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Deadline Extended: Sherman Award for Excellence in Patient Engagement 0 P. McTiernan DEADLINE EXTENDED: Sherman Award for Excellence in #PatientEngagement. Submit outstanding programs by 3.10.17!
by P. McTiernan
Thursday, March 2, 2017
2/27 Webcast: Sleep Deprivation, Health Care Providers, and Patient Safety 0 K. Rowbotham Thank you to those that attended today’s webcast titled Sleep Deprivation, Health Care Providers, and Patient Safety with Christopher P. Landrigan, MD, MPH of Boston Children’s Hospital, Brigham and Women’s Hospital, and Harvard Medical School.   Please see some additional resources below. Make sure to check out our recent blog post on this issue. Read the recent Washington Post article co-authored by Dr. Landrigan. For more background, see Dr. Landrigan’s interview with AHRQ’s PSNet. We also encourage you to continue the discussion on health care provider fatigue by adding your comments or questions below.
by K. Rowbotham
Monday, February 27, 2017
A Health Care Change that Could Prove Catastrophic 0 P. McTiernan If you are interested in ACGME review of duty hour limits for PGY-1 interns, you may be interested in this op-ed co-authored by Dr. Christopher Landrigan.   Dr. Landrigan is the research director of the Inpatient Pediatrics Service at Boston Children’s Hospital, director of the Sleep and Patient Safety Program at Brigham and Women’s Hospital and an associate professor at Harvard Medical School. Charles A. Czeisler is director of the Sleep Health Institute and chief of the Division of Sleep and Circadian Disorders at Brigham and Women’s Hospital and a professor at Harvard Medical School.   Read their piece in yesterday's Washington Post here,   Dr. Landrigan is the speaker for our next webcast, Monday, Feb. 27, at 1pm ET, on Sleep Deprivation, Health Care Providers, and Patient Safety. Register at
by P. McTiernan
Thursday, February 23, 2017
Nominations Closing Soon: 2017 Sherman Award 0 J. Carmona We wanted to let you know that nominations will close soon for the 2017 Sherman Award for Excellence in Patient Engagement. This award was created by to recognize the innovative work being done by providers to advance patient and family engagement. The award is conferred annually in conjunction with the National Patient Safety Foundation’s Lucian Leape Institute and Taylor Healthcare.   We hope you will consider submitting a nomination. One person from the winning organization will receive an all-expenses paid trip to the National Patient Safety Foundation's Annual Congress from May 17-19 in Orlando, Fla., where the award will be presented. Additionally, the winning program will be recognized on and through other public relations outreach. The award is a great way to recognize your work and showcase the exceptional patient and family engagement programs you have created. Please note that self-nominations are accepted and the award nomination form is fairly simple and should not be time-consuming.   Please take a few moments to visit to download the nomination form. Deadline for award submissions is March 3, 2017.
by J. Carmona
Tuesday, February 21, 2017
Sleep Deprivation, Health Care Providers, and Patient Safety 0 J. Carmona Fatigue can compromise the safety of patients and the health care workforce. by Joanna Carmona Christopher Landrigan, MD, MPH   Medical residents working shifts of 24 hours or more make 36% more serious medical errors than those who are limited to working 16 consecutive hours, according to a 2004 study published in the New England Journal of Medicine. Even with patient and physician safety in jeopardy over sleep deprivation and fatigue, there’s still much debate over reducing trainees’ hours. Some of the objection to duty hour limits comes from the idea that trainees need to work extra hours in order to gain clinical experience and that shorter shifts may cause harm due to the increased handoffs required. To Christopher P. Landrigan, MD, MPH, research director of the Inpatient Pediatrics Service at Boston Children’s Hospital, director of the Sleep and Patient Safety Program at Brigham and Women’s Hospital, and associate professor of pediatrics and medicine at Harvard Medical School, however, the misunderstanding of this key issue is the jumping off point to start discussion and change. In a 2013 interview in PSNet, Dr. Landrigan said that “the trick is to implement changes in work hours in concert with concentrated efforts to improve the handoff process, teamwork, and infrastructure. Doing so can address fatigue-related errors without necessarily leading to a substantial increase in handoff errors. The net result can indeed be one where fatigue-related errors are reduced and handoff errors are not increased either.”           Dr. Landrigan has a wealth of experience on this topic and is the featured speaker for the National Patient Safety Foundation’s next Professional Learning Series Webcast, Sleep Deprivation, Health Care Providers, and Patient Safety, on February 27, 2017. He has led numerous landmark studies on the epidemiology of medical errors and adverse events, and interventions designed to reduce their incidence. His most important work has been focused on developing reliable patient safety measurement tools, and improving the organization of residency programs and academic medical centers. Dr. Landrigan’s work has contributed to national changes in resident work hour standards. In 2011, the Accreditation Council for Graduate Medical Education (ACGME) created a set of requirements stating that duty periods of PGY-1 (Post Graduate Year One) residents must not exceed 16 hours in duration. Most recently, however, ACGME is in the midst of a re-review of the requirements with the intention of deciding whether or not to revert these requirements, allowing PGY-1 residents to take on 28-hour shifts like their more senior colleagues. We know that when restrictions on shift hours are put in place, residents report that their quality of life improves and the rate of serious medical errors is reduced. We’ll discuss this and much more on the relationship between health care provider work hours, sleep deprivation, and patient safety. Please join us for this timely discussion.    
by J. Carmona
Tuesday, February 21, 2017
NPSF E-News, February 0 P. McTiernan White Paper: A Framework for Safe, Reliable, and Effective Care The Institute for Healthcare Improvement (IHI) has released a white paper which offers strategies to advance patient safety issues in areas, including leadership, teamwork, negotiation, transparency, reliability, improvement and measurement. Read the paper here,   Get more NPSF News and Patient Safety News and Resources via our February e-News, available at
by P. McTiernan
Thursday, February 16, 2017
Don Berwick Announced as Keynote Speaker: NPSF Congress 0 P. McTiernan   19th Annual NPSF Patient Safety Congress Wednesday, May 17–Friday, May 19, 2017 Orlando, FL           Visit the Congress Website Register Online Now and Save $200 Join us at the one and only globally relevant conference with a sole focus on patient safety. The 2017 program includes Inspiring keynote sessions with renowned thought leaders Hands-on educational breakout sessions led by get-it-done experts The engaging and interactive Learning & Simulation Center Optional Immersion Workshops provide in-depth full-day sessions on specific issues in workforce and health care safety Plus — More than 100 posters Live and interactive medical simulation 80 solutions providers 2 networking receptions, daily breakfast and lunch — and more. Who Should Attend Patient safety, quality, and risk professionals Hospital executives and board members Frontline clinicians, including nurses, physicians, and pharmacists Patient advocates, payors, researchers, and policy setters All those dedicated to patient safety — Across the continuum | Across all specialties Don Berwick Announcing Keynote Sessions Among others —  The History of Safety, Reflections on the Past, Look to the Future With featured speaker Donald M. Berwick, MD, MPP, FRCP Don Berwick, President Emeritus and Senior Fellow, Institute for Healthcare Improvement, is also former Administrator of the Centers for Medicare & Medicaid Services. A pediatrician by background, he has served on the faculty of the Harvard Medical School and Harvard School of Public Health, and on the staffs of Boston's Children's Hospital Medical Center, Massachusetts General Hospital, and the Brigham and Women's Hospital. Dr. Berwick served two terms on the Institute of Medicine's (IOM's) Governing Council, was a member of the IOM's Global Health Board, and served on President Clinton's Advisory Commission on Consumer Protection and Quality in the Healthcare Industry. In 2005, he was appointed "Honorary Knight Commander of the British Empire" by Her Majesty, Queen Elizabeth II, in recognition of his work with the British National Health Service. Dr. Berwick is the author or co-author of over 160 scientific articles and six books. Breakout Sessions Choose from 30 informative sessions in six educational tracks: Advancing Safety Science Implementation Caring for the Caregiver Culture of Safety in the Workplace Innovative Technology Medication Safety Across the Continuum Patient Safety Beyond the Walls of the Hospital Immersion Workshops Make the most of your Congress experience by participating in our Immersion Workshops (additional day, separate registration). Select one of these full-day programs that take deep dives into compelling areas of patient safety. Leadership Day: The Business Case for Patient Safety Certified Professional in Patient Safety Review Course Patient Safety 101 Emotional Harm and Peer Support NEW THIS YEAR! Hotel Information Attendees can book accommodations by going online to or by calling the hotel directly at 1-800- 266-9432. Please indicate that you are with the National Patient Safety Foundation. Sleeping rooms are available on a first-come, first-served basis within the designated NPSF block. Rates are $189 per night, exclusive of state and local taxes. REGISTER for Congress Today Stand Up for Patient Safety members receive a 20% discount on Congress registration. Check the member pages of for details. Members of the American Society of Professionals in Patient Safety (ASPPS) receive a 10% discount on Congress registration. Check the member pagesof for details. Supporters, Exhibitors Learn more about supporting or exhibiting at the Annual NPSF Congress. Special Discount NPSF Patient Safety Congress Keynote Speaker Series Couldn't make it to the last Annual NPSF Congress? We’ve got you covered: Watch three of the Keynotes and earn continuing education credits at the same time. You can now purchase the Keynotes for the discounted rate of $29 each. Available until May 15, 2017. Learn more here.
by P. McTiernan
Friday, February 10, 2017
Patient Safety News Roundup, February 6 0 J. Carmona   Improving Medication Reconciliation PSQH|December 9, 2016   Intentional Rounding to Prevent Patient Falls Journal of Clinical Nursing| December 22, 2016   MRSA Prevention Initiative American Journal of Infection Control| January 1, 2017   Risk of Infection with Endoscopes American Journal of Infection Control|February 1, 2017   High Risk Drugs and Medication Errors Applied Nursing Research|February, 2017   White Paper: A Framework for Safe, Reliable, and Effective Care Institute for Healthcare Improvement|2017
by J. Carmona
Thursday, February 9, 2017
NPSF Offers New Health Literacy Educational Module 0 J. Carmona New Complimentary Educational Module Promoting Clear Health Communication Limited health literacy is a serious problem facing our health care system. By some estimates, nearly 9 out of 10 adults have difficulty using information that is routinely available from health care facilities, in their communities, and in the media.    The newest educational module from NPSF, Promoting Clear Health Communication with Ask Me 3®, reviews the nature of limited health literacy as well as what health care professionals can do to help patients increase their understanding of health care information. View the 26-minute video individually or with staff and learn how to: Define limited health literacy and identify its prevalence and impact Identify potential at-risk populations and red flag behaviors related to limited health literacy Outline best practices for improving patients’ understanding of health care information Outline tactics for successfully implementing Ask Me 3 within organizations   Learn more and access the new educational module as well as other complimentary Ask Me 3 materials. Please note that registration and agreement with the terms and conditions regarding usage is required.   
by J. Carmona
Wednesday, February 8, 2017
Human Factors and Ergonomics Society: Call for Proposals 0 J. Carmona The Human Factors and Ergonomics Society welcomes proposals for the 2017 International Annual Meeting, to be held October 9-13 at the JW Marriott in Austin, Texas. HFES particularly invites submissions on work related to topics such as patient safety, medical devices and systems, workplace safety and health, handoff practices/protocols, environmental/facility design, simulation and training, and health-care information technology. Share your work and network with an international group of about 1,200 human factors/ergonomics professionals to improve patient safety. The deadline to submit your proposals is Monday, March 6.   Detailed instructions for submitting your work may be found in the Call for Proposals, now available at   For more information about attending this year’s Annual Meeting, visit
by J. Carmona
Wednesday, February 8, 2017
Partnered Hotels 0 W. Hyman The partnering of hotels with nearby hospitals (with co-located facilities in some cases) may present the problem of extending hospital safety issues into the hotel. Sharps and bloodborne/fluid pathogens are one area of concern. Are hospital's paying attention to such issues, and helping protect hotel workers, notably housekeeping? Or are they ignoring them? One such partnered hospital has been fined by OSHA for the second time.
by W. Hyman
Monday, February 6, 2017
NPSF Joins Consumer Partnership for eHealth 0 J. Carmona   The National Patient Safety Foundation (NPSF), a central voice for patient safety since 1997, has joined the Consumer Partnership for eHealth (CPeH).   Led by the National Partnership for Women & Families, CPeH is a coalition of more than 50 consumer, patient, and labor organizations working to advance health information technology to meet the needs of patients and families. Through its initiatives, CPeH seeks to shape the policy landscape, amplify the consumer voice, and enhance access to and use of health information.   “The goals of CPeH are in parallel with recommendations of the National Patient Safety Foundation’s Free from Harm report,” said Tejal K. Gandhi, MD, MPH, CPPS, president and chief executive officer of NPSF. “Ensuring that that technology is safe and partnering with patients and families are two keys to advancing patient safety, and we look forward to working with the Partnership.”   CPeH’s members collectively represent 127 million people.  The Partnership aims to measurably improve lives through health IT and digital health tools.   “The ability for consumers and providers to easily and efficiently share critical health care information with each other is paramount to facilitating patient-centered care and promoting shared decision making,” said Erin Mackay, associate director, Health Information Technology Policy and Program, National Partnership for Women & Families. “We look forward to input and support of NPSF as a new member.”   To learn more about the Consumer Partnership for eHealth, visit
by J. Carmona
Thursday, February 2, 2017
Safety Leadership Errors 0 W. Hyman UL has a nice post entitled 5 Things Safety Leaders Do to Make Employees Mock Safety. (   I will paraphrase: 1. Forget that exposures effect real people 2. Talking change without attention to buy-in 3. Know-it-all and demanding leadership attitude that automatically generates resistance 4. Turning safety breaches into opportunities for blame and punitive actions 5. Mocking safety, eg The XXX is making you wash your hands and glove, not me   Are you guilty of any? Are there others?
by W. Hyman
Tuesday, January 31, 2017
Nominations Open: 2017 Sherman Award for Excellence in Patient Engagement 0 P. McTiernan Nominations now open for 2017 Sherman Award for Excellence in Patient Engagement opened nominations today for the John Q. Sherman Award for Excellence in Patient Engagement. The Sherman Award, a partnership between, the National Patient Safety Foundation, and Taylor Healthcare, recognizes outstanding programs focused on engaging patients and families in care to improve patient safety and boost outcomes.   Nominations will be open through Friday, March 3. Download this year’s newly streamlined nomination form.   Questions? Contact Arundi Venkayya, curator of and Sherman Award administrator or call 937-221-4482.
by P. McTiernan
Monday, January 30, 2017
Workarounds 3 W. Hyman am new to safety field,background is in PT...seems like work arounds become normalized deviance and this suggests something needs to be changed in the system and/or workflow...Unfortunately humans make mistakes and we don't always choose to do the"right "thing but sometimes choose to do the "quick" thing.
by L. Kahan
Wednesday, January 18, 2017
WHO Technical Series on Safe Primary Care 0 P. McTiernan In case you missed it, in December, the World Health Organization published a technical series on Safer Primary Care. The series consists of nine monographs on topics such as patient engagement, human factors, and diagnostic error. Access it at
by P. McTiernan
Thursday, January 12, 2017
"A View from the Edge" (N Engl J Med)-Perspective on Organizational Culture 1 A. Spielman I have had a related question. If you were to become a patient in your own institution are there staff that you would prefer be taking care of you, and staff that you definitely wouldn't want to be taking care of you, based on their skills and delivery of those skills? If the latter group exists then patients are being exposed to people we wouldn't want taking care of ourselves. Is this ethical? How can it be addressed?
by W. Hyman
Wednesday, January 11, 2017
Patient Safety Priorities 0 P. McTiernan What are your patient safety priorities for 2017? We'd love to hear from you and what you are working on.
by P. McTiernan
Monday, January 9, 2017
Support for Family Caregivers (commentary in New Engl J Med) 0 A. Spielman A commentary published in the December 29, 2016 issue of New England Journal of Medicine might be of interest to readers of this forum. It talks about the need to provide better support for unpaid family caregivers, who play a major part in managing the health care of millions of older Americans, but whose role often goes unrecognized by the health care professionals treating these patients.   The commentary references a 2016 report from the National Academies of Sciences, Engineering, and Medicine that examined the issue of family caregiving.   Free full text of the commentary:   National Academies report:
by A. Spielman
Thursday, January 5, 2017
"Ask Yourself..." Campaign 1 W. Hyman Great idea, and thanks for your kind offer to share the resources you created. The “Ask Yourself” theme made me think of some studies that suggest that training health care professionals to examine their practices through a process of regular self-reflection (not just admonishing them to “be more careful” after an accident occurs) could increase awareness of safety issues, which could help prevent potential future errors from actually happening.         Here is one example of such a study: Hoke LM, Guarracino D. Beyond Socks, Signs, and Alarms: A Reflective Accountability Model for Fall Prevention. Am J Nurs. 2016 Jan;116(1):42-7.
by A. Spielman
Wednesday, January 4, 2017
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