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General Patient Safety Discussion
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NPSF has merged with IHI 0 P. McTiernan It's official: the National Patient Safety Foundation merged with the Institute for Healthcare Improvement (IHI) effective May 1, 2017. Read more about the merger at    
by P. McTiernan
Monday, June 26, 2017
Risk/quality/patient safety structure 0 K. Johnson What role (risk management, attorney/legal, patient safety, quality, other, etc.) in your hospital/health system is assigned to the following general responsibilities: Review of patient safety events in your reporting system to assign proper follow up actions Identification of significant patient safety events including the initial investigation of the event Root cause (or other cause analysis methodology) of appropriate patient safety events Overall analysis and reporting of patient safety event data Serving as patient safety officer Education on patient safety culture or prevention of harm strategies Proactive risk assessment such as FMEA, facility tracers or walk-throughs Claim and litigation management Management of patient grievances Management of workplace violence events Management of abuse/neglect allegations How many FTEs are assigned to each of the roles you listed above? Tell us about the size of your hospital or health system you are providing information for: Is there anything else about your structure that would be helpful for us to consider?
by K. Johnson
Wednesday, September 19, 2018
Strategy and process innovation for hand hygiene compliance 0 R. Govindarajan Strategy and process innovation to achieve hand hygiene compliance by Dr. Rajaram Govindarajan, M.D., Ph.D.    Hospital Acquired Infections (HAI) caused by Multi-Drug Resistant Organisms (MDROs), which are mostly spread through the contaminated hands of healthcare employees, are on the rise worldwide. The great majority of the literature offers convincing evidence that improved hand hygiene practices lead to a reduction of HAIs.  Since 1980 organizations have tried to promote hand hygiene practices through awareness training, without any significant sustained improvement on compliance levels. Decades-long historic compliance level of <50% world-wide is the proof that things won´t get any better with current strategy. From the operations management experience in other type of production systems, the compliance of any critical Standard Operating Procedure (SOP), for example, the use of flight take-off checklist by pilots, is never left so optional and voluntary as it is done with hand hygiene in healthcare. Whenever there is a serious consequence for non-compliance, there are always control mechanisms to detect and warn non-complying individuals so that they slowly create the culture of compliance.   In my opinion, healthcare organizations have not put in place an effective control mechanism to detect individual non-compliance levels for subsequent follow-up to form the right, hand-hygiene habit. In the absence of such systems, employees cannot be blamed. It is a systemic problem, so it needs a systemic solution.  I have designed and patented an intelligent dispenser (please see the 14 seconds video) to achieve this change in strategy. This innovative solution, with a return of investment of 4 months, will help hospitals monitor individual compliance-levels. The govisystem* consists of a number of intelligent dispensers placed at different points of use. When a user places his/her hand in a dispenser to obtain gel (like you can see in the video), the middle finger is guided to a finger-print reader while almost instantaneously releasing the gel into his/her palm. The system records in real time the hand hygiene moments of all employees: who, when and at which dispenser.  All systemic issues are eliminated through its LAVAGE formula: L-Location of geolocated dispensers at different points of use; A-Availability levels of gel in all dispensers are monitored in real time on the computer screen of the person responsible for replenishment; V-Validity of the gel is ensured through quality control;  A-Amount of gel released  to each user is personalized as finger print is correlated to hand size; G-Guidance to employees is made available through protocols; E- Evaluations of individual compliance and follow up are made until habits are formed.   Biography Rajaram Govindarajan has undergraduate degrees both in Engineering and Medicine. He received Ph.D. in Engineering from Iowa State University and M.D. in Medicine from Universitat Autònoma de Barcelona. He is a Professor at the Department of Operations Management, Innovation and Data Sciences at ESADE Business School and a senior healthcare management consultant.    *No commercial interest statement More information at  GovisystemTM is a not-for-profit social-initiative deigned to save lives by significantly increasing hand hygiene compliance in healthcare, food and pharmaceutical industries. 
by R. Govindarajan
Thursday, August 23, 2018
Billing Adjustments / Quality of Care 0 C. Bow   We are currently reviewing our process for patient billing when a potential quality of care concern  exists.   How do you manage billing adjustments in those situations?     What information can you offer as to the management of that process?
by C. Bow
Tuesday, July 24, 2018
IV Iron Infusion Question for Inpatient units 0 R. Zastrow Hello all! I am wondering whether any acute care hospital folks out there have created expanded monitoring guidelines for IV iron infusions, specifically Feraheme, which has a black box warning. Infusion centers, including ours, tend to have pretty well defined guidelines, but not our inpatient side. The black box warning on Feraheme is: Observe for signs or symptoms of hypersensitivity reactions during and for at least 30 minutes following ferumoxytol infusion including monitoring of blood pressure and pulse during and after ferumoxytol administration. The INS references the need for "close observation" for 30 minutes but does not define it. Anyone defining/ managing this proactively?
by R. Zastrow
Tuesday, June 26, 2018
Legal vs Preferred Name 0 D. Baka Hi all-I am wondering if anyone has had discussions or is able to provide best practice around using a patients legal name vs Preferred name in patient identification. We are starting to have this discussion as we are having more and more patients that are transgender or identify different then birth sex. To help improve pt. satisfaction we are working on using the preferred name and having it display in different areas of the EHR but that brings into question using the preferred or legal name when doing patient identification. I would appreciate any insight or experience or thoughts you may have.
by D. Baka
Thursday, May 17, 2018
New book on Suicide Prevention 0 B. Ward Hello, My name is Brian Ward, I'm an editor with HCPro.    I'm working on a new guide on suicide prevention and ligature risks in hospitals. It’ll have updated best practices, checklists, tools, the new CMS ligature requirements, and case studies.   Before I can get it approved by my bosses, I need to get feedback on what people think of the idea. Specifically:  Is there an interest in suicide prevention in hospitals? Is ligature/self-harm prevention an area where healthcare orgs need help? What should such a book include? Would anyone here be willing to let me know if they think?   I don’t need much in way of responses, a few sentences would do. I'd greatly appreciate any feedback you'd be willing to give. And if you do respond, please leave me your name!   Thanks!  Brian
by B. Ward
Monday, April 23, 2018
Plans vs Reality 1 W. Hyman We often talk about what should happen, what usually happens and what did happen when researching safety concerns. IHI's model for improvement and the Spread articles should help control for this type of issue. If the form was evaluated post-implementation (using IHIs Model) and audits performed on the use of the form to include staff feedback that should help ensure appropriate use and adoption of the form. This sounds like a checklist that included everything....The Checklist Manifesto by Atul Gawande covers checklists quite well and suggests, "Checklists can either be DO-CONFIRM or READ-DO and must be kept between 5-9 items."Hope that helps
Thursday, April 19, 2018
RCA - Calling in to the meeting 4 D. Strong Appreciate everyone's input. Not sure it has made a difference, allowing leaders to call-in, but it does complicate the process. As others have pointed out to be successful one needs to provide the documents up front and if there is a way to display those documents it is helpful for those who remote in to the RCA. Thanks again for the input!
by D. Strong
Thursday, April 19, 2018
Hospital Acquired Pressure Injuries-Present on Admission 0 C. Bow A recent discussion with our Pressure Injury management team brought this question forward. Do you consider pressure injuries to be Hospital Acquired if they are not documented on admission or do you have a time frame of 24 Hours to document on a PI before it becomes Hospital Acquired? How is this handled in other organizations?
by C. Bow
Tuesday, February 20, 2018
Timely removal: Ureteral stents and/or IVC filters 0 D. Dorman Greetings,    My name is Daniel Dorman. I am a graduate student at the Marcella Niehoff School of Nursing at Loyola University, Chicago, Illinois.   I am working on a project focused on timely removal of ureteral stents and inferior vena cava filters. I am specifically interested in learning about processes that organizations have implemented to track patients with a temporary device over time.    Thank you,    Dan Dorman             
by D. Dorman
Sunday, February 18, 2018
Patient Safety Awareness Week 2018 - Activities and Ideas Sharing 1 N. Universal Login Hi,  IHI/NPSF is still formulating plans for Patient Safety Awareness Week 2018, March 11-17, and we will be posting some ideas on the United for Patient Safety website soon (http://www.unitedforpatientsafety) but if you are interested in seeing what some organizations did last year, you can view some activity here 
by P. McTiernan
Wednesday, January 17, 2018
Implications of Promising to Do Better 0 W. Hyman I have been intrigued by the Patient Safety Movement Foundations (not to be confused with NPSF) accumulation of hospitals promising to let fewer people die unnecessarily, and giving specific numbers of patients that will be saved. Isn't this a direct admission of not only having allowed patients to die unnecessary, but that you know exactly how many such deaths there were? And if you know how many does that mean you know exactly who they were? Is there a list of such patients? Do the patient's families know their family member is on that list? What is the disclosure rate of unnecessary (preventable) deaths? How do you handle the idea of past and future preventable deaths?
by W. Hyman
Tuesday, January 16, 2018
Deadline Extended: Submit Speaker Proposals by October 23 0 P. McTiernan Have you been involved in a successful patient safety initiative in your organization? Submit a speaker proposal by October 23 and you may be invited to share your work at the 20th IHI/NPSF Patient Safety Congress, May 23-25, 2018, in Boston.   Visit the website for details and download the abstract form outline to help plan your abstract before submission,
by P. McTiernan
Friday, October 13, 2017
Moving Beyond Safety I to Safety II 0 P. McTiernan Moving Beyond Safety-I to Safety-II to Transform Patient Safety IHI/NPSF Professional Learning Series Webcast Traditional patient safety efforts have been designed and implemented under the premise that our systems are well understood, well designed, and predictable. Therefore, when things go wrong, individuals are usually identified as the cause and focus for developing actions to prevent future error and harm. Unfortunately, the vast majority of preventable health care errors are due to systems issues that are often overlooked. This "new view" of addressing and improving safety is captured by the term "Safety-II." This presentation will provide a practical model for thinking about systems, define Safety-I and –II, and explore the relationship between Safety-I and –II, with suggestions for applications by safety teams. What You'll Learn At the conclusion of this program, participants will be able to: Describe the need to understand and address systems issues that contribute to preventable health care harm Differentiate between the concepts of Safety-I and Safety-II Apply the concepts of Safety-I and Safety-II to their safety strategy in their individual organizations Register or learn more.
by P. McTiernan
Thursday, October 12, 2017
ISMP Launches First High-Alert Medication Safety Self Assessment 0 P. McTiernan The Institute for Safe Medication Practices (ISMP) has introduced a new tool to help hospitals, long-term care facilities, and certain outpatient facilities evaluate their best practices related to high-alert medications, identify opportunities for improvement, and track their experiences over time. The ISMP Medication Safety Self Assessment® for High-Alert Medications focuses on general high-alert medications and 11 specific medication categories--including opioids, insulin, neuromuscular blocking agents, chemotherapy, and moderate and minimal sedation.   Participants who submit assessment findings to ISMP anonymously via a secure internet portal will be able to obtain their weighted scores so they can compare themselves to demographically similar organizations. Participation also can help organizations meet requirements for managing high-alert medications from regulatory and accrediting agencies, such as the Centers for Medicare & Medicaid Services and The Joint Commission.   To access the self assessment workbook, go to:
by P. McTiernan
Wednesday, October 4, 2017
Call for Speakers: 2018 IHI/NPSF Patient Safety Congress 2 P. McTiernan Hi, the link has been fixed! Thanks for letting us know. You can also copy and paste this into your browser, Proposals are being accepted through 10/16/17.
by P. McTiernan
Wednesday, October 4, 2017
Public Opinion Survey on Medical Error and Patient Safety 0 P. McTiernan The vast majority of Americans are having positive experiences with the health care system, but 21 percent of adults report having personally experienced a medical error, according to a new national survey released today by the IHI/NPSF Lucian Leape Institute and NORC at the University of Chicago. The survey further finds that, when errors do occur, they often have lasting impact on the patient’s physical health, emotional health, financial well-being, or family relationships. The nationwide survey of more than 2,500 adults was conducted by NORC from May 12–June 26, 2017. The survey expands on a 1997 survey conducted by the National Patient Safety Foundation (NPSF), which merged with the Institute for Healthcare Improvement (IHI) earlier this year.   Read the press release and download the survey report or fact sheets,   Read a related article from FierceHealthcare,
by P. McTiernan
Thursday, September 28, 2017
Kaiser Permanente Fellowships for Young Physicians 0 P. McTiernan The Kaiser Permanente Northern California Patient Safety Fellowship is a one-year program offered by the Regional Graduate Medical Education Office and Regional Quality and Safety Leadership, and may be located at any number of our KP medical centers. The purpose of the Interprofessional Fellowship Program in Patient Safety is to provide post-residency trained physicians an in-depth education in patient safety practice, leadership and research. Up to two positions are offered each year.   The program is currently seeking candidates for the 2018-2019 year. Learn more at
by P. McTiernan
Wednesday, September 27, 2017
AHRQ Antibiotic Stewardship Project 0 P. McTiernan AHRQ Safety Program for Improving Antibiotic Use: A National Program for Antibiotic Stewardship Join the Project at The Agency for Healthcare Research and Quality (AHRQ), in conjunction with the Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality and NORC at The University of Chicago, created the AHRQ Safety Program for Improving Antibiotic Use to develop and implement a bundle of interventions designed to improve antibiotic stewardship and antibiotic prescribing practices across acute care, long-term care, and ambulatory care facilities across the United States. Antibiotics are a precious resource and can be critical for improving the outcomes of patients with serious infections. However, antibiotics also have the potential to cause patient harm, including allergic reactions, Clostridium difficile infections, and antibiotic resistance both at the individual patient level and for society as a whole. We want antibiotics to be effective for future generations, and that is only possible if we use antibiotics judiciously.   Hospital Registration Now Open Acute-care hospitals across the United States and Puerto Rico can now register for this 12-month project, which begins in December 2017. Learn about Participating. Future cohorts are planned for long-term care facilities (beginning December 2018) and ambulatory and urgent care facilities (December 2019).   Learn more about how to participate in this project or sign up for an informational webinar to get your questions answered,
by P. McTiernan
Monday, September 25, 2017
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