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Evidence As a Seed for Collaboration: Separating the Wheat from the Chaff

Posted By Administration, Wednesday, July 6, 2016
Updated: Tuesday, July 5, 2016

Organizations should have individuals who monitor published research in order to help their clinicians and executives apply findings to address local gaps.

by Lorri Zipperer, MA


I have been monitoring the patient safety literature for more than two decades now, first as the information project manager at the National Patient Safety Foundation, and for more than a decade as the development editor for AHRQ Patient Safety Network. As those in patient safety might attest and applaud, the evidence base has gotten more robust over the years, spurred by increased funding for research and public interest in the topic.


This expanding wealth of literature creates a challenge for organizations and individual practitioners. The unintended consequence of this explosion is that there is more wheat to sift through. The growing set of materials makes tracking useful evidence more cumbersome while in turn increasing the messiness of translating existing research results into actions that make sense and conclusions that are credible. We know that just because it’s science doesn’t necessarily mean it’s good science. We know that just because it’s published, identified, and shared within an organization, community, or team that evidence derived from science is not necessarily applied or able to be translated for use on the front line.(Zipperer 2016)


While somewhat editorial in nature,
Dr. Shojania’s presentation brought nuance
to seeing how the evidence exploring these areas
can play a part in our understanding of them.

There are tools out there to help with creating awareness of materials, such as AHRQ Patient Safety Net and the NPSF Current Awareness subscription service. However, not only should organizations have individuals trained to monitor these resources, also the search for particular evidence needs to address local gaps in understanding and effectively disseminate the literature to decision makers. Someone in the organization should navigate this output in order to help their clinicians and executives apply it if it is going to enrich the design of interventions and implementation of programs and contribute to enhancing the reliability of their patient safety work.


We could all use someone like Dr. Kaveh Shojania to help translate what is written to help create actionable knowledge in health care.


Dr. Shojania—with whom I work in my role at AHRQ Patient Safety Network, as he is on the editorial team—has for three consecutive NPSF Congresses provided a thoughtful and provocative analysis of key articles and the trends they indicate for conference attendees. This year’s session, entitled “Hot Topics in Patient Safety: Selected Papers Advancing the Field in the Past Year,” did not disappoint. Dr. Shojania covered literature on 6 important topics:

  • Diagnostic errors
  • Rudeness’ impact on team performance
  • Trends in adverse events over time
  • Incident reporting
  • Fall prevention
  • Reducing high-risk prescribing in primary care, with a focus on the current opioid abuse/misuse epidemic in the US

These themes should be no surprise to those in the patient safety community. While somewhat editorial in nature, Dr. Shojania’s presentation brought nuance to seeing how the evidence exploring these areas can play a part in our understanding of them. While some analysis of research design was applied, and the value of results was discussed, Dr. Shojania’s insights should enhance our ability to be more critical of what is published and by whom.


Imagine the opportunity that the sort of dialogue generated by this type of expert assessment could provide in an organization. The exercise could be brought to our care environments as more than a social or intellectually opportunity. If positioned as a patient safety improvement tactic, it could serve a more impactful role.


Dr. Shojania was challenged by an attendee, and his response provided thoughtful seeds for all of us who seek to partner to “plant” evidence-based solutions in the patient safety community garden. Imagine the learning and collaboration that could be generated in organizations if teams had these types of conversations on a regular basis, with accountability assigned to do something with the issues raised. Could the dialogues support increasing the transparency around sharing of ideas, forming of shared mental models, leveling of hierarchy, and engaging of individuals to form multidisciplinary teams to do research to reflect the frontline needs of improvers? Could be.

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What tools, techniques, and team members do you use to identify, analyze, and infuse the most relevant literature to innovate and anchor patient safety efforts throughout your organization? Comment on this post below. Note: to post a comment you must be logged in. Register or log in.


Zipperer L. Jones BB, Esparza JM, Wahr J. Evidence, information, and knowledge as elements of safe surgical care. In: Stahel P, ed. Surgical Patient Safety. New York: McGraw-Hill Education; in press.


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Lorri Zipperer, MA, is the principal at Zipperer Project Management in Albuquerque, NM, specializing in patient safety and knowledge management efforts and bringing multidisciplinary teams together to envision, design, and implement knowledge sharing initiatives. Her latest collaboration was with The Risk Authority Stanford as a co-editor and contributing author of their 2016 publication Inside Looking Up. Contact her at

Tags:  2016 NPSF Congress  patient safety research 

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Member Spotlight: Shelley Castellino

Posted By Administration, Wednesday, June 22, 2016
Updated: Tuesday, June 21, 2016

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 

Shelley Castellino is a member of ASPPS.


Shelley Castellino, BSN, RN, Providence Regional Medical Center, Colby Campus


Tell us why you chose to get into the field of nursing.

I used to ride horses all the time and on one particular day when I was 22, my horse and I had an argument. He jumped and I was thrown 30 feet up into the air. When the ambulance arrived, I was in a coma. I came out of it nine days later, but was completely paralyzed, and so I thought my life was over. In the hospital, the nurses were fabulous and their positivity was so important to my recovery. Because of that, I wanted to be a nurse and facilitate patients' healing.


What brought you to join the ASPPS?

“When I saw what the ASPPS does for patient safety, it really spoke to me. ASPPS allows people to become proactively involved in patient safety. This is necessary as we have a medical system that results in too many medical errors. I feel membership is the first step towards involvement and making a difference for reducing their occurrence. Through patient safety involvement we provide better outcomes for our patients, which, I believe, in turn improves our job satisfaction.”


In your opinion, how do you move forward to promote a culture of safety?

“Awareness promotes safety. Awareness of your own self, of your actions, as well as an awareness of the patient, and their response to care matters. As a nurse, I feel that if the staff doesn’t take care of themselves, along with the support of hospital management, we will not have the where-with-all to take care of our patients. I love being part of a team culture where I can stand up and say, I don’t understand or I need help and receive the assistance that I need so I can support my patients.”


What is an example of something you (or anyone) can do to keep safety standards high?

“Two things:


Listen to the patient. Every body is different. You have to listen because a patient is an expert in his or her own body. If a patient is telling you something is off, perk up your ears and poke around to see if you can find out what the problem may be.


Take care of yourself. If you are well rested and alert, you can be your best possible self and the best possible nurse for your patients.”


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


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Tags:  ASPPS  ASPPS Member Spotlight 

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Advocate, Educate, Communicate: What Patients Need to Know

Posted By Administration, Monday, June 20, 2016
Updated: Monday, June 20, 2016

It is always the obvious that proves challenging and communication between doctor and patient is no exception.

by Betsy M. Cohen, CRC, LRC, CCM, ABDA


In 2012, I left a pile of paperwork on my desk convinced that I would complete it later that afternoon when I returned from my first colonoscopy. It never occurred to me that morning that my colon would be perforated, that my insistence that something had gone wrong during the procedure would be ignored, and that I would require emergency surgery to resect my colon. I did not imagine that I would wake up in an intensive care unit and face a series of complications and mistakes that would change my body and life forever.



I did not imagine that I would
wake up in an intensive care unit
and face a series of complications
and mistakesthat would change
my body and life forever.  


If you or a loved has one experienced a medical accident or an unexpected outcome from a medical procedure or hospitalization, perhaps this sort of nightmare sounds familiar. You know the surreal feeling of losing control of your health, of being engaged in battle to regain your physical and mental equilibrium while desperately attempting to find your way back to some semblance of a quality life. 


I have worked in and around health care for 30 years, but was unable to prevent three medical errors resulting from a routine procedure. Ultimately, I survived and created a new way to flourish by actively taking control of my well-being. During my recovery, I wrote a book to help others navigate their health crises and reclaim their lives.


Here are the most important tips that I offer to anyone endeavoring to overcome medical challenges.


1. Advocate. One of the most difficult things to do when you are lying vulnerable in a hospital bed is to feel powerful, able, and strong. Each of us needs an advocate regardless of our physical condition or well being. Solicit a family member, friend, or case manager at the hospital to listen with you to your doctor’s recommendations and advocate on your behalf.


Be certain that everyone involved in your care knows your wishes about pain medication, additional tests and procedures, as well as what kind of heroic measures you sanction as a component of your care. If you have allergies especially to medications, review these with each new provider involved in your care.


Never assume that each doctor or nurse has thoroughly read your chart or is aware of your medical history. Health care providers are human and mistakes occur. Speak up to prevent additional complications whenever feasible.


2. Be Open. You may have a speedy and complete recovery after a medical accident or, like me, your body may only experience a partial restoration of function. Become an open-minded and educated consumer of medical and health services by inquiring about all of your treatment options.

Discuss any interest you have in exploring complementary, alternative medicine, and rehabilitation therapies with your doctors. Complementary and rehabilitation treatment providers tend to focus on function and prevention with the goal of maximizing your physical, emotional, spiritual, and behavioral health. Treatments such as acupuncture; cranial sacral therapy,; occupational, physical, and speech therapy; biofeedback; and mindfulness training are but a few of the possible adjunct services that you may find helpful, with regard to pain management, improved sleep, and learning to regain your capacity to manage your day-to-day responsibilities irrespective of whatever illnesses or chronic conditions may continue to persist.


3. Communicate. It is always the obvious that proves challenging and communication between doctor and patient is no exception. When you experience a medical crisis, your health care team will often be focused on the technical aspects of what transpired and what they need to do to stabilize your health.  None of that changes your need or right to know what is happening to your body, what efforts are being made to rectify the medical issues that exist, and your treatment team’s thoughts about your prognosis. Trusting your providers is important, but blind trust benefits neither patient nor doctor.

Be certain to speak up and talk to your doctors about concerns that you have related to your health or healing. No matter how invested anyone is in your care, you are the only person who will eventually go home and live with your body, as well as the impact that these medical events will have on your health. If your medical team is not communicating the information that you need to hear, don’t be afraid to initiate that conversation to assure yourself that everyone is committed to your best possible recovery outcome.

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Betsy M. Cohen is a Certified and Licensed Rehabilitation Counselor, a Certified Case Manager, and an American Board Certified Senior Disability Analyst specializing in the treatment of individuals who are affected by neurological and neuropsychiatric conditions and chronic illnesses. She is the author of Illness To Wellness: Reclaiming Your Life After A Medical Crisis. Ms. Cohen is also a member of the American Society of Professionals in Patient Safety (ASPPS) at NPSF.

Tags:  patient advocate  patient story  Voice of the Patient 

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June Is National Safety Month

Posted By Administration, Friday, June 10, 2016
Updated: Friday, June 10, 2016

Patients and families can play a critical role in preventing medical errors and helping to reduce the risk of medical harm. For National Safety Month, we focus on a few key actions.

by Joanna Carmona


Mark your calendars—and with good reason this time. In a world of National Chocolate Macaroon Day and Put a Pillow in Your Fridge Day, National Safety Month is something worth talking about.


The National Patient Safety Foundation (NPSF) this month, and every month, aims to empower patients to ask the critical medical questions that can make a difference in their care. The National Patient Safety Foundation's stance is that while patients and families can play a critical role in preventing medical errors and reducing harm, the responsibility for safe care lies primarily with the leaders of health care organizations and clinicians and staff who deliver care.


Even with the onus on health care practitioners to make care safe, here’s how you can take charge of your own safety:


1. Ask questions about the risks and benefits of recommendations until you understand the answers.

“The best advice I can give is to be your own advocate. Question, question, question until things are explained in a way you understand. A health care system that doesn't address your concerns is a risky one,” said Peter Pronovost, MD, PhD, director of Adult Critical-Care Medicine and a patient-safety researcher at the Johns Hopkins University School of Medicine in Baltimore in a recent article. If you aren’t sure what questions to ask, check out our Ask Me 3 program.



2. Don’t go alone to the hospital or to doctor visits.


Bring a sibling, spouse, friend, or neighbor— anyone you trust to be your ally.


According to a 2011 article in the American Family Physician journal, an advocate can:

  • Speak up for the patient who may not be expressing all of their medical concerns.
  • Help to keep track and remember all instructions.  
  • Provide emotional support, even if they don’t interact directly with medical staff.

3. Always know why and how you take your medications, and their names.

In a 2015 study published in the Journal of the American Medical Association (JAMA), researchers found that from 1999 to 2012, the percentage of adults taking five or more prescription drugs doubled from 8% to 15%.


With prescription medications on the rise and with patients juggling multiple prescriptions, a two-way conversation around drug safety is needed.


Here’s what you should ask, according to a 2014 article from the Agency for Healthcare Research and Quality (AHRQ):


  • What is the medicine for?
  • How am I supposed to take it and for how long?
  • What side effects are likely? What do I do if they occur?
  • Is this medicine safe to take with other medicines or dietary supplements I am taking?
  • What food, drink, or activities should I avoid while taking this medicine?

4. Be sure you understand the plan of action for your care plan.

“Limited health literacy is a hidden epidemic. It can affect health status, health outcomes, health care use, and health costs,” according to 2008 article in The Permanente Journal. Oftentimes, medical information and terminology is complex, so if you don’t understand something, don’t hesitate to ask.


5. Say back to your clinicians in your own words what you think they have told you.

By practicing this step on a regular basis, it may help you remember the instructions after you leave and helps clinicians know if you’ve understood. For example, “Just so I understand, I need to take X medication, X times per day, for the next X days?”


6. Arrange to get any recommended lab tests done before a visit.

The advantage of getting lab tests completed before seeing a doctor is that the results can be discussed during the visit, instead of during a follow-up or having the results explained over the phone.


7. Determine who is in charge of your care.

Many health care settings are moving toward team-based care. If admitted into a teaching hospital, for example, you may find that multiple clinicians are involved in your care. There may be interns, a hospitalist, nurses, and doctors taking care of you at any given time. You can ask: “Who is the key person in charge of my care?”


For more information on patient safety for patients and families, visit our website.


Looking for more patient resources? 

  • Download this report of the Informed Patient Institute, done in conjunction with Consumer Reports, which evaluates what type of information is available to consumers on medical board websites nationwide. 

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


Tags:  Ask Me 3  national patient safety foundation  national safety month  patient and consumer  patient safety 

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When Behavior Undermines Safety

Posted By Administration, Thursday, May 12, 2016

A Breakout Session at the NPSF Patient Safety Congress will detail a systematic method for
addressing colleague reports of unprofessional behavior.

by Patricia McTiernan, MS



Safety protocols are only effective if people follow them. Take hand hygiene, for example. While effective hand hygiene can reduce the spread of certain infections, the Centers for Disease Control and Prevention reports that, on average, health care professionals practice hand hygiene less than half the time that they should.


The difference between an inadvertent slip and an intentional disregard for a safety practice has been discussed before. So what is a health care worker to do if he or she sees a colleague behave in a way that undermines safety?


The Center for Patient and Professional Advocacy (CPPA) at Vanderbilt University Medical Center recently published results of a robust program to address colleague reports of unprofessional behavior. Lynn Webb, PhD, assistant dean for faculty development and lead author of the recent paper documenting the program, will be one of the speakers discussing this work at the NPSF Patient Safety Congress in Scottsdale later this month.


A Nonpunitive System of Change

  "It’s really important to emphasize
that this is not a punitive process."
—Lynn Webb, PhD

The Vanderbilt CPPA team already had experience with patient reports of unprofessional behavior. The Vanderbilt Patient Advocacy Reporting System (PARS) is a method of collecting and aggregating patient complaints of physician behavior. According to Dr. Webb, PARS data have shown that 5% of physicians and advanced practice professionals (APPs) are associated with 35-40% of patient complaints about their medical professionals. The PARS method for graduated interventions has been adapted and put into place at more than 140 hospitals and medical groups nationwide.


Now, the principles behind the PARS program have been utilized to develop the Co-worker Observation Reporting SystemSM (CORS).


“The CORS program was established to provide systematic feedback to professionals associated with reports from co-workers about what appeared to be unsafe or disrespectful behavior,” Dr. Webb says. The system involves a method of capturing, reviewing, coding, and tracking data. Peer “messengers” are trained to share reports with professionals associated with the reports. The time between when a report is received by the system and the peer discussion is usually less than one week.


Dr. Webb emphasizes that the system is designed to address behavior that seems inconsistent with the Vanderbilt “Credo,” a statement of values shared by professionals and staff. “It’s important to share reports as soon as possible, giving professionals an opportunity to reflect on the issues raised in them,” says Dr. Webb.


In analyzing reports over a 3-year period, the CPPA team found that 3% of professionals were associated with 45% of reports. After the CORS intervention process was implemented, 70% of identified professionals have not been associated with another report.


At Vanderbilt, CPPA also compared physicians identified in the CORS program with those identified in the PARS process. “We found little overlap of professionals having high numbers of patient complaints and those having a pattern of coworker concerns,” says Dr. Webb.


The Vanderbilt CPPA team has compiled a “project bundle” for use by other organizations considering the implementation of such a system. The bundle includes elements of the program that organizations should have in place to help ensure successful implementation. These include strong leadership commitment, program champions, and policies that address expectations for professional conduct. Co-presenter Roger Dmochowski, MD, Vanderbilt’s executive medical director for quality, safety, and risk prevention, believes that success of the CORS program at Vanderbilt was linked to the early involvement of physician and nursing leaders in the development phase.


“It’s really important to emphasize that this is not a punitive process,” Dr. Webb says. “By having a colleague share an observation with another colleague, the intent is to be restorative and change unsafe or disrespectful behavior.”

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Lynn Webb, PhD, and Roger Dmochowski, MD, will present details of the CORS program in Breakout Session 202 at the NPSF Patient Safety Congress. Find out more about the Congress agenda at


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

Patricia McTiernan, MS is assistant vice president for communications at the National Patient Safety Foundation and editor of the P.S. Blog. Contact her at

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Tags:  2016 NPSF Congress  culture 

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