds of thousands of Americans experience avoidable harm in our nation's hospitals, and estimates suggest that tens of thousands of those people die. Medical errors and unintended harm in the US health care system are driven in part by the breakdown in the relationships that ought to be the foundation of good medicine.

   Shannon Brownlee, MS
Part of the tragedy of harmful medical care is that often treatments that end up causing harm weren't needed in the first place. Unnecessary medical procedures are shockingly common. Unnecessary or ineffective medical treatments, tests, drugs, and days in the hospital account for anywhere from 10 percent to 30 percent of total medical expenditures in the US. Examples range from PSA tests to CT scans, medication for mild blood pressure, and cardiac stents for patients who don’t have symptoms of heart disease. A recent analysis found that in a single year, about 40% of Medicare recipients received at least one from a list of just 26 examples of useless or low-value procedures.

Asking questions can help patients better understand their treatment options. Patients and families can reduce their risk of suffering an error or hospital infection by avoiding unnecessary medical treatment in the first place. Here are five questions to bear in mind when discussing your treatment options with your doctor:
  1. What are all of my options for treatment? For many conditions and illnesses, there can be more than one treatment. Sometimes changing your lifestyle (diet and exercise) can reduce your symptoms or the risk of a bad outcome. Sometimes, not getting treated at all is a reasonable choice. Ask your doctor what all of your options are, and ask for clear explanations you can understand for each.

  2. How exactly might the recommended treatment help me? 
You need to know exactly how you might benefit from a treatment. Even if you think you know, it’s important to ask. A hip replacement, for example, might allow you to walk again with greater ease, but it won’t cure your arthritis. In fact, you may need another replacement in 10 to 20 years. A drug might relieve some of your symptoms and not others. Other treatments have no effect at all on how you feel now and are supposed to help prevent a disease from harming you in the future. Ask how the proposed treatment is supposed to help you.

  3. How good is the evidence that I’ll benefit from the treatment or test?
 Many treatments and tests that doctors prescribe have never been fully tested to see if they work, or have been tested, but not in patients like you. Find out if the treatment or test your doctor is recommending is a proven therapy. If not, your doctor should explain why he or she thinks it’s a good idea for you. 

  4. What side effects can I expect, and what bad outcomes might happen? 
Every test, drug, surgery, and medical procedure has side effects, and some can be serious. Simply being in the hospital exposes you to medical errors and hospital-acquired infections. You need to know the risks so you can decide if the danger or discomfort of your condition is more concerning than the risks of the proposed treatment. If it’s a test, ask how often it’s wrong, and what will happen if it shows you’re sick when you’re really not. If it’s a drug or surgery, ask what all the serious side effects can be, and how often they occur.

  5. If it’s a test, what does your doctor expect to learn from it, and how might it change treatment? 
If a test won’t change the way you’ll be treated, or if you’ve already decided you don’t want the possible treatment, ask why you should be tested.

We salute the National Patient Safety Foundation for promoting Patient Safety Awareness Week. We hope this week helps everyone in the health care system—patients, doctors, nurses, and everyone else—to focus on the critical mission of keeping patients as safe and healthy as possible.

To learn more about unnecessary treatment, and what you can do to protect yourself from it, read Overuse 101 or explore the Lown Institute website at


The Lown Institute hosts the Road to RightCare Conference in San Diego from March 8-11, 2015. For more information, visit, and follow the conversation on Twitter at #Lown2015.


Shannon Brownlee, MS, is senior vice president of the Lown Institute. Ms. Brownlee has been a national leader in highlighting the scope and consequences of overuse in health care. An internationally known writer and essayist, her book, Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer, was named the best economics book of 2007 by New York Times economics correspondent, David Leonhardt. Her articles and essays have appeared in such outlets as The Atlantic, New York Times Magazine, The New Republic, Time Magazine, and The Sunday Times of London, among other publications.


Tags:  overtreatment  undertreatment 

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Stories and Strategies: Addressing Challenges to Disclosure

Posted By Administration, Friday, December 19, 2014

By Lorri Zipperer, MA

With year-end comes the time to get serious again after the craziness of the holidays, to reflect and for some of us, to write. Thinking back on sessions I attended at the NPSF Congress in 2014, a session that has stuck with me was Susan Anderson and Geri Amori’s presentation about disclosure. Entitled “The Art and Science of Disclosure,” I knew it would be interesting. (With a bachelor’s degree in studio art, I find anything with “art” in the title to be interesting.)

I also knew that Ms. Amori has an interesting method of presenting content that melds the science of her topics with a creative and engaging approach to bringing them home to her audience. She staged a successful presentation for NPSF in 2004, when Linda Kenney and Rick van Pelt first presented their experience as a patient and a physician involved in a medical adverse event. The disclosure of that error serves as the foundation for Medically Induced Trauma Support Services (MITSS), which Ms. Kenney founded as a resource to provide support to other patients and health professionals dealing with the consequences of medical error. (Kenney and van Pelt 2005) Ms. Amori has also co-authored a chapter with me on what we can learn from improvisation to inform knowledge sharing in the health care space. (Amori et al. 2014).

Disclosure is a complex issue. Sensitive to the personal and emotional nature of the topic, the presenters touched upon what makes discussions of error with patients and families successful, such as respect, trust, humbleness, responsibility, empathy, accuracy, non-defensiveness and healing. Noting that a successful disclosure may still result in litigation or payout and not necessarily make everyone happy, they turned to the primary focus of their talk — what gets in the way of effective disclosure.

The presentation primarily focused on the challenges to effective disclosure:

  • Admitting that disclosure is appropriate
  • Preparing providers
  • Surprising organizers with unexpected participants
  • Cultural differences
  • Unexpected occurrences at the disclosure
  • Communication challenges
  • Demanding remuneration at the onset
  • Scaring people!
  • Denying the need for the conversation
  • Debriefing ineffectively or inappropriately
  • Assuming the patients and families are happy


The presenters polled the attendees to get a sense of their experience in actually conducting disclosures and then spent extra time on the three barriers that the group saw as most prevalent. In each instance, Ms. Amori introduced the psychological factors that contribute to the problem. To bring a real-world feel to the discussion, Ms. Anderson then shared her experiences at University of Michigan as a member of the team of early adopters there who practice early disclosure and resolution and have noted success on addressing the challenges to disclosure.

  • Admitting that disclosure is appropriate: Stressors to beginning the process center around getting clinicians to recognize that it’s the right thing to do—even if the disclosure concerns a known complication or a near miss. Practical advice: Michigan doesn’t keep disclosure training in a silo, it is built into many training and educational opportunities on various levels throughout the organization like Grand Rounds and residency training. They share disclosure success stories regularly. Their support program is available to all in configurations for both teams and individuals.
  • Preparing providers: Because clinicians care and believe they did the right thing — they think they are ready for anything and don’t need to practice or prepare for the disclosure. In general clinicians can’t take in the enormity of the situation — their own error is a challenge to their belief in their abilities and the high standards to which they hold themselves. They may believe because they care they don’t need to practice the disclosure. Practical advice: Make sure the participants in the disclosure have all the information they need and how the process will unfold. It is essential they are aware of the facts, understand the context of the event and how it transpired. It’s best to avoid surprise reactions at any point in the discussion.
  • Surprising organizers with unexpected participants: Attendees shared their perceptions as to why unexpected people (attorneys, friends, clinicians outside the care circle) arrive for disclosures. Patients feel weak, they don’t trust the proceedings, they are angry. Power is at play in disclosure. Patients and families see health care as having all the power. Surprises give them some leverage. They see power associated with the expectation that money will change hands. Practical advice: A little meeting management can go a long way. Do the best you can to confirm who will be at the meeting and find a private, quiet space that works for that size group. If someone does join you who wasn’t anticipated — don’t overreact.

The session ended with a role-playing exercise that explored how these and other challenges in the session might reveal themselves in an actual situation.

Do you see ways to employ storytelling and role play not only to support learning from error, but to help your staff be comfortable with the process of disclosure? Comment on this post below.

Lorri Zipperer, MA, is the principal at Zipperer Project Management in Albuquerque, NM, specializing in knowledge management efforts and bringing multidisciplinary teams together to envision, design, and implement knowledge sharing initiatives. Among her publications, Ms. Zipperer recently served as editor for two texts, Knowledge Management in Healthcare and Patient Safety: Perspectives on Evidence, Information and Knowledge Transfer, both published earlier this year by Gower Publishing (UK).

Kenney LK, van Pelt RA. 2005. To err is human; the need for trauma support is, too. Patient Safety Qual Healthc. January/February.2:6, 8-9.

Amori G, Chindlund J, Zipperer L. 2014. Strategies for knowledge sharing: lessons from improvisation. In: Zipperer, L. ed. Knowledge Management in Health Care. London, UK. Gower.


Tags:  dislosure  error  families  patients 

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More Than Just a Chapter

Posted By Administration, Friday, November 7, 2014

By Ana Pujols McKee, MD

Every book has that chapter; the one that you remember the most. We know what chapter that will be in the Joint Commission’s Comprehensive Accreditation Manual for Hospitals.


When the manual is released January 1, 2015, you’ll find a new chapter – “Patient Safety Systems.” This is more than just a chapter. It’s a first-of-its-kind resource that brings together our existing standards to provide hospital leaders with a framework for building a comprehensive patient-centered system. 


We felt strongly that the information was important for leaders of all organizations to have. So, in an effort to serve the health care community and underscore our commitment to quality and patient safety, we have made the chapter permanently available on our website to customers and non-customers – the first time we have done so with a chapter.


It’s important to note there are no new standards in this chapter, and the standards that are highlighted will be covered in their respective chapters. The intent is to use these existing standards to inspire and support hospital leaders who are striving for the highest quality and patient care in their organizations.


You might be wondering if this chapter is solely for accredited organizations or something for which one would have to pay extra. No, and no.


The Patient Safety Systems chapter centers around three guiding principles:

  • Aligning existing standards with daily work in order to engage patients and staff throughout the health care system, at all times, on reducing harm.
  • Assisting health care organizations with advancing knowledge, skills, and competence of staff by recommending methods that will improve quality and safety processes.
  • Encouraging and recommending proactive methods and models of quality and patient safety that will increase accountability, trust, and knowledge while reducing the impact of fear and blame. 

By following these principles and highlighting all of the related standards in one chapter, our goal was to provide hospital leaders with a road map for implementing a fully integrated patient safety system. The chapter clearly outlines exactly how staff and leaders can work together to eliminate complacency, promote collective mindfulness, treat each other with respect and compassion, and learn from patient safety events.


While the chapter is in the manual for hospitals, other types of health care settings may benefit by applying the strategies discussed in the chapter to enhance patient safety. After all, all health care organizations should be continually focused on eliminating systems failures and human errors that may cause harm to patients, families, and staff.


You can wait until January to bookmark the chapter, but with something this important, we didn’t want to make you wait. The chapter is available for download right now.  We hope you’ll find this material useful in helping your organization build a foundation for an effective patient safety system.


Ana Pujols McKee, MD, is executive vice president and chief medical officer, The Joint Commission. Contact her via email.  

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Bob Wachter Talks of Hope, Hype, and Harm On Sep 23, 2014

Posted By Administration, Tuesday, September 23, 2014
Updated: Friday, October 24, 2014

Keynote presentation at NPSF Lucian Leape Institute Forum & Gala looks at the digitization of medicine.

By Patricia McTiernan, MS

Anyone who trained as a physician 20 years ago probably recalls spending a lot of time on the hospital medical-surgical units, making notes in patients’ charts after rounds. There was one physical chart for each patient, and it lived at the nurses’ station or outside the patient rooms, where interns, residents, and attending physicians spent time—among nurses and other staff—and where team interactions could occur naturally.

Today, with the widespread use of computers in medicine, records can be read or updated from virtually anywhere. Consequently, the chances of running into a colleague in the hall have largely diminished. According to Bob Wachter, MD, the withering of these social interactions is only one downside of the digitization of medicine. In an enlightening (and entertaining) keynote presentation at the 7th Annual NPSF Lucian Leape Institute Forum & Gala in Boston last week, Dr. Wachter made the case for why health professionals and systems need to take a closer look at implementation of electronic records.

Dr. Wachter, who is a professor of medicine at the University of California, San Francisco, is no technology-fearing Luddite. As he proved by displaying his many electronic gadgets (and a selfie he took with his smart phone), he is a proponent of computers. Author of a popular blog (Wachter’s World) and editor of the AHRQ websites PSNet and WebM&M, which together have a million unique visitors every year, he has led the way in the use of digital technology to promote the spread of information. He has even been an advisor to the digital giant, Google.
“We have to do it,” he said of the digitization of medicine, “but so far we are not getting it right.”

Currently visiting professor at the Harvard School of Public Health, Dr. Wachter has spent much of his time recently writing a book about this subject, which will be published in 2015. Extensive interviews with those in the field, as well as his own experience and research, are fueling the project, which formed the basis of his talk at the Leape Institute Gala.

One of the problems with computers in medicine, he said, is that health professionals have approached digitization as a technical issue when, in reality, it is “the mother of all adaptive problems.” Referencing the work of Dr. Ronald Heifetz, he noted that technical problems often have a relatively clear (though not necessarily easy) solution, whereas adaptive problems require people—the users of the technology—to change behaviors and attitudes.

In a step-by-step recap of a medical error that occurred at his own institution, he illustrated how terribly easy it is for computers to enable human missteps. An initial “catch” by a pharmacist led to a dosing error by the resident who tried to correct it. Subsequent alerts were ignored because of confirmation bias and the simple fact that there are too many alerts. And the nurse who administered the medication – a 39-fold overdose of a common antibiotic – was hampered by a barcode scanning system that informed her she was doing the right thing (which in this case involved a 16-year-old taking a cupful of pills).

Some attendees shook their heads in the how-could-this-happen fashion. Yet the overall sentiment in the room seemed to be one of understanding exactly how it could happen—within the setting of a clunky computer interface, busy hospital unit, amidst pressure to get the work done, and reluctance to “bother” other busy people. The nurse who administered the dose was devastated, but there were at least two other points along the way where the error could have been caught.

Fortunately, after experiencing a grand mal seizure, the patient recovered with no lasting effects. But as this example so clearly demonstrates, the urge to listen to the computer at the risk of turning off our own judgment is all too real.
Do you have a story about hope, hype, or harm and computers in medical care? Comment on this post below.


Patricia McTiernan, MS, is senior director of communications at the National Patient Safety Foundation and editor of the P.S. Blog. Write to her at

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