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Monday, May 23, at the 2016 NPSF Patient Safety Congress
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Day 1 Highlights

We had a great first day of Immersion Workshops, simulations, and networking at the NPSF Patient Safety Congress! Here are some of the highlights:

More than 350 attendees joined us for all-day Immersion Workshops on four topics:

  • Communication and Resolution Programs to Improve Safety
  • High Reliability: Putting the Science into Practice 
  • RCA2: Root Cause Analysis and Actions to Prevent Harm
  • CPPS Review Course for professionals planning to take the Certified Professional in Patient Safety certification exam

Spotlight On:
Communication and Resolution Immersion Workshop

Despite the best efforts of care providers, adverse events happen far too often in health care. Most efforts to respond to them do not actively improve patient safety or meet the needs of patients and clinicians.

Communication and resolution programs (CRPs) turn adverse events into opportunities for improvement. They ensure open communication after an adverse event is discovered, a comprehensive analysis of what happened, with subsequent safety improvements, emotional support for patients and providers, and an appropriate resolution.

   Tom Gallagher, MD,
and Rick Boothman, JD

This session, which NPSF offered in partnership with the Collaborative for Accountability and Improvement, brought together faculty from a number of hospitals and health systems that already have CRP programs in place, such as the University of Washington, University of Michigan Health System, and Beth Israel Deaconess Medical Center, as well as a patient advocate and others.

“Communication and resolution programs are reshaping the response to patient harm, promoting quality and safety rather than deny and defend,” said Thomas Gallagher, MD, professor and associate chair, Department of Medicine, University of Washington, who chaired the program at the NPSF Congress. Dr. Gallagher is also executive director of the Collaborative for Accountability and Improvement.

With a grant from the Ullem Charitable Gift Fund, NPSF recently worked on development of a curriculum for leaders interested in implementing CRP programs, a project spearheaded by Richard Boothman, JD, chief risk officer at the University of Michigan Health System, and Kenneth Sands, MD, MPH, chief quality officer at Beth Israel Deaconess Medical Center in Boston, and done in partnership with the Collaborative for Accountability and Improvement. If you missed last month’s complimentary webinar about this project, visit the website for the replay.

“We at NPSF believe very strongly in the power of CRP programs to not only bring closure to patients and families after harm occurs during care but also allow investigation of errors and causes of harm so that they can be prevented,” said Tejal K. Gandhi, MD, MPH, CPPS, president and CEO, NPSF.

In related news, the Agency for Healthcare Research and Quality (AHRQ) released a new online toolkit to help hospital and health system leaders and clinicians communicate accurately and openly with patients and their families when something goes wrong with their care. The new toolkit will help expand use of an AHRQ-developed communication and resolution process called Communication and Optimal Resolution, or CANDOR, which gives hospitals and health systems the tools to respond immediately when a patient is harmed and to promote candid, empathetic communication and timely resolution for patients and caregivers.

The CANDOR Toolkit is the result of $23 million in grants to states and health systems, the largest federal investment of this kind. Erin N. Grace, MHA, of AHRQ’s Center for Quality Improvement and Patient Safety, was on hand to discuss the CANDOR toolkit at today’s NPSF Congress Immersion Workshop.

“The CANDOR process is a synthesis of multiple communication and resolution programs from early adopters in this field and AHRQ’s patient safety and liability demonstration grants,” Ms. Grace said. “This is a proactive approach that health care institutions and practitioners can use to respond in a timely, thorough, and just way to unexpected patient harm events.”

Get more information about the AHRQ CANDOR Toolkit on the agency's website.

Welcome Reception

   Tess Earley (right) with
NPSF staffer Jennifer Walker
won a free registration
to the 2017 NPSF Congress
in Orlando. Visit the NPSF Booth
#401 for your chance to win

We chose the first first lucky winner of the NPSF raffle. Visit NPSF at Booth #401 in the Learning & Simulation Center for your chance to win at the Networking Receptions on Tuesday and Wednesday!

The first round of simulations got under way this afternoon in the Learning & Simulation Center. If you missed this evening’s demonstration, be sure to check out the simulations on Tuesday at lunch (Noon to 1:30 PM) and at the Networking Reception (4:15 to 6:15 PM).

See the Learning & Simulation Center Guide and the Supporter & Exhibitor Guide (which you should have received at registration).


Stand Up for Patient Safety Management Awards

  Susan Noaker and Pat Schlagel of
Fairview Health Services with
NPSF President and CEO
Dr. Tejal Gandhi (far right)
and Dr. Gregg Meyer,
chair of the NPSF
Board of Directors (left)


The Stand Up for Patient Safety Management Awards were conferred at the Member Networking Event.

The 2016 recipients are:

  • US Naval Hospital, Guam, for a program that improved medication reconciliation in the Family Care Clinic
  • Fairview Health Services, based in Minneapolis, for a program to improve the way biological specimens are managed

The Stand Up award is given each year to two member organizations of the National Patient Safety Foundation's Stand Up for Patient Safety program in recognition of the successful implementation of an outstanding patient safety initiative that was led by, or created by, mid-level management.  Read more about this year’s award recipients.

We had a great turnout of members of the American Society of Professionals in Patient Safety, the Stand Up for Patient Safety program, and those holding the Certified Professional in Patient Safety (CPPS) credential.


And so much more to come. . . .

Be sure to stop by the United for Patient Safety table opposite the Learning & Simulation Center. Learn about our ongoing campaign to raise awareness of patient safety, take the pledge, and show that you believe that We Are All Patients and  "Every Day Is Patient Safety Day."


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