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The Patient's Voice in Action

Posted By Administration, Friday, October 28, 2016

If you are involved in patient safety, you’ve probably heard your share of bad news.
This is a good news story.

by Patricia McTiernan, MS

Marian Hoy attended the 2016 NPSF
Congress on a patient scholarship and
"the lightbulbs just went off.”


In January of 2014, Marian Hoy, then 66 years old, became ill with what she thought might be the flu. “I felt bad for three days,” she recalls. “There were red flags that it wasn’t just the flu, but I didn’t recognize them.”

A former Dallas police officer and police trainer, Ms. Hoy lives in a small town outside of Austin, Texas. Her illness led her to become so disoriented that she called the town’s chief of police and asked him to bring her a soft drink. “I know the police chief,” she says, “but I never would have called him for that had I not been suffering confusion.”


When she realized the trouble she was in, she called the EMTs and was taken in the middle of the night to the hospital that she chose, Seton Southwest, part of Ascension Healthcare. Doctors there discovered that scar tissue from a long-ago surgery had surrounded Ms. Hoy’s small intestine and stopped her system. She underwent surgery to repair the problem, and in the days afterward she experienced complications that included sepsis and pneumonia.

“Everything was going south” for a time, she recalls now. “I would say to the doctor, ‘am I in danger?’ because I couldn’t say the words, ‘am I going to die?’ And he would say, ‘No, Ms. Hoy, you are not in danger.’


“In other words," she says, "he thoughtfully used my own words, so as not to frighten me.”


If you’ve read this far you are probably thinking, “Wasn’t this supposed to be a good news story?” Indeed, Marian Hoy spent three weeks in the hospital, and she recovered very well. But that’s not the only good news. When she tells her story, it’s all about her experience of care.

“They treated me like I was the only patient they had,” she says. “They gave me very individual care. When I called for a nurse, they were there in minutes. My doctors, surgeons, internseverybody knew my labs over the 24-hour period, but they came to my bedside to talk to me to see if I could put together a declarative sentence and understand their questions, something I was unable to do when I was admitted. And they spoke to me with language I could understand.”


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Patient Experience Matters

Patient experience of care has been defined as “the sum of all interactions, shaped by an organization’s culture, that influence patient perceptions across the continuum of care.” A 2013 study found “patient experience is positively associated with clinical effectiveness and patient safety,” and supports the use of patient experience as a measure of quality.

Ms. Hoy’s experience puts a face to that research. Grateful for the care she had received, she wrote a letter of thanks. She was subsequently recruited to join Ascension’s system-wide Patient and Family Engagement Steering Committee. Through her work with Ascension, Ms. Hoy became aware of the NPSF Patient Safety Congress and was awarded a patient scholarship to attend the 2016 meeting.


“When I went to Arizona for the NPSF Congress, I had no idea what to expect,” she says now. “I was extremely naïve about safety in hospitals. I don’t know that a lot of patients understand the gravity of patient safety issues. The lightbulbs just went off.”

As a former law enforcement officer, Ms. Hoy was particularly interested in issues discussed during a breakout session on workplace violence in health care, which is on the rise. “Until we include an in-depth discussion of how today’s violence can and does impact the hospital setting, I don’t think we’ve completed the conversation on safety,” she says.

Today, Ms. Hoy serves on three patient advisory boards within the Ascension system. She is intent on sharing her experience because, “they saved my life, and there is no way one can repay that debt.”

She wants people to know about it. But she is also adamant about urging others to speak up and bring an advocate with them if they can when they visit the doctor or hospital.

“Participate in your own illness, ask questions,” she says. “If your doctor doesn’t want to answer questions, find another doctor. This a conversation about your health.”

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Do your health care practitioners make it easy for you to be engaged in your care? Comment on this post below. Note: to post a comment you must be logged in. Register or log in.

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

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Tags:  2016 NPSF Congress  patient advocate  Voice of the Patient 

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Getting the Lowdown on Opioids

Posted By Administration, Friday, October 7, 2016
Updated: Friday, October 7, 2016

The nation’s opioid crisis was a hot topic at the 2016 NPSF Patient Safety Congress.

by Patricia McTiernan, MS


A recent survey conducted by the National Patient Safety Foundation showed gaps in health professionals’ knowledge regarding use of opioid painkillers. Only two-thirds of respondents were familiar with the Joint Commission Sentinel Event Alert on the Safe Use of Opioids in Hospitals, for example, and only 14% were familiar with the National Action Plan for Adverse Drug Event Prevention.


It may come as no surprise, then, that one of the most well-attended breakout sessions at the NPSF Patient Safety Congress in May focused on “DEA Drug Trends.” Thomas Prevoznik, liaison unit chief for the U.S. Drug Enforcement Administration, addressed some of the current questions health professionals have about what they can do to mitigate unintended harm from opioids.


According to the Centers for Disease Control and Prevention, opioid prescription painkillers led to more than 19,000 overdose deaths in 2014. Moreover, the DEA reports that 8 out of 10 new heroin users began by abusing prescription painkillers.


At the NPSF Congress, attendees were most interested in learning about proper disposal of unused or unwanted pharmaceuticals and how the DEA and health care professionals can work together to combat the opioid epidemic to ensure public health and safety.


The DEA is in the process of conducting Pharmacy Diversion Awareness Conferences at the state level to educate health professionals about tactics they can use to minimize unintended outcomes. These events include speakers from the state’s pharmacy board, the police, the Department of Health and Human Services, and the DEA.


  Thomas Prevoznik

Thomas Prevoznik speaking at the 2016  

NPSF Patient Safety Congress

Mr. Prevoznik says the events offer an opportunity to provide practical tactics to pharmacists and clinicians, for example:


  • Asking patients if they have a place to keep the prescription opioid painkillers under lock and key.
  • Asking clinicians to be more aware of the opioid epidemic and more conscious of the unintended effects of overprescribing.

Disposing of unused medications is another effort under way. Twice each year, the DEA, in collaboration with state and local law enforcement, sponsors National Prescription Drug Take-Back Day, an opportunity for people to clean out their medicine cabinets and safely dispose of unused medication. The last event was held in late April of this year, yielding almost 900,000 pounds of drugs—the highest amount collected since these events began in 2010.


“People are getting the message that they don’t need to save that just-in-case bottle,” Mr. Prevoznik says. “It’s better to get rid of it.”


The next Prescription Drug Take-Back Day is scheduled for October 22. Get details at


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About the Author: 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



Tags:  2016 NPSF Congress  opioids 

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Stand Up Standout: Fairview Health Services

Posted By Administration, Tuesday, August 23, 2016
Updated: Wednesday, August 24, 2016

The Stand Up for Patient Safety Program is an organizational membership program that supports patient safety initiatives.

This is part of a series of member profiles.  

by Joanna Carmona 

Susan Noaker (middle left) and Pat Schlagel (middle right) 

of Fairview Health Services accepting the Stand Up for Patient Safety Award

at the 2016 NPSF Patient Safety Congress in Scottsdale, Arizona.


Fairview Health Services and their collective commitment to a culture of excellence in their hospitals is what stood out to the National Patient Safety Foundation when awarding this year’s Stand Up for Patient Safety Management Award. This award is given each year in recognition of the successful implementation of an outstanding patient safety initiative that was led by, or created by, mid-level management.


Fairview Health Services, consisting of six hospitals within Minnesota, aimed to prevent errors in specimen management to make care safer for their patients. Fairview identified specimen mismanagement as a “never event” and thus started the complex process of reducing the risk of mishandling.  


According to the Agency for Healthcare Research and Quality (AHRQ), mislabeling errors are one of the most common preanalytic errors in laboratories. Many initiatives were put in place, including Fairview’s use of specimen label printers which made a big difference in specimen management. As a result of system-wide changes, including standardizing processes of surgical debriefing, handoffs, and labeling, there was a 70% decrease in the risk of specimen mismanagement.


Here’s what Fairview Health Services had to say about this important work.


What were the biggest challenges involved in a project such as this?

Our two biggest challenges were information technology issues, including getting various programs to talk to each other and making our electronic medical record more user-friendly, and standardizing processes. Initially, we assumed our processes varied widely from site to site, but after mapping out processes across our system, we learned we had more in common than we previously thought.


What surprised you about the process, either in regard to the way the project team worked or in regard to something you learned about the processes that you did not already know?

“Learning that labels and specimens were labeled and logged by hand, which is not best practice, reinforced our drive to improve. We knew we could do better for our patients. On the plus side, our team became highly functional very quickly. We used multi-voting techniques to prioritize the work so that all voices were heard, not just those belonging to squeaky wheels.”


You mentioned that patients are often unaware of the life-altering consequences of error in specimen management. How do you explain the importance of specimen management to your friends or family (i.e., someone unfamiliar with this topic) and what it means for their safety? 

“If a specimen—something we obtained from a biopsy—is lost, we may not be able to make a diagnosis in a speedy manner. We may need to repeat the biopsy. Furthermore, some specimens are so unique that they are irreplaceable. A lost specimen of that type may mean losing essential information about the patient’s health. It may not sound all that important, but proper specimen management is utterly essential to helping us drive a healthier future for our patients.”


What are some ways to successfully engage physicians in the problem-solving process?

“We know physicians appreciate seeing data that proves the need for change and demonstrates the likelihood that the change will result in improved patient outcomes. Also, like most employees, physicians want to be asked for their input and know that their contributions are valued and acted upon.”


What are two tips you would offer others undertaking similar projects that might help them succeed? 

“First, system-wide changes require system-wide representation. In addition to the appropriate subject matter experts, you should also include people who provide support services, such as IT, Operations, Communications, and Human Resources. These team members help the group think of broader implications of a proposed change, and can often contribute to coming up with corresponding solutions.


Second, getting people to agree to serve on yet another committee or workgroup can be tough. Show participants you value their time by creating unusual, but effective meetings. Get people up and moving by breaking into small groups spread out across the room. Record ideas on flipcharts and draw process flow maps on white boards. Award small prizes for attending. Improving patient safety is serious work, but by engaging employees and physicians in different ways, we can often come up with better solutions.”


Could you talk in general about lessons learned from this process?

“It’s important to obtain the support of an executive sponsor—someone at the highest levels of leadership. This indicates to everyone involved that the project is a high priority and reinforces the urgency of successfully completing the change. Get IT involved in the project from the start and know who to turn to when you need to escalate concerns. Use a system team of stakeholders that is truly representative of all entities and divisions. Be aware of unintended consequences. When you change one part of a process, there may be unintended negative consequences. Be open to discovering, and correcting this. In fact, embracing a spirit of discovery can make all the difference for improving the health of our patients.”


Responses from Beth Thomas, DO, Fairview interim chief medical officer & Susan Noaker, PhD, LP, Fairview project manager, surgical services 

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Have you worked on a similar improvement project at your organization? 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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Tags:  2016 NPSF Congress  specimen management  Stand Up for Patient Safety 

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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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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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