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Member Spotlight: Paul Epner

Posted By Administration, Tuesday, May 10, 2016

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

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

by Joanna Carmona


Paul Epner is a Lifetime Member of ASPPS

Paul Epner, MBA, MEd, Co-Founder and Executive Vice President for the Society to Improve Diagnosis in Medicine, Chair of the Coalition to Improve Diagnosis, Immediate Past President for the Clinical Laboratory Management Association


Why patient safety?

“I was diagnosed with Crohn’s Disease at 16. I was subsequently hospitalized many times as an adult with some significant adverse events, giving me the drive to get involved with the patient engagement and safety movement. Coincidentally, I worked for 31 years in the Diagnostics Division of Abbott Laboratories working in the US, Japan, and China. When I left Abbott, it was to focus on issues of patient safety and quality of care, especially from a clinical laboratory focus as I believe the current narrow emphasis on in-lab costs totally misses the economic and patient benefits of a more care-centric clinical laboratory. That led me to diagnostic error, which led me to the Society to Improve Diagnosis of Medicine, and that led me to the National Patient Safety Foundation. It’s been a journey and I'm still on it.”


Why did you join the ASPPS?

“My activities following my retirement from Abbott reflect a shift from making a profit to making a difference. I saw what was happening at the ASPPS, I went through the programming, heard the patients’ stories, and I said, ‘This is great! I have to invest in this. This is an investment in me, it's an investment in healthcare, and it's worth doing.’”


"This is an investment in me,
it's an investment in healthcare,
and it's worth doing

—Paul Epner

In your opinion, what’s the future of the patient safety movement?

“This movement is critical to strengthening the quality and cost of care. I believe we have made great progress, but that people do recognize we're not there yet, and so the journey is still moving forward. I feel pretty good that with every step forward we will be saving lives and improving the experience for patients.”


Could you tell us about your work with diagnostic error at the Coalition to Improve Diagnosis?

“The Society to Improve Diagnosis in Medicine (SIDM) catalyzed the NAS report on Improving Diagnosis, but we recognized that we were too small to maximize the impact of this important work, so we convened the Coalition to Improve Diagnosis in order to partner with like-minded organizations in making diagnosis more accurate, safe, reliable, and efficient. It’s very exciting that the Coalition has grown to 23 major organizations. In addition to the individual actions each organization has committed to implement, we will work collectively to move some major initiatives that are still in the planning stage.”


What’s something unique or interesting about you?

“I have been fortunate to inherit many great things from my parents, but with them came a long list of chronic health conditions. In order to combat them, I took up running in my mid-forties and am hoping to run a marathon this year. It won’t be my first. In fact, for my 50th birthday, I ran a 50-mile ultramarathon, but it’s been more than 10 years since my last marathon, so I am really looking forward to the training challenge.”

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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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Celebrate National Nurses Week: May 6-12

Posted By Administration, Friday, May 6, 2016

A Culture of Safety? It Starts with You

by Joanna Carmona

Rachel Whittaker, BSN, RN, CPN, will receive
the NPSF-DAISY Award for Extraordinary Nurses
at the 2016 NPSF Patient Safety Congress.


Friday kicks off a week-long celebration of nurses nationwide sponsored by the American Nurses Association (ANA). The 2016 theme is “Culture of safety—It starts with you,” and the National Patient Safety Foundation (NPSF) would like to recognize the numerous ways nurses make a difference in the lives of patients and more specifically how they keep them safe from harm.


Like the ANA, NPSF recognizes the importance of creating a culture of safety. National Nurses Week is a great opportunity to acknowledge the many ways nurses contribute to safety culture.


Nurses Taking Initiative

“Nurses spend more time with patients than any other providers of care,” said Martha Cangany, a medical-surgical clinical nurse specialist at Franciscan St. Francis Health hospital in Indianapolis in a recent article. This is why nurse-led safety initiatives can be a powerful boost to patient care.


One example of nurses taking charge of the safety of patients occurred recently within seven Pennsylvania-area hospitals. While participating in the American Association of Critical-Care Nurses (AACN) training program, a group of nurses instituted a number of changes that led to the reduction of the average length of hospital stays for patients. Some of their initiatives included working on patient mobility and making improvements in team communication. These initiatives are vital steps forward in the movement to make medical care safer for everyone.

Top of the Ranks

Americans reported that they trust nurses more than any other profession, according to data from a 2015 Gallup poll. This isn’t a new finding as nurses have been ranked number one for the past 14 years.


Patients who are in the hospital or other care facility for a procedure, surgery, or accident, often are not there by choice. When they have a nurse who cares for them and brings a bit of positivity to the experience, it can make a difference in their care and recovery.


“Nurses are vital to creating and sustaining cultures of safety and ensuring safety of patients, families, and the workforce,” said Patricia McGaffigan, RN, MS, senior vice president and chief operating officer, NPSF. “And while nurses in any role are equally important to advancing safety, a large percent of nurses are serving in roles as patient safety officers, and managers, and an increasing number of nurses hold the Certified Professional in Patient Safety credential.”


Award-Winning RNs

The National Patient Safety Foundation plans to honor one exceptional nurse and one team of nurses in May at the NPSF Patient Safety Congress in Arizona. The honorees will receive the NPSF-DAISY Award, and we are excited to recognize the extraordinary work of these winners.


Read more about the 2016 honorees and the DAISY Award for Extraordinary Nurses.

NPSF and Nurses

“Nurses are leaders in advancing patient safety across the world and have been essential to the NPSF mission. They contribute regularly to the direction of our organization through participation on our boards, as members, and faculty for our webcasts and annual Congress,” said Tejal K. Gandhi, MD, MPH, CPPS, president and CEO of NPSF.


Nurses, we thank you!

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What are your plans for National Nurses Week? 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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Medication Barcode Optimization

Posted By Administration, Monday, May 2, 2016

Is it ever okay to override the barcode on a medication? That’s one of the questions that will be addressed
during Breakout Session 304 at the NPSF Patient Safety Congress.

by Patricia McTiernan, MS

Joe Melucci, MBA, RPh, will share
lessons learned about barcoding
at the 2016 NPSF Patient Safety Congress.


According to the Agency for Health Care Research and Quality’s PSNet, about 5% of hospitalized patients experience a medication error, and the rate may be even higher for patients treated in ambulatory settings. The use of barcodes on medications, mandated by the Food and Drug Administration back in 2004, has led to widespread adoption of barcode technology in hospitals, with studies showing broad reductions in medication errors.


Joe Melucci, MBA, RPh, medication safety officer at Ohio State University Wexner Medical Center (OSUWMC) and an alumnus of the AHA-NPSF Patient Safety Leadership Fellowship (class 12), points out that the literature shows that workarounds to barcode workflows are still too common in inpatient settings. For example, a nurse may scan the medication after, rather than before, administering it. Or the nurse may print a duplicate wrist band if it is perceived to be more practical to scan an ID band that is not attached to the patient’s wrist.


“In some cases, the nurse may not realize the importance of barcoding as a safety measure,” says Mr. Melucci. “They may only consider it as a way of documenting what they have done.”


At OSUWMC, the team wanted to bring this technology to Emergency Departments, ambulatory infusion centers, and outpatient clinics. They addressed the challenges in inpatient care, eventually raising scanning compliance to their goal of 97%, or 97 of every 100 doses being scanned. That target allows for necessary exceptions, such as emergencies where taking the time to scan would compromise the care.


They recognized that different settings would present unique challenges. “The workflows are different, the pace is different. In procedural areas, they have to totally change the workflow to have orders in the system prior to the procedure to be able to have something to check the medication scan against,” says Mr. Melucci.


“Still other challenges are presented by dialysis units, because dialysate solution is considered a medical device, not a medication, and therefore does not exist in the pharmacy database. “We have to create medication records to allow nurses to scan those, because they can still make mistakes with grabbing the wrong concentration or the wrong formulation of solution,” says Mr. Melucci.


In psychiatric settings, patients can harm themselves with wrist bands, or the wrist band may become a distraction to the patient, interfering with their treatment.That’s where the question arose of whether it is ever okay to administer medication when a wrist band is not attached to the patient. “In the literature it is a no-no, because there is no evidence it is effective,” says Mr. Melucci, even though an organized method of scanning was created for this purpose.


One of the chief lessons learned in implementing barcode technology and sustaining compliance, says Mr. Melucci, is the importance of being transparent and consistent in the information provided to nurses and managers. It’s also important to know when to make an exception to the rule.


“Outpatient areas simply do not administer the same volume of medications as do inpatient areas,” he adds. “Making the investment in the technology and training reflects a deliberate decision to set the same standard of care for outpatient and inpatient settings.”

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Representatives of Ohio State University Wexner Medical Center and Hospital Sisters Health System will present lessons learned and challenge attendees to think about exceptions to bar code scanning during a joint Breakout Session at the NPSF Patient Safety Congress. Find out more about the Congress agenda at


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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  medication 

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When a Shadow Brings Light

Posted By Administration, Thursday, April 28, 2016

Patient and family shadowing can be an easy and low-cost way to get started on improving patient experience of care,
and subsequently, patient safety.

by Patricia McTiernan, MS

Michelle Bulger
Michelle Bulger will discuss patient
and family shadowing at the
NPSF Patient Safety Congress.


Patients’ experience of care is increasingly thought to contribute to safety and health outcomes. A recent paper summarized 55 studies of patient experience, concluding in part that “patient experience is consistently positively associated with patient safety and clinical effectiveness across a wide range of disease areas, study designs, settings, population groups and outcome measures.”


Health care organizations committed to improving the patient experience of care may choose from a number of tools to help assess opportunities for improvement, including patient surveys and Patient and Family Advisory Committees.


Another tactic is patient and family shadowing. Unlike other methods of assessing experience, shadowing gives a picture of a patient’s experience in the moment, while it’s happening. “You’re seeing things from the end-user point of view, and in real-time, which is something that we really have not done in health care,” says Michelle Bulger, a trainer at the Patient and Family Centered Care (PFCC) Innovation Center of University of Pittsburgh Medical Center (UPMC).


Shadowing was developed under the guidance of Anthony M. DiGioia III, MD, a practicing orthopaedic surgeon and the medical director of the Bone and Joint Center at Magee Womens Hospital of UPMC. Dr. DiGioia is medical director and founder of the PFCC Innovation Center of UPMC and creator of the 6-step PFCC Methodology and Practice (PFCC M/P™), a process that, Bulger says, can help “take you from your current state of any care experience to a more ideal state of care. Shadowing comes to us from Step 3 of the PFCC Methodology – Evaluate the Current State – and it enables care givers to view care through the eyes of the patient and family.”

As Ms. Bulger explains, the patient and family are the only common denominator in the health care process, and they experience everything from inpatient care, outpatient care, and rehabilitation to making appointments, dealing with insurance, and more. By shadowing patients and families, care providers get a truer sense of the experience and how it can be improved, and can sometimes begin to effect improvements on the spot.


“We define caregiver as anyone in a care setting who directly or indirectly touches the patient and family experience,” says Ms. Bulger. “So, it’s not just the traditional care givers like doctors, nurses, and therapists; all of us are supporting the experience, whether we work in dietary, security, parking, facilities or elsewhere.”


Ms. Bulger emphasizes that shadowing is flexible in that different members of the care team can shadow the patient and family through different steps in their care. “It’s not necessary to tax any one shadower or any one patient, as long as you cover the entire care experience,” she says.


Ms. Bulger emphasizes that shadowing can also be an effective way to enhance patient safety, by revealing gaps or opportunities to reduce risk that are not easy to spot or appreciate from a care provider’s usual role. One example is of a patient still groggy from surgery trying to get out of bed. The person shadowing that patient was not only able to act in the moment to prevent a fall, but the protocol in that unit now calls for a companion to remain with the patient until they are cleared to get out of bed.


When caregivers shadow patients and families, they are acting on a one-to one basis, which generates empathy, which in turn drives an urgency to spark to change when they see something that could be improved. “What we find is that shadowing really re-engages the caregivers,” says Ms. Bulger “The connections made and perspective gained through shadowing reminds them of why they chose to be a care giver in the first place.

Ultimately, shadowing can be a driving force in the co-design of care, getting patient and family members’ direct input on how to improve processes for a better experience, and potentially better outcomes.


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Michelle Bulger will be speaking on the topic of shadowing and training attendees on techniques during Breakout Session 103 at the 18th Annual NPSF Patient Safety Congress. Get details about the full Congress program  at


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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  patient experience 

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Teamwork Grows Up

Posted By Administration, Tuesday, April 26, 2016

True teams work together and share what they know and what they learn to achieve safety.

by Lorri Zipperer, MA


At the NPSF Patient Safety Congress,
the Lucian Leape Institute will present
a Keynote Session, Teaming at
the Heart of Safety. The presenation
and panel discussion will be led by
Prof. Amy Edmondson.

“Teamwork -- Teamwork -- that’s what counts!”


I was a cheerleader in junior high school. While it was fun at the time, that was enough of that.


Uninspired to take the same path in high school, I participated in both live theater and a variety of musical group activities (pep band, marching band, jazz band, symphonic band) that provided me with the chance to work with others toward shared goals. I thought I understood what teamwork was – until I grew up.


My first introduction to teamwork as a component of safety was as a staff member at the National Patient Safety Foundation. It was then that I was presented with the idea that teamwork was much more complicated than staying in line during marching practice. Granted, to be in a marching squad you had to commit to knowing your role, pay attention to what others were doing, achieve some level of reliable proficiency, give up your personal preferences as warranted for the greater good (is standing on a wind-swept football field in January in Chicago what any teenager wants to do?) and be aware that if you failed, the group could do poorly.


But, despite some similarities, teams and their role in safety go beyond that. In the safety sense of the word, teams rely on communication, mindfulness, and culture to enable their processes to be as highly reliable as possible during times of crisis. The focus on the flattening of hierarchy to encourage and support performance that is sensitive to, while capitalizing on, the humanness of people working together contributes to the reliability of collective action that expands beyond band practice in the 1970s. Trust and understanding create an environment that facilitates individual, group, and organizational learning from failures through a team’s commitment to feedback and open discussion.


It is no news to readers of this blog that team training models have been adopted from other high-risk industries to help health care evolve in the right direction. Commercial aviation and the military are the obvious examples. Given health care’s experiences with crew resource management and the Agency for Healthcare Research and Quality’s TeamSTEPPS initiative, the idea of building teamwork skills and the expectation that clinicians develop professional competencies in this area serves the logical foundation to infusing team practice and improvement into the frontline of care delivery. People are taught to do this well because poor teamwork can be catastrophic.

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Explicit attention to the team roles of health care executives came later. And patient safety leaders—as they have done in other instances—looked outside health care for successful models. The business world certainly has had C-suite members that walk-the-talk of teamness. With credibility and integrity, those who model team behaviors and enable a culture at their company that support teamness provide examples to emulate its value. They demonstrate for health care executives the importance of purposely training and engaging a wide range of staff as team members.


Business schools and executive books champion teamwork skills as a foundational competency. The language and ideas of how to recognize and practice those skills from the business literature always resonated with me, a non-clinician. From that field, one author of particular interest is Harvard Professor Amy Edmondson. Edmondson’s writings caught my eye early on in my safety career. Her discussions about how organizational, unit, and peer culture and leadership affect staff willingness to report errors was inspiring to seeat a time when the value of that approach wasn’t as universally accepted as it is now (Edmondson 1996).


I distinctly remember working hard to get copies of her early articles (read pre-World Wide Web as we know it today). I still have the hard copies of those reports. Once a librarian, always a librarian.


Professor Edmondson’s publishing output since then covers a range of topics that touch on patient safety. Her articles on organizational and individual learning from failure are core resources in my readings list (Edmondson 2008, 2011). They provide foundation to my belief that knowledge management is a key driver of that learning. Edmondson’s 2012 Teaming is an excellent resource for considering how a culture of sharing what is known amongst people working closely together on a collective goalno matter what box on the organizational chart represents themis imperative to both team success and continuous learning (Edmondson 2012). She emphasizes that process, commitment, and leadershipboth informal and at the executive level—must be present to translate learning into sustainable change in iterative constant fashion.


The sustained commitment to a culture of teams and teaming at variety of levels across a health care system can make that happen. True teams work together and share what they know and what they learn to achieve safety. Training and facilitating all health care workersoutside of rank and roleto participate in the cross-functional activity of teaming is vital to safety achievement. It offers health care yet another opportunity for synergy that presents clinicians, the organizations they work for and the patients they care forwith a chance to really make teamwork count.

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Find out more about the Keynote Session on teaming and the complete program for the NPSF Patient Safety Congress at Comment on this post below. Note: to post a comment you must be logged in. Register or log in.

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Edmondson AC. 1996. Learning from mistakes is easier said than done: group and organizational influences on the detection and correction of human error. J Appl Behav Sci. 32:5-28.


Edmondson AC. 2008. The competitive imperative of learning. Harv Bus Rev. 86:60-67, 160.


Edmondson AC. 2011. Strategies of learning from failure. Harv Bus Rev. 89(4):48-55, 137.


Edmondson AC, Schein EH. 2012. Teaming: How Organizations Learn, Innovate, and Compete in the Knowledge Economy. San Franscisco, CA: Jossey-Bass.

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  teaming 

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