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Surveillance Monitoring for All

Posted By Administration, Tuesday, May 9, 2017

Breakout session at the upcoming NPSF Patient Safety Congress details an initiative to institute continuous surveillance monitoring on a large scale.

by Patricia McTiernan, MS

The Joint Commission’s 2012 Sentinel Event Alert #49 on the safe use of opioids in hospitals came as a wake-up call to many clinicians and leaders. Although opioids can be largely safe for many patients, the alert warned of dangerous potential side effects, particularly respiratory depression.

Just a few months after the release of that alert, an event related to respiratory depression and opioid analgesics resulted in a patient’s death at Wake Forest Baptist Medical Center in Winston-Salem, NC. A root cause analysis was conducted, and one of the recommended actions was to use surveillance monitoring of patients receiving opioids. That led to a major initiative resulting in widespread use of surveillance monitoring in multiple facilities.

Kristina Foard RN, MSNEd, SCRN, Nurse Practice Specialist, joined the effort to identify the best system for Wake Forest and assist with the implementation. She and Dr. Robert Weller, physician champion for the surveillance monitoring deployment and response to SE#49 at Wake Forest, were asked to evaluate some of the available bedside monitoring systems that would allow for surveillance monitoring.


Historically, medical/surgical nurses have relied on spot-checking their patients by collecting and recording vital signs every 4 to 8 hours. Of the opioid-related sentinel events reported to TJC between 2004 and 2011, 29% were related to improper monitoring of the patient. As early as 2011, the Anesthesia Patient Safety Foundation was calling for continuous electronic monitoring of oxygenation and ventilation in patients on opioids.

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Once the Wake Forest team had evaluated the options, they began a 20-week pilot program on a neurosurgery unit. Because they wanted to capture as much data as they could during the pilot, they decided that any bedded patient on that unit would be placed on continuous monitoring. At the end of the pilot period, they evaluated the data with the nursing staff and with patient and family input. When they presented the results to their leadership team, the decision was made to deploy surveillance monitoring broadly throughout their institution.
Karen Luse, MSN, Robert Weller, MD, and
Kristina Foard, RN, MSNEd, SCRN, of Wake
Forest Baptist Medical Center. Ms. Luse and
Ms. Foard will present a Breakout Session at the
upcoming NPSF Patient Safety Congress
about their organization's experience
instituting continuous monitoring


“One important lesson we learned by monitoring everyone is that risk stratification is extremely difficult,” said Ms. Foard. “We like to look at comorbidities and whether patients are opioid naïve or opioid tolerant, if they are obese or have Obstructive Sleep Apnea (OSA), because things like that put them at higher risk for opioid induced respiratory depression. But, in fact, many of the interventions triggered by continuous monitoring were not necessarily opioid-related. We also identified cardiovascular events including tachy- or bradydysrhythmias and hypo- or hypertension that we may have failed to identify if we hadn’t been doing surveillance monitoring on all patients.

“We elected then to apply surveillance monitoring as our standard of care. If you got bedded on a unit that had the monitoring, you were placed on monitoring and the provider had to write an order to remove you,” she added.

Some providers have asked for development of risk stratification that would allow for selective rather than surveillance monitoring of all patients, and this continues to be a barrier to overcome, Ms. Foard said. Both physicians and nurses commonly suggest that “young” and “healthy” patients did not need continuous monitoring, but an effective risk score to apply selective monitoring is not yet available.

Another challenge was alarm fatigue. The system cannot do the kind of critical thinking that nurses do, for example, so the team had to take care in setting wide enough parameters that would minimize non-actionable alarms without missing true deterioration events. These parameters were tested and optimized relative to alarm frequency. Ms. Foard and Dr. Weller also collaborated with their Rapid Response team to develop a flow chart to help the nursing staff manage and respond to alerts.

Ms. Foard and her co-presenter will discuss the technical challenges as well as the cultural challenges involved in such an initiative.

“Leadership support and buy-in from managers of the unit is an absolute must,” she said. “Without manager support, you’re not going to get the buy-in from the bedside nurses. Even beyond that, having the executive support for that cultural shift, especially a shift that impacts providers and nursing staff, is critical.”

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Kristina Foard and her co-presenter, Karen Luse, MSN, will talk about this initiative in Breakout Session 304: Surveillance Monitoring on General Care Floors, at the 19th Annual NPSF Patient Safety Congress. See details of the full Congress program.


Comment on this post below. Note: to post a comment you must be logged in. Register or log in.

Patricia McTiernan is editor of the P.S. Blog. Contact her at

Tags:  2017 Patient Safety Congress  opioids  respiratory depression 

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Patient Complaints and Post-Operative Complications

Posted By Administration, Thursday, April 20, 2017
Updated: Thursday, April 20, 2017

Do rude and disrespectful behaviors have an effect on patient safety? 

by Gerald B. Hickson, MD


Patients and their families are critical members of the health care team and are uniquely positioned to observe the behaviors of clinical team members. Organizations who listen will find that patients’ stories can be sources of valuable information that can promote improvements in care. 

"Study results remind me how important it is

to engage patients and families in our efforts

to promote safe care."

—Gerald B. Hickson, MD


Fifteen years ago, our Vanderbilt research team recognized that if patients’ unsolicited complaints were documented, coded, and aggregated, they reliably identified a small subset of physicians (2-8% by specialty) who accounted for more than 75% of malpractice claims and costs. Our early studies, however, did not answer an important question: Is high claims risk simply about making patients and families unhappy or is there something more?


In a study published in JAMA Surgery, we asked if patients who received care from surgeons associated with high numbers of complaints about perceptions of disrespect were more likely to experience complications from surgery than patients who were seen by surgeons who attracted few, if any, complaints.


We used data from the American College of Surgeon’s National Surgical Quality Improvement Program (NSQIP®) and our Vanderbilt Patient Advocacy Reporting System (PARS®), which uses unsolicited patient complaints to identify physicians with a high risk for malpractice claims. The study design allowed us to look at a surgeon’s complaints for 24 months prior to the target surgery and any postoperative complications in the 30 days post procedure. Seven medical centers that participate in both PARS® and NSQIP® contributed 817 surgeons and more than 32,000 surgical procedures to the study.


The analysis revealed that patients whose surgeons were associated with the highest numbers of complaints had almost 14% more postoperative complications when compared with patients seeing surgeons viewed as respectful, even when the analysis controlled for patient, surgeon, and operative characteristics. If extrapolated throughout the US (27,000,000 surgeries annually), failures to model respect and communicate effectively contribute to more than 350,000 additional surgical site infections, cases of sepsis, and urinary tract infections, representing more the $3 billion in additional costs with no way to calculate the magnitude of the impact on patients and families.


Study results remind me how important it is to engage patients and families in our efforts to promote safe care. Patients experience our dysfunctional systems and unprofessional clinicians. The question is, when they are willing to share, are we willing to listen, learn, and respond? Patients do not always describe their observations in "proper" medical language and as a result are too often discounted or ignored. Our results make it clear, however, that what is experienced and reported is valuable and serves to identify surgeons who have difficulty working with others contributing to surgical complications and excess malpractice claims risk. We suspect that our research team will identify similar findings in ICUs, emergency rooms, cath labs and wherever medicine is practiced.


Results also answer the question that our team has pondered for 20 years: Is high claims risk just about the random bad outcome and routinely making patients and families unhappy? The answer is no. It is not "just" about modeling disrespect toward patients. The same behaviors reported by families are also experienced by medical team members who can become distracted, lose situational awareness and willingness to speak up or ask for help when needed contributing to thousands of avoidable surgical and medical complications each year.


The good news is that our experiences in supporting interventions, with more than 1800 high-risk clinicians from our national partnerships, has taught us that most physicians modeling patterns of disrespectful behaviors (approximately 75%) just need to be made aware that they stand out (see Pichert et al. 2013). However, setting the stage to deliver “awareness” is critical and requires leadership that does not blink (rationalize) when the disrespectful surgeon is perceived to have special value. It also requires leadership that will commit to building the infrastructure to support professionals who are willing to deliver peer-based comparison data to help their at-risk colleagues pause and reflect on how their behaviors are experienced by others. The work is not for the faint of heart but is professional and aligns with the NPSF commitment to creating a world where patients and those who care for them are free from harm.


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Have you witnessed disrespectful behavior that you think contributes to the quality of care? Comment on this post below. Note: to post a comment you must be logged in. Register or log in.


Gerald B. Hickson, MD, is senior vice president for quality, safety and risk prevention and Joseph C. Ross chair for medical education and administration at Vanderbilt University Medical Center and a long-serving member of the NPSF Board of Directors. 

Tags:  disrespect  patient reporting  research 

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Member Spotlight: Frank Khan

Posted By Joanna Carmona, Tuesday, April 11, 2017

The American Society of Professionals in Patient Safety (ASPPS) is a membership program for professionals

and others interested in patient safety. This is part of a series of member profiles. 

by Joanna Carmona 

Adrian White

Frank Khan is a member of ASPPS


Frank Khan, MBA, CPPS, CPHQ, HACP, LSSGB, patient safety manager, Palo Alto Medical Foundation (A Sutter Health Affiliate) 

What are the biggest challenges you face as a patient safety manager at Palo Alto Medical Foundation?


“One of the biggest challenges I face is the fact that I am a not a clinician. While it is not a requirement for my job, it has presented some challenges in terms of understanding various clinical processes and terminology. However, in an effort to mitigate this, I have developed strong partnerships with various providers and leaders so that we can work together in developing effective and collaborative solutions for patient safety. Without the help of the physicians, nurses, pharmacists, medical assistants, and others, I wouldn’t know where to even begin in terms of defining and developing meaningful measures for patient safety at PAMF. It’s been a wonderful partnership, and I hope to continue this legacy as I transition into my new role as a patient safety consultant for Sutter Health.”


Tell us why you became a member of ASPPS?


“I joined ASPPS in hopes of connecting with other nonclinical professionals like myself. It’s extremely important for me to connect with others who share my passion for patient safety. I feel that the more people I can connect with and learn from, the more effective I will become at leading change. I have dreams of becoming a national leader in patient safety, and I believe that I can achieve this goal through the learnings and networking opportunities afforded to me as a member of ASPPS.”  


What made you interested in the patient safety field?


“Believe it or not, I actually fell into the patient safety profession. I worked at Stanford University Medical Center in the field of Neuropsychology for 11 years, but then I decided to try something completely different and pursue an MBA. Shortly after graduating, a former business school classmate of mine reached out to me regarding a potential opportunity at her hospital. After speaking with her and the director of clinical quality improvement, interviewing, and learning more about the job, I realized that it was an opportunity that I just couldn’t pass up.  The job was for a patient safety officer role at Doctors Medical Center in Modesto, Cal. I absolutely loved it, and it was through this first experience as a PSO that I found my niche in health care. And the rest, as they say, is history.”  


In your opinion, what is the future of the patient safety field?


“There are a number things that I anticipate will happen in the future:


“One, I believe that as the patient safety field continues to grow, more people will be engaged in this work, particularly with frontline staff. They have the greatest perspectives and the best ideas, but sometimes their voices aren’t heard enough. As leaders in patient safety, we must continue to support a culture that encourages their engagement. Because in the end, their engagement will translate into providing safer care to our patients.


“Two, I also think that from a consumer standpoint, patient safety will become increasingly important.  Now that there is more research in this area, and that patients are utilizing social media to share their experiences, the general public will demand safer and more reliable care.


“Lastly, I believe more nonclinical leaders will join the patient safety movement. It’s such a rewarding and exciting profession to be in, which are elements that many professionals want out of their career. What can be intimidating, however, is the clinical aspects as I mentioned earlier. But through strong partnerships and dedication, I know that it can be done. I’d like to think that I’m living proof of that.”   



MOE is Palo Alto Medical     Foundation's

patient safety mascot


What keeps you up at night?


“The most worrisome to me also happens to be the most motivating. The fact that medical errors remain one of the leading causes of death in the United States is mind-boggling to me. Even in this age of technology, we are still prone to error when it comes to patient safety. To me this suggests that perhaps technology isn’t always the answer, and that there are still creative, yet simple solutions that are waiting to be discovered.


“I love exploring ideas with interdisciplinary groups, and figuring out simple solutions that we can try and test today. For example, as a fun and inspirational way to engage employees with our patient safety efforts, we created a patient safety mascot exclusively for use at the Palo Alto Medical Foundation. We then built on the idea of using the mascot to engage staff by holding a “name the patient safety mascot” contest, where the winner earned a lunch for his or her department and a feature in the monthly newsletter.


“The winning entry was MOE, which stands for “Mindful of Environment.” MOE has become quite the celebrity, making cameo appearances in promotional videos and publications, as well as branding for patient safety awards and acknowledgments. One of our leaders even had MOE made as a plush toy that she keeps in her office for everyone to enjoy. MOE’s presence has truly enhanced engagement, and lends well to the culture of safety at Palo Alto Medical Foundation.”  


What is something unique about you?


“I am a retired professional salsa dancer. I used to perform, compete, and teach with a dance team in the Bay Area. While I don’t dance anymore, I stay connected with the team as they remain as some of my closest friends.”  


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Comment on this post below. Note: to post a comment you must be logged in. Register or log in.

Joanna Carmona is communications coordinator at the National Patient Safety Foundation. Contact her at





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Stand Up Standout: Improving Communication, Engaging Patients

Posted By Administration, Wednesday, April 5, 2017
Updated: Wednesday, April 5, 2017

Stand Up Stand Out is an occasional feature on the blog highlighting the work of organizations that belong
to the NPSF Stand Up for Patient Safety program. In this post, read how one New York City health center
is making strides to overcome low health literacy.

by Patricia McTiernan, MS


The National Patient Safety Foundation has long advocated for patients and family members to be regarded as integral members of the health care team. When patients are actively engaged, they can help improve patient safety and experience better outcomes.


Yet getting patients engaged in their care is more challenging than it might appear. Barriers to engagement are still common at many levels of the health care system, with a 2014 report from the NPSF Lucian Leape Institute citing low health literacy as one of the chief barriers.


Health literacy has been defined as “the degree to which an individual has the capacity to obtain, communicate, process, and understand basic health information and services to make appropriate health decisions.”

The most commonly cited data suggest that only 12% of English-speaking adults in the U.S. are at a proficient level of health literacy. That means many of us struggle to comprehend care plans, medication regimens, and follow-up instructions.


To ensure that patients are able to understand important health care information, it is critical that providers recognize the nature of patients’ health literacy challenges and implement strategies to promote clear health communication. Ask Me 3, a program of NPSF, is designed to improve the lines of communication among patients, families, and health care professionals. The program encourages patients to ask the following three specific questions of their health care providers to better understand their health conditions and what they need to do to stay healthy.  The program encourages health care providers to use this framework to be prepared to answer the questions.


The Ask Me 3 program is one of the
tools being used at NYC Health +
Hospitals/Cumberland to improve
communication between patients and
health care providers.

1.     What is my main problem?

2.     What do I need to do?

3.     Why is it important for me to do this?

Through the use of these questions, Ask Me 3 empowers patients to become more involved in their health care, organize the provider-patient conversation, focus discussion on the answers to key questions, and help patients acquire the information they need to take care of their health. 


Staying Focused in Brooklyn

NYC Health + Hospitals/Cumberland, a Gotham Health Center, in Brooklyn, NY, is one of many health care organizations that have implemented the Ask Me 3 program to address health literacy. As part of NYC Health + Hospitals, the largest public health care system in the country, Cumberland has more than 57,670 patient visits every year from all walks of life and cultural backgrounds. Marlene Dacken, RN, patient safety officer, points out that “empowering patients to be active members of the patient/provider relationship and ensuring that communication is clear are essential components of patient safety.”

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The hospitals under the auspices of NYC Health + Hospitals have been long-time members of the NPSF Stand Up for Patient Safety program. As part of a larger effort to engage patients in their care, Cumberland introduced the Ask Me 3 program in adult primary care clinics, specialty care departments, and pediatrics.


Overall, approximately one-third of patients at Cumberland have used the program, according to Cynthia Boakye, MD, medical director. “For adult medicine, we try to give it to every patient,” she says. “Those who choose to use it fill out the form and organize their thoughts before they see the provider.”


Before rolling out the program, the Cumberland team ensured that all staff members were on board by providing training on health literacy and the program. The program has become a part of the culture of care at Cumberland with ongoing training of staff and all new hires.


A nurse or nursing assistant explains the program to the patients and provides them the questions on a form. Physicians refer to the form during the visit and are able to correlate the information they want to tell the patient to the patient’s questions.


“Staff members believe that the program really helps the patient get focused on what they want to ask the physician during the encounter,” says Ms. Dacken. “This helps outline their process to keep focused on what their concerns are.


“I started to use it myself, because even as a nurse, sometimes you do forget or you lose focus,” she adds. “As a patient, the communication is often physician-directed, the provider asking all the questions, but there are questions not on the health provider’s radar that may be on the minds of patients.”


The team has also developed a program called Take the Pledge, Take Your Meds, to improve medication adherence, another common issue in outpatient care.


Results of these efforts are so far anecdotal, with patients and staff both reporting positive feedback. “The patients think that it’s a good idea,” said Dr. Boakye. “It helps them focus on what they have to ask the physician and keeps everything in alignment so they are not diverted.”


NPSF offers complimentary Ask Me 3 materials and resources to organizations interested in implementing the program. Posters and fliers in English and Spanish are provided, along with an implementation guide and other materials. In addition, a new educational module is now available to help educate clinicians and staff regarding health literacy and the Ask Me 3 program.


Some 2,000 individuals have downloaded the materials in the past year, and the Ask Me 3 program continues to be one of the most frequently visited areas of the NPSF website.


“We are very pleased with the growing interest and use of this program over the past few years,” said Patricia McGaffigan, RN, MS, senior vice president for program strategy and management and chief operating officer of NPSF. “We see it as a very useful addition to other tools organizations may be using with both patients and health care professionals to better engage and communicate with their patients.”


To learn more and download complimentary materials, please visit


Ask Me 3 is a registered trademark licensed to the National Patient Safety Foundation.

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What steps does your organization take to improve communication between patients and health care providers? Comment on this post below. Note: to post a comment you must be logged in. Register or log in.

Patricia McTiernan is editor of the P.S. Blog. Contact her at

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Tags:  ask me 3  health literacy  Stand Up for Patient Safety 

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Three Organizational Strategies to Reduce Burnout and Build Engagement in Health Care

Posted By Administration, Thursday, March 16, 2017

Leaders should focus on both organizational and individual factors that contribute to burnout.

by Paula Davis Laack, JD, MAPP


It is a challenging time to be working in health care. There are new care delivery models being developed, declining reimbursements due to price competition and narrowing of insurance networks, and medical practices are consolidating. Meanwhile, use of electronic health record technology has dramatically increased the clerical burden for providers, and staffing is increasingly difficult with national shortages of physicians and nurses in certain specialties. Furthermore, there is constant pressure for health care organizations to implement new quality metrics and requirements for public reporting, along with the ever-present competition to maintain high patient satisfaction scores. (See Shanfelt and Noseworthy 2017.)

Burnout contributes to decreased well-being,
lower retention rates, higher staff turnover,
low morale, and a lack of cohesiveness in the
organization as a whole. 

Successfully navigating these challenges requires engaged and resilient leaders and providers who are able to effectively handle both the business aspects and the stress associated with this level of change. Burnout is a key factor impacting the engagement of health care providers across specialty areas:

  • Approximately 54% of doctors are burned out to some degree, which is an increase from 33-40% of doctors reporting such symptoms just a few years ago.
  • Half of critical care nurses report feeling emotionally exhausted, 60% have difficulty sleeping, and 20% are clinically depressed.
  • Burnout rates for physician assistants, administrative staff, and medical technicians are at 62%, 36.1% and 31.9%, respectively.

There is a strong business case for reducing burnout and increasing engagement in health care. Burnout contributes to decreased well-being, lower retention rates, higher staff turnover, low morale, and a lack of cohesiveness in the organization as a whole. Physician burnout has been shown to influence patient care, patient satisfaction and patient safety, and burnout is positively correlated with a physician self-reporting suboptimal care.


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One study showed that even just a one-point increase in the exhaustion and cynicism components of burnout resulted in a respective 5% and 11% increase in likelihood of reporting an error. Conversely, hospitals in which burnout was reduced by just 30% had a total of 6,239 fewer infections for an annual cost savings of up to $68 million.

Leaders should focus on both organizational and individual factors, with a recent meta-analysis suggesting that the benefits derived from individual programs would get a boost by also adopting organizational-directed approaches. Three organizational-directed approaches that have been shown to build engagement and reduce burnout are as follows:


Build More Job Resources

Job resources are the motivational aspects of a person’s job that energize. Leaders should focus in these five areas:

  1. Increase autonomy
  2. Foster high-quality connections with colleagues
  3. Create opportunities for excellence (people want to be both challenged and part of something meaningful)
  4. Offer FAST feedback that is frequent, accurate, specific, and timely
  5. Maximize leader support

Minimize Job Demands

Job demands are the aspects of your work that take sustained effort and energy. Not all job demands are created equal, and research points to three specific ones to be minimized because they accelerate burnout and kill engagement:

  1. Role conflict (“I have received conflicting requests from two or more people”)
  2. Role ambiguity (“My duties and work objectives are unclear to me”)
  3. Organizational constraints/unfairness (“I had to go through many hassles to get projects/assignments done”)

Foster Personal Resources

An important personal resource for leaders and their constituents to develop is resilience. Resilience can be taught, and it is built through a set of core competencies that enable mental toughness and mental strength, optimal performance, strong leadership, and tenacity (resilient people give up less frequently when they experience setbacks).


Given the strong connection to patient safety, patient care, and patient satisfaction, it makes good business sense for health care organizations to implement strategies to reduce burnout and build engagement. The time to take action is now.

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Do you know of an organization that is taking steps to reduce burnout among health care professionals? Comment on this post below. Note: to post a comment you must be logged in. Register or log in.


Paula Davis Laack, JD, MAPP, is a lawyer turned stress and resilience expert who works with healthcare organizations and individuals to implement strategies that reduce burnout and build stress resilience. You can connect with Paula at

Tags:  burnout 

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