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General Patient Safety Discussion
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6/21 Webcast: Shared Decision Making and Patient Safety 0 K. Rowbotham Thank you to those who attended the June 21, 2017 Professional Learning Series webcast titled Shared Decision Making and Patient Safety: Making the Connections with Ben Moulton, JD, MPH, Senior Vice President, Advocacy & Policy, Healthwise.    For more information about Healthwise, please click here.   We encourage you to continue the discussion by adding your comments or questions below.
by K. Rowbotham
Wednesday, June 21, 2017
Patient Safety Event Reporting Policies 1 V. Enter I am currently reviewing our process for this as well. I would appreciate feedback also. Thank you.   Denise M. QI/IC RN
by D. Mente
Tuesday, June 20, 2017
Post-event Drug testing 0 A. Swindler Are there any organizations out there that practice mandatory post-event drug testing? If so, how do you define "event"? (Serious Safety Event? Harm score threshold?) Also, what has been the effect on the reporting culture? Would anyone be willing to share a policy related to this with me? Thank you in advance for any assistance!   Ann Marie Swindler, BSN, JD, LLM, CPHRM, CPPS, CPHQ Executive Director Corporate Risk Management & Insurance         Memorial Health University Medical Center
by A. Swindler
Tuesday, June 20, 2017
Patient Safety Program Staffing Estimates 1 C. Blalock Have you gotten any response for your question? I am interested as well. I am a new Patient Safety Officer and I am by myself with my Risk Manager.
by T. Parker
Friday, June 9, 2017
Trivia question 0 W. Hyman In what industry might one see the sign "CAUTION Handle Doctor Blades With Extreme Care?" I will send a picture of such a sign seen on site to anyone who requests it at
by W. Hyman
Thursday, May 11, 2017
Can't Travel? Stream NPSF Congress Keynotes Live 0 P. McTiernan Be a part of the NPSF Patient Safety Congress without leaving home!   You can catch any or all four keynote sessions live by joining us virtually with our Keynote Speaker Series.   Learn more and register at   Speakers include: Donald M. Berwick, MD, MPP, FRCP, former Administrator of the Centers for Medicare and Medicaid Services (CMS) under President Obama (2010-2011) and President Emeritus and senior fellow at the Institute for Healthcare Improvement (IHI) Zubin Damania, MD, an internist and founder of Turntable Health, an innovative health care startup that was part of an ambitious urban revitalization movement. His videos, created under the pseudonym ZDoggMD, have gone epidemically viral with over 160 million views on Facebook and YouTube, educating patients and providers while mercilessly satirizing our dysfunctional health care system. See the full list of speakers and view session details at Continuing education and continuing medical education credit will be available. Check out the Keynote Speaker Series and learn at your desk,
by P. McTiernan
Wednesday, May 10, 2017
ECRI Patient Safety Inventory 0 C. Blalock Does anyone have a copy of the ECRI Patient Safety/Risk Inventory? I read about it in this article. Patient Safety recently transitioned out of Risk and we have a new Risk Manager starting and we'd like to determine responsibilities.   Thanks, Casey
by C. Blalock
Monday, May 1, 2017
Coalition to Improve Diagnosis: Survey 0 P. McTiernan The Coalition to Improve Diagnosis is conducting a survey looking to learn about effective tools and implementation. The deadline to complete this survey is May 1. Learn more and take part in this important initiative:
by P. McTiernan
Friday, April 21, 2017
4/19 Webcast: Improving Serious Illness Care 0 K. Rowbotham Thank you to those that attended today’s webcast titled Improving Serious Illness Care: More, Earlier, and Better Conversations about Patient Values and Goals with Ellen DiPaola, JD of Honoring Choices Massachusetts and Joanna Paladino, MD of Ariadne Labs.   For more information about Ariadne Labs, click here. For more information about Honoring Choices Massachusetts, click here.    To join the Community of Practice referenced during the webcast, see below. • Go to: • Click “Create an Account” on the right side of the page • Complete the account information page. You will receive an email to authenticate your account. • Return to and click on Serious Illness Community of Practice on the bottom left of the page. • Click “Request Membership.” Complete the additional profile information. • You will receive an email once the Administrator has accepted your request.   We encourage you to continue the discussion by adding your comments or questions below.
by K. Rowbotham
Wednesday, April 19, 2017
Staff and ventilated patients 0 W. Hyman A recent ventilator recall for non-alarming raised what might be some interesting expectations for staff. In brief these include: 1. Ensure patients are appropriately monitored (with constant attention) by trained caregivers 2. Always have an alternate power source and means of ventilation available when the ventilator is in use 3. Always use appropriate monitors to ensure sufficient oxygenation and ventilation Overall the message is: Do not rely on the ventilator alarms themselves.   Are there things real world expectations? If they aren't real world and there is a patient problem the manufacturer might blame you for not following the instructions.
by W. Hyman
Wednesday, April 5, 2017
NPSF Open Access Webcast Archive 0 P. McTiernan Missed a Webcast? View the Replay in the NPSF Webcast Archive We are pleased to announce that complimentary access to past Professional Learning Series webcast replays is now available in the NPSF Webcast Archive. Learn more at Please note that continuing education credit is not available for replays and was only available to those who attended the live event. If you are interested in viewing a webcast for continuing education credit, please click here to view the upcoming webcast schedule. Webcast replays will be added to the archive on a quarterly basis, so be sure to check back often.
by P. McTiernan
Tuesday, April 4, 2017
April Webcast: Improving Serious Illness Care 0 P. McTiernan Professional Learning Series Webcast The NPSF Professional Learning Series offers the convenience of continuing education and peer-to-peer collaboration in an online learning environment. Improving Serious Illness Care: More, Earlier, and Better Conversations about Patient Values and Goals April 19, 2017 | 1:00-2:00 pm Eastern Time Find out more and register, Featured speakers: Ellen DiPaola President & CEO Honoring Choices Massachusetts Joanna Paladino, MD Assistant Director of Implementation Serious Illness Care Program Ariadne Labs This webcast will review the importance of high quality communication between clinicians and patients about values and goals of care. We will discuss patient-centered, effective serious illness communication and its outcomes, including reduced physical and emotional suffering for patients and families, improved well-being, and improvements in the quality of serious illness care. In particular, we will discuss high quality communication as a patient safety issue and the ways in which the absence of communication, its initiation late in the illness course, or the lack of accessible documentation about patient goals can harm patients. The activity will also share best practices for improving patient/provider communication throughout a patient’s lifetime.
by P. McTiernan
Tuesday, April 4, 2017
Patient Safety Risk Assessment 4 C. Blalock Thank you for offering to share your Patient Safety Committee risk assessment. My email is
by G. Castleberry
Tuesday, March 21, 2017
Patient Safety Awareness Week 2017 In Review 0 P. McTiernan Patient Safety Awareness Week took place March 12-18, 2017, with health care organizations, patients, and health professionals from across the country and internationally demonstrating their commitment to safe care. Thank you for all who took part. If you have not already shared your activities, you can still do so at   Read about the week's highlights here,
by P. McTiernan
Monday, March 20, 2017
Patient Safety Awareness Week Special Offer 0 P. McTiernan In honor of Patient Safety Awareness Week, NPSF has just announced a special, limited time offer: Save 10% on registration for the NPSF Patient Safety Congress, May 17-19, in Orlando when you use the code PSAW10 and register by midnight on March 31, 2017. The Early Bird rate is in effect until March 31, so you save twice!   For details of the meeting, go to
by P. McTiernan
Friday, March 17, 2017
3/15 Webcast - The Voice of the Patient and the Public 0 K. Rowbotham Thank you to those that attended today’s webcast titled The Voice of the Patient and the Public with Marshall Allen of ProPublica, Rosemary Gibson of The Hastings Center, and Martin J. Hatlie, JD of Project Patient Care.   Get Involved in Patient Safety Awareness Week >>  Download Free Campaign Materials >>  Visit the Online Store >>  Help Us Spread Awareness by Donating to the Cause >>  Join the Discussion >>  Share Your Plans   Make sure to download and share the newly released Call to Action here.   Don’t forget to use the event hashtags #unitedforpatientsafety and #PSAW2017 to let everyone know what you are up to for the week.   We also encourage you to continue the discussion by adding your comments or questions below.
by K. Rowbotham
Wednesday, March 15, 2017
AHRQ and NPSF: #UnitedforPatientSafety 0 P. McTiernan Twenty years ago, the National Patient Safety Foundation (NPSF) was created to enhance awareness of issues related to patient safety. Two years later, AHRQ was officially designated as the Federal government's lead patient safety agency. So it's fair to say that our two organizations have been working alongside clinicians and others in leading the field toward solutions for the pernicious problems that affect far too many of our patients every day. Read this full blog post by Jeff Brady, MD, MPH, AHRQ's Center for Quality Improvement and Patient Safety and an assistant surgeon general in the U.S. Public Health Service. Dr. Gandhi is president and CEO of the National Patient Safety Foundation.
by P. McTiernan
Monday, March 13, 2017
Institute for Healthcare Improvement and NPSF Agree to Merger 0 P. McTiernan   Organizations uniting to advance common goals and accelerate progress in patient and workforce safety Boston, MA, March 13, 2017 — Recognizing that patient safety is a public health issue in need of fresh, robust approaches and constant focus for health care systems today, the Institute for Healthcare Improvement (IHI) and the National Patient Safety Foundation (NPSF) announce plans for a merger, effective May 1.   Read the press release.
by P. McTiernan
Monday, March 13, 2017
Patient Safety Awareness Week Starts Today 0 P. McTiernan   Join us in celebrating Patient Safety Awareness Week and help us spread the message that #WeAreAllPatients. Patient Safety Awareness Week Day 1 It’s the first day of Patient Safety Awareness Week! We have lots of opportunities for you to engage with us this week, and we hope you’ll join us in the celebration by taking our polls, sharing your plans, and spreading the word.   Visit!   Patient Safety: What Patients Want (and Need) to Know Tuesday, March 14, 2017 | 1:00-2:00 pm ET Use the hashtag #PSAW17chat to join the conversation!   Register for the Complimentary Webcast at   The Voice of the Patient and the Public Wednesday, March 15, 2017 2:00pm – 3:00pm (Eastern) | 1:00pm – 2:00pm (Central) | 11:00am – 12:00pm (Pacific) This webcast will look at the advancing role of the patient and the public in patient safety. We will explore past efforts that brought forth transparency to patient safety issues, examine where we are today, and discuss how we can shape the future together.
by P. McTiernan
Sunday, March 12, 2017
Better Than "Be Careful!" 0 W. Hyman A UK medical device recall related to the hazards of dropping the batteries included notice that a "Representative will schedule an on-site visit to affix a “Do Not Drop” label on the battery and provide additional instructions which will indicate to take extra care to avoid dropping the battery." How effective do you think labeling something Do Not Drop would be? And if effective, how might this concept be extended, eg Do Not Break, Do Not Misuse, or the more general Do Not Err.
by W. Hyman
Tuesday, March 7, 2017
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