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NEWST H E C E N T E R FO R PAT I E N T S A F E T Y
PSOS U M M E R 2 01 6 N E WS L E T T E R
MEETING OF THE MINDS CPS' ANNUAL PATIENT SAFETY CONFERENCE BRINGS TOGETHER EXPERTS FROM ACROSS THE COUNTRY WITH A SINGULAR GOAL: ELIMINATE HARM.
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MAKING THE ROUNDS | IN THIS EDITION
LEARNING OPPORTUNITIES
Just culture, keynote speakers among the highlights as this year's PSO Day and Patient Safety Conference bring together attendees from
across the nation, all who have the same goal in mind: eliminate patient harm! 12
ON THE COVER:
A NEED FOR SPEEDImproving Event Investigation through the Development of SPRINT: Serious Patient Safety Event Rapid Investigation Teams. 4
THE ORANGE DOORFacing use of street drugs and alcohol, and decreased availability of medical care and facilities for individuals suffering mental or behavioral illnesses, Liberty Hospital has been able to stem the tide using a multi-disciplinary approach to helping create a safer care environment for staff and patients alike. 6
ALSO INSIDE:
PSO LEGAL UPDATE:
Cases involving the Patient Safety and Quality Improvement Act continue to work their way through state and federal courts. 15
EMS UPDATE:
New CPS report seeks to raise awareness of safety concerns in the EMS community. 16
8TH ANNUAL AHRQ PSO MEETINGWhat the AHRQ guidance means for providers and their patients. 11
ALSO IN THIS ISSUE:
SAFETY INSIDER 9
PSO UPDATE 18
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CALL TO ACTION: CHANGE THE STATISTICAN ARTICLE RELEASED IN MAY FROM BMJ INDICATES MEDICAL ERRORS ARE THE THIRD LEADING CAUSE OF DEATH IN HEALTHCARE IN THE UNITED STATES AFTER HEART DISEASE AND CANCER. CALL TO ACTION RECOMMENDS CULTURE IMPROVEMENTS.
BY ALEX CHRISTGEN, BS, CPPS Center for Patient Safety
The article follows the 1999 IOM report which made the first attempt to determine preventable harm in healthcare. The IOM report estimated a staggering 44,000 to 98,000 patient deaths each year due to medical errors. In 2013, the IOM's reported numbers were determined to be grossly underestimated based on a newer study suggesting the actual number was likely to be more than 400,000 deaths per year as result of medical errors.
In 2013, the IOM's reported numbers were determined to be grossly underestimated based on a newer study suggesting the actual number was likely to be more than 400,000 deaths per year as result of medical errors.
Although the BMJ article specifically references medical errors in the inpatient hospital setting, CPS’ recently released annual report suggests medical errors in LTC, home care, and EMS settings may be just as prevalent.
The following call to action is recommended:1. make errors more visible when they occur so their
effects can be intercepted2. have remedies at hand to rescue patients3. make errors less frequent by following principles that
take human limitations into accountThis Call to Action aligns with the recent IOM update in 2015,
which lists eight recommendations for improving patient safety, and specifically diagnostic errors, in healthcare. Two of the eight recommendations call for:
1. an enhanced focus on a culture that supports the open discussion of errors
2. a collaboration of patient safety across the continuum of care through organizations, such as a Patient Safety Organization (PSO), that support safe sharing and
learning. The Center for Patient Safety (CPS) has recognized these
areas as strategic approaches to reduce harm for quite some time. We’ve embedded supportive culture improvement programs (Just Culture, CUSP, TeamSTEPPS, Second Victims Programs, and culture assessments) and offer safe sharing opportunities (as a PSO) that support CPS’ vision of improving patient safety for all patients and healthcare providers, in all processes, all the time.
Through our program objectives of Protecting, Learning, and Preventing, CPS is currently working with hundreds of organizations and thousands of healthcare providers in 38 states across the country to improve patient safety every day. Together, we will reduce preventable harm in healthcare.
Contact me if you have questions about any of the recently released reports or if you would like to talk about what you can do to join the healthcare movement to safer care.
CALL TO ACTION | REPORT HIGHLIGHTS NEED FOR CHANGE
ALEX CHRISTGEN is the interim Executive Director for the Center for Patient Safety. You can reach her at [email protected].
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BY BECKY DOERHOFF, RN, MSN, CNL & MICHAEL LANE, MD, MPHS, CPPSBJC Healthcare
The Joint Commission (TJC) adopted a formal Sentinel Event Policy in 1996 to help promote careful investigation and analysis of patient safety events as well as to encourage effective corrective actions to prevent future events. Accredited institutions are expected to identify and respond appropriately to all sentinel events (such as unintended retained foreign items) and are subject to review by The Joint Commission.1
The pioneering efforts initiated by TJC attempted to set the framework for healthcare investigators to take a systems-based approach to event analysis. This initiative alone has been not been sufficient in preventing events of harm that occur every year. In a study released this spring from Johns Hopkins, it is suggested that medical error be considered the 3rd leading cause of death in the CDC ranking of most common causes of death, which would translate to roughly 400,000 lives.2
A NEED FOR SPEEDIMPROVEMENT OF EVENT INVESTIGATION THROUGH THE DEVELOPMENT OF SPRINT: SERIOUS PATIENT SAFETY EVENT RAPID INVESTIGATION TEAM
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In 2014, representatives from Risk and Patient Safety across the BJC Health Ser-vice Organizations (HSOs) began to design and pilot a core team that could assist in the analysis, action plan development and the dissemination of learning from serious patient safety events (SPSEs)* throughout the system. The vision of the process was to have ‘a cadre of well-trained, highly re-spected expert investigators guiding local investigations...’ that would reinforce the values of the organization and provide a standard and robust investigation lifecycle. The process was inspired by several in-vestigative methods, such as, The London Protocol, James Reason Model of Accident Causation, RCA2: Improving Root Cause Analyses and Actions to Prevent Harm.
The team was named ‘SPRINT’ and
launched with Patient Safety Specialists from the system level and volunteers from three other facilities, representing commu-nity, academic and alternate sites. During the pilot phase roughly 20 events were investigated over 6 months using the new process. The team was composed of a HSO lead, a SPRINT lead, key HSO leadership, staff or subject matter experts and physi-cians. SPSE and close call events that had a high likelihood of harm if a barrier had not been in place were in scope for the pilot. See content above for more information on process components and event action plans.
Investigations during the pilot phase were more robust and resulted in stronger action items. A rapid improvement event was held to further enhance the process.
Resource allocation was deemed essen-tial for ongoing success and to ensure that appropriately trained, dedicated facilita-tors for event investigation were available to achieve consistent and reliable results. The 2nd phase was launched in the fall of 2015. Process Improvement Engineers were added to the team composition to expand the expertise and independent as-sessment of the process. Automatic action plan check-in’s were added at 6 months and 1 year to aid in identifying barriers that were not predicted when initially planning for stronger more entailed interventions. Weekly updates of events are communi-cated to the system executive team. The executive team receives a quarterly update with process metrics and themes.
SPRINT continues to evolve and refine over time. Areas of focus for improvement include: disseminating pertinent informa-tion to frontline staff, providing consistent clinician support by trained experts in a systematic way and incorporating proac-tive risk assessment into the process.
BECKY DOERHOFF is the Manager for Patient Safety for the Center of Clinical Excellence at BJC Healthcare. You can reach her at [email protected].
MICHAEL LANE is an Outcomes Physician at the Center of Clinical Excellence at BJC Healthcare and Assistant Professor of Medicine, Division of Infectious Diseases at Washington University School of Medicine. You can reach him at [email protected].
Foundational to the SPRINT process is the application of Just Culture, which ensures justice in response to human error and behavioral choices. High Reliability and Human Factors Engineering principles were also integrated into the process. A few of the standard process tools utilized by the team include: causal diagrams, timelines, process maps, diagrams and payoff matrix for proposed interventions. Weekly calls, using a standard agenda template, occur to discuss new and ongoing events with all the Patient Safety and Risk Managers across the system. Event action plans are discussed at the system Risk and Patient Safety Council and selected interventions are rated for strength of action based on Human Factors Engineering principles.
REFERENCES: 1. The Joint Commission. Sentinel Event Policy and Procedures. https://www.jointcommission.org/sentinel_event_policy_and_procedures/. Published January 6th, 2016. Accessed May 10th, 2016. 2. Makary, Martin & Daniel, Michael. Medical error-the third leading cause of death in the US. BMJ. http://www.bmj.com/content/bmj/353/bmj.i2139.full.pdf. Published May 3rd, 2016. Accessed May 10th, 2016.
* SPSEs are events in medical care that are clearly identifiable, preventable, and resulted in severe temporary harm, permanent harm or death. Severe temporary harm is critical, potentially life-threatening harm lasting for a limited time with no permanent residual, but requires transfer to a higher level of care/monitoring for a prolonged period of time, transfer to a higher level of care for a life-threatening condition or additional major surgery, procedure, or treatment to resolve the condition. In contrast, some events, although serious and adverse, relate to a patient’s underlying medical condition. Preventability implies that methods for averting a given injury are established and that an adverse event results from failures to apply that knowledge. SPSEs include those events deemed preventable upon review and defined by the Joint Commission as reportable and reviewable Sentinel Events, National Quality Forum (NQF) Serious Reportable Events in Healthcare.
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BY JOANIE PETERSON, RN, JD Liberty Hospital
It’s been more than four years since Liberty Hospital, a 233-bed medical center north of Kansas City, began its “Orange Door” program. With the increased use of street drugs and alcohol, and decreased availability of medical care and facilities for individuals suffering mental or behavioral illnesses, patient violent behavior was getting out of control. Unfortunately, in the past, healthcare providers traditionally accepted violent
behavior as “part of the job” and were reluctant to speak up or report incidents. This culture presented an unsafe environment for staff, patients and visitors.
TAKING ACTION - CODE WHITE In 2012 Liberty Hospital took action to address this growing
challenge. They partnered with the “Handle with Care” (HWC) Behavior Management program to provide de-escalation training for all patient care staff. A small multi-disciplinary team revisited their process for getting additional security personnel to the scene of the disruptive behavior. The team realized that sometimes a person in uniform can escalate tension rather than de-escalate. It also was determined that a “show of force/support” can deter some from becoming aggressive when faced with more than one staff member. A multi-disciplinary approach was identified for this process instead of just using security officers. “Code White” was developed, which alerts the crisis intervention response team that additional assistance is needed to handle a violent patient, family member or visitor. View Code White Policy - CPS PSO participants only
THE “ORANGE DOOR”Staff needed a way to identify patients as imminent risk to self
or others. Clear communication to identify which patients are at risk is addressed by the “Orange Door”, which includes:
• A placard placed on the door of any patient at risk for violent behavior to self or others;
• Revision of the communication board at the nursing stations so the patient’s name is highlighted in light orange for all staff to be alerted of potential violence;
• Additional training for staff to understand and identify sui-cide-imminent risk to self and others
• Communication with the patient, family members and/or vis-itors regarding expectations as defined in the Suicide: Imminent Risk to Self or Others policy. View Policy - CPS PSO participants only; and
• Constant Observation program - Training and brochures for
THE ORANGE DOOR
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the staff member who is sitting with the patient and one for the patient and their families on what to expect while under Constant Observation.
IT TAKES A VILLAGEEducation is key for the success of this program. All staff have
three hours of de-escalation training at orientation. Patient care and other identified staff members are recertified every 2 years. The ED, ICU, Nursing Supervisors, Social Services, and Code White (Critical Incident Response Team) staff members take a full eight-hour training in addition to the three-hour education and again are recertified every 2 years. In-house instructors for Handle With Care are recertified every year. The hospital works closely with lo-cal law enforcement agencies, fire departments, and EMS services, educating on what happens when a non-medical patient with vi-olent behavior is brought to Liberty Hospital’s ED. Since Liberty has no behavioral medicine beds, the patient must be assessed in the ED and be held until staff can arrange a safe transfer to a facility that provides mental healthcare. These first responders are taught how to identify the need for behavioral care in the field so patients can be taken to the appropriate facilities whenever possi-ble. When known behavioral health/violent patients are brought
to the ED, they are admitted to a “safe room”, when available. This room (located just inside the ambulance bay foyer) has been de-signed specially with a small “garage door” that can be activated to come down to cover medical equipment/gas connections. In the remote situation where the door needs to be closed to help with de-escalation, there also is a computer that can monitor the patient via camera, allowing staff to remain safe and keep a con-stant visual of the patient during the de-escalation process. The adjoining bathroom is specially equipped with metal fixtures that deter any attempts at self-harm or destruction of property. The patient can de-escalate in a safe environment and staff members are able to assist without excess equipment that could get in the way if restraint becomes necessary in the therapeutic process.
Recently “Orange Door” visitor lockers were installed on each of the patient care units to ensure safe keeping of visitors’ belongings and to keep dangerous items out of the patient rooms. In a recent situation, a visitor was thankful the hospital provided lockers for her to store her items, which assisted in loss prevention or damage.
Another wife was grateful that no one had been hurt when her husband became aggressive, swinging and kicking, and told Josh Stewart (a certified instructor and member of the critical incident response team) she had never been anywhere where she felt she had more assistance with her husband and said it was great.
THE RESULTSLiberty Hospital has seen solid results from the “Orange Door”
program. Many times staff don’t feel they need to call for a Code White
because they are able to verbally de-escalate the situation before it becomes violent.
Changing the hospital’s approach to managing aggressive be-havior is difficult because it requires a change in mindset that any patient can pose a risk. Caregivers are trained to give care, not to think of patients as potential risk for aggressive behavior, violence and harm. Liberty Hospital continues to change that mindset as the bedside caregivers, medical staff members and first respond-ers work together to mitigate the risks of this issue.
WORKMAN'S COMP COSTS DUE TO VIOLENT BEHAVIOR YEAR: COST: INJURIES:2014 $57,000 32015 11,000 12016 0 0
CODE WHITE CALL RESOLUTIONS BY VERBAL DEESCALATIONYEAR: DEESCALATIONS:2014 802015 652016 17
FOR MORE INFORMATION on implementing the Orange Door process, contact Joanie Peterson. You can reach her at [email protected].
Liberty Hospital is a 250-bed facility in Liberty, Mo.
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The Center for Patient Safety, in collaboration with the University of Missouri Health System’s Second Victim Program is pleased to host the following workshop:
Date: November 7
Time: 7:30 a.m. to 3 p.m.
Location: Saint Luke’s North Hospital – Barry Road, 5830 Northwest Barry Road, Kansas City, MO 64154, located just 10 minutes from the Kansas City International Airport (MCI).
Cost: $399 per person ($349 for each additional person from the same organization)
Registration: https://www.eventbrite.com/e/second-victim-train-the-trainer-workshop-registration-20923246995
“Healthcare team members involved in an unanticipated patient event, a medical error and/or a patient related injury can become victimized in the sense that they are traumatized by the event. Frequently, these individuals feel personally responsible for the patient outcome. Many feel as though they have failed the patient, second guessing their clinical skills and knowledge base.”
Who can benefit: When patients suffer an unexpected clinical event, healthcare clinicians involved in the care may also be impacted and are at risk of suffering as a “second victim”. Understanding this experience and recognizing the need for supportive interventions is critically important. This workshop will provide insights into the experience as well as interventions of support. This workshop will also provide instruction so that each participant will return to their organization with the knowledge, skills, and techniques necessary to support and train their peers.
SECOND VICTIMTRAIN-THE-TRAINER
WORKSHOP
The Center for Patient Safety, in collaboration with the University of Missouri Health System’s Second Victim Program is pleased to host the following workshop...
PRESENTED BY THE CENTER FOR PATIENT SAFETY AND THE UNIVERSITY OF MISSOURI HEALTH SYSTEM’S SECOND VICTIM PROGRAM
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SAFETY CHECKLISTSThe American Hospital Association’s
Hospital Engagement Network (HRET) has published 16 safety checklists to eliminate patient harm. The checklists are developed from evidence-based best practices and include improvement strat-egies, action items and resources that may be effective within your organiza-tion. Use each checklist to assess your organization to identify your opportu-nities for improvement.
RECOMMENDATIONS FROM THE NPSF
Last year the National Patient Safety Foundation convened an expert panel to assess the state of patient safety across the nation and set the stage for the next 15 years. Their focus is on the estab-lishment of a total systems approach resulting in an improved culture of safety. Government, regulators, health profes-sionals, and others are called to place higher priority on patient safety science and implementation by following these eight recommendations:
1. Ensure that leaders establish and sustain a safety culture2. Create centralized and coordinated oversight of patient safety3. Create a common set of safety met-rics that reflect meaningful outcomes4. Increase funding for research in patient safety and implementation science5. Address safety across the entire care continuum
6. Support the health care workforce7. Partner with patients and families for the safest care8. Ensure that technology is safe and optimized to improve patient safetyRead the full report here.
PSO HOLDS VALUE FOR LONG TERM CARE
Do you have an affiliation with a long-term care facility (LTC)? The value of par-ticipating in a PSO is spreading across the continuum of care. CPS has historically offered PSO services to hospitals, medical clinics, ambulatory surgery centers and emergency medical services. However, LTC providers may now join the PSO. Many are already taking advantage of Just Culture training and measuring their culture with the safety culture survey. For further information, contact Kathy Wire, [email protected].
CPS RELEASES ITS 2015 ANNUAL REPORT
The Center’s 2015 Annual PSO Report was released earlier this year and con-tains information on the data received through the PSO. More than 45,000 events are summarized in the report. If you have not already reviewed the report, we encourage you to download it here.
HOW TO AVOID DEADLY INFECTIONS ASSOCIATED
WITH ENDOSCOPESMany hospitals across the US are deal-
ing with infections caused by inappropri-
ate duodenoscope reprocessing. Don’t be one of them! The Center for Patient Safety partnered with the North Carolina Quality Center PSO in April to sponsor a webinar addressing the issue. CPS PSO participants heard from Dr. William Rutala, Director of Epidemiology at the University of North Carolina Health, as he explains the breadth of the challenge, alternatives to scope processing and how to prevent future infections.
PROMOTING SAFETY WITH LEUR CONNECTORS
Historically, the Luer connector was used for many incompatible purposes: intravenous infusions, epidural catheters, enteral feedings, blood pressure cuffs, etc. Misconnections have occurred with catastrophic results. California law will soon mandate that hospitals use mutu-ally incompatible connectors for three purposes: intravenous, neuraxial (e.g., epidural), and enteral. While the law driv-ing the adoption deadline is in California, hospitals throughout the world will be making this change.
Dr. Rory Jaffe, Executive Director of the California Hospital PSO, is actively engaged in the ISO standards process and device manufacturers’ rollout planning. Hear the inside story, from one of the few on the International Standards Working Group involved in planning the deploy-ment of the new devices. Major changes will occur in the supply chain and at hospitals. Prepare your hospital for the change, and understand some of the potential pitfalls ahead.
“The best bet right now for organizations to support learning is to be part of a PSO. PSOs rep-
resent a learning community. I urge PSOs to be open and generous with their work and share
great stuff.” Dr. Donald Berwick, past president of IHI
CHECKLISTS, CHANGES BRING TRANSFORMATIONS TO THE PATIENT SAFETY COMMUNITY
PATIENT SAFETY INSIDER | NEWS YOU CAN USE
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Center for Patient Safety (CPS) staff Kathy Wire, Lee Varner and Eunice Halverson joined other PSO represen-tatives from around the country at the Agency for Healthcare Research and Quality (AHRQ) Headquarters in Rockville, Maryland, for the 8th Annual AHRQ PSO Meeting in April. As one of 81 PSOs certified nationally, operating within 28 states and District of Colum-bia, CPS continues to be a leader in PSO activity. CPS is:
• 1 of nine PSOs with more than 250 PSO contracts
• 1 of 67 PSOs receiving reports• 1 of 23 PSOs with more than
10,000 reports• 1 of 38 PSOs offering services in
all states• 1 of 2 PSOs providing services to
EMS services• 1 of 36 PSOs receiving reports in
all AHRQ defined safety categories• 1 of 11 PSOs submitting data to
the national PSO database (PSOPPC)
HIGHLIGHTS OF THE MEETING• AHRQ and CMS representatives dis-
cussed the regulations for Section 1311(h) of the Affordable Care Act which were released earlier this year. The Section re-quires hospitals with more than 50 beds to engage with either an AHRQ-certified PSO or alternative evidence-based initia-tives, in order to be eligible to participate in Health Insurance Exchanges. This reg-ulation is effective January 1, 2017. CMS strongly encourages organizations to re-port patient safety events using AHRQ’s standardized common data formats.
• Nidhi Singh Shah, CMS, noted that the AHRQ and CMS have “reached an agreement in principle” regarding coordi-nation of PSO activity and protections and needs of CMS state surveyors to ensure regulatory compliance.
• David Hunt, MD, Medical Director of the Office of the National Coordinator (ONC), advised that the ONC Health IT Committee continues to work with NQF to “learn, improve and lead” in the patient safety world. They are seeking to identify
and prioritize IT patient safety measures. • PSO legal updates were shared by
Andrea Timashenka of the Department of Health and Human Services. Details of current legal cases can be found on the CPS website (click to review). A team from Baptist Health in Florida described how hospitals across the state have worked with their state regulators and agreed how documents in patient safety evaluation systems will be addressed. De-spite Amendment 7 in Florida, hospitals have been successful in protecting their patient safety work product. Presenters cautioned, however, that PSO participants need to have well-defined policies and re-port to their PSO in order to successfully claim the federal protections of the Pa-tient Safety and Quality Improvement Act of 2005 in court. If you need help updating your PSO policy, contact Eunice Halverson.
• The AHRQ has provided, and will con-tinue to develop, resources to help pro-viders better understand PSOs and select a PSO on its website at www.pso.ahrq.gov.
FOR MORE INFORMATION, or for assistance updating your PSO policy, contact Eunice Halverson. You can reach her at [email protected].
The Agency for Healthcare Research and Quality is headquartered in Rockville, Maryland.
A UNITED FRONT TO IMPROVE CARE
ONLINE: To learn more about the Agency for Healthcare Re-search and Quality, visit their website at ahrq.gov.
8TH ANNUAL AHRQ PSO MEETING
BY EUNICE HALVERSON, MACenter for Patient Safety
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INCREASING OUR UNDERSTANDING
Patient Safety Organizations (PSOs) and their participants have struggled with interpreting the Patient Safety and Quality Improvement Act (PSQIA) with respect to handling patient safety work that may be necessary to satisfy mandatory reporting or other operational requirements. In an effort to ease
anxiety and develop a common understanding, the Agency for Healthcare Research and Quality (AHRQ) has issued a statement (“Guidance”) on the interface of (1) PSO protection of Patient Safety Work Product (PSWP) and (2) mandatory reporting and operational requirements. AHRQ’s statement is available online (click here). Below are some highlights, based on the questions CPS gets most often from its participants. CPS participants are encouraged to contact the Center’s staff with questions.
• The PSQIA has always required that PSO participants keep the information required to satisfy mandatory reporting requirements outside of the PSWP “pro-tected” space. The Guidance reinforces that requirement. However, the PSQIA and the Final Rule allow participants to gather information inside the PSES until they know whether it will need to be reported. If outside reporting is required, then the information gathered in the PSES that has not yet been reported to the PSO can be pulled back out, so that it can be used to satisfy the outside reporting requirement. The Guidance recognizes both this early PSES protection and the opportunity to pull information from the protected space when necessary.
• Like the Final Rule, the Guidance em-phasizes that analysis that takes place in the PSES cannot be “dropped out.” It must remain as PSWP.
• If a participant has a known obligation under state or federal law to report certain information, the provider should plan on
developing it outside the PSES, as it cannot be PSWP.
• The Kentucky Supreme Court’s Tibbs decision held that work surrounding man-datory state reporting could not be pro-tected, as the state retained the right to investigate how the provider was accom-plishing its reporting obligations. AHRQ’s Guidance seems to question that position, noting instead that information related to the required reporting “form” could be protected once the essential reporting obligation has been fulfilled by submitting the actual form, as long as the original doc-uments from which the report was devel-oped are still available.
• A variety of projects may take place after a patient safety event. AHRQ’s Guid-ance contains some helpful examples on pages 6-7 of how that work can be viewed as inside or outside of the PSES, and when it will have to be non-PSWP because of outside reporting requirements.
• AHRQ encourages PSOs and their par-ticipants to work with state agencies and
regulators to determine what information they need access to and what can reliably be viewed as PSWP, so that there are fewer confrontations on the front lines about those issues. (NOTE: CPS has historically supported its participants wherever pos-sible.)
• The Guidance emphasizes that PSWP is protected because it has been developed for reporting to the PSO, and that the PSES is a protected space for developing that information. CPS has encouraged its par-ticipants to view PSO reporting as the end point of their PSES activities, and to actu-ally report to the PSO. AHRQ’s Guidance underscores the importance of reporting.
• The Guidance specifically mentions hospitals’ requirement under the Con-ditions of Participation to track adverse events, noting that there is a “legitimate outside obligation” to keep those records. 42 CFR 482.21(a)(2) (https://www.law.cornell.edu/cfr/text/42/482.21). Incident reports have been a flashpoint in many states with respect to surveyors’ ability to see PSWP. PSO participants should care-fully consider what routinely reported event information goes into or out of the PSES. For example, some PSO advisors recommend that basic incident data that includes just patient name, date, location and a brief description would allow regu-lators to conduct their own investigations while protecting the PSO participant’s deeper investigation and analysis of those events.
• The action plans or other actions or changes that result from analysis inside the PSES cannot be protected and can always be shared with surveyors.
WHAT THE AGENCY FOR HEALTHCARE RESEARCH AND QUALITY’S GUIDANCE MEANS FOR HEALTHCARE PROVIDERS AND THEIR PATIENTS.
AHRQ GUIDANCE | WHAT DOES IT MEAN TO ME?
BY KATHY WIRE, JD, MBA, CPHRMCenter for Patient Safety
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Each year the Center for Patient Safety (CPS) offers a PSO Day for its participants to meet face-to-face to network and learn from each other. This year’s Safe Table discussions on April 6 centered around early identification of
sepsis and management of suicide ideation for patients not on behavioral medicine units. One participant noted, “I appreciate the opportunity to meet others who often have the same challenges we face at our hospital. I always look forward to learning from my colleagues and determining what changes we can implement to improve patient care, thus decreasing the chances of future harm to our patients.” Safe Table information is available to the Center’s PSO participants. (CPS PSO Participants only)
SAFETY CONFERENCEOver 140 health care professionals from several states gath-
ered at CPS’ 2016 Patient Safety conference in St. Louis on April 7. Highlights included:
High Reliability - David Marx, the “father of Just Culture” and well-known author and systems design engineer, provided insights into “The Human Role in High Reliability”. Using his recent per-sonal experience of a family member’s hospitalization, Marx chal-lenged attendees to maximize human reliability by influencing the design of the health care system and its processes. Throughout the day, Marx spoke with attendees and autographed his newly released book, “Dave’s Subs: A Novel Story about Workplace Ac-countability”, a gift for each attendee.
Just Culture - Professionals from CoxHealth in Springfield, MO shared their experience with the implementation of Just Culture across their system. Vicki Good (Quality and Patient Safety), Mark Alexander (Pre-hospital Services) and Cheryl Dunn (Employee Re-lations) each explained the significance of their role in not only implementing Just Culture but what they do to ensure it continues
LEARNING OPPORTUNITIES:HIGHLIGHTS FROM THIS YEAR’S PSO DAY AND PATIENT SAFETY CONFERENCEBY EUNICE HALVERSON, MACenter for Patient Safety
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to be “alive and well” at CoxHealth. Contact [email protected] for more information.
Staff Empowerment – Jerry Reinke, representing the National Associa-tion of Health Care Assistants, shared how improving relationships between all caregivers, including nurse assistants, has a positive impact on direct pa-tient care.
Patient Safety Across the Continuum of Care – Michael Handler, MD, Medical Director for CPS, as well as other Center staff challenged attendees to consider patient safety concerns across the many settings of care: EMS, ED, inpatient, surgery, ancillary departments, rehab, long-term care and hospice. Ensuring complete and accurate communication, especially during hand-offs of care, will help prevent errors which sometimes result in patient harm.
Pediatric Errors in EMS – Peter Antevy, MD and EMS Medical Director for several fire departments in southern Florida, explained how the human brain contributes to human errors – and it can’t be avoided! He shared his ongoing research to improve outcomes of pediatric arrests outside the hos-pital.
Many positive comments were received from PSO Day and conference attendees, all who have the same goal in mind: eliminate patient harm!
“Don’t tell the Board how you messed up last month, but rather tell them how you are preventing harm next month. You can do this by completing RCAs on near misses and measuring behavioral choices. Design good systems to support good decisions. In the end, you will help wonderful nurses be wonderfully safe nurses who make good choices to be great caregivers.”
— David Marx, CEO, Outcome Engenuity
POSTERSPosters from ten organizations in six states
provided more opportunities for learning:• Antibiotic Stewardship – Hannibal Re-
gional Healthcare System – Missouri• Implement a Clinic-Centered Safety
Program – Mercy Clinic East Community – Missouri
• Integrating an Institution-Wide Multidis-ciplinary Safe Learning Environment to Address Patient Safety Issues and Quality Initiatives – VA Nebraska Western Iowa Health Care System – Nebraska
• Medication Safety: Less Noise – Hannibal Regional Healthcare System – Missouri
• Mitigating Preventable Adverse Events with the Use of Safety Advisors – The Hos-pitals of Providence Sierra Campus – Texas
• Novel Cutaneous Identification Device as an Inpatient Identifier – Lenox Hill Hospi-tal – New York
• Population Health – Hannibal Regional Healthcare System – Missouri
• Revitalizing the Traditional Hospital-Based Root Cause Analysis with Lean Six Sigma – Memorial Health System – Illinois
• Stay Standing: A Falls Prevention Collab-oration – Still University – Area Health Education Center - Missouri
• Using Human Performance Tools to Re-duce Pediatric Medication Errors – Univer-sity of Michigan Health System – Michigan
PSONEWS SUMMER 2016
FOR MORE INFORMATION on PSO Day or the Conference, email Eunice Halverson at [email protected].
PSONEWS SPRING 2016 CENTERFORPATIENTSAFETY.ORG THE CENTER FOR PATIENT SAFETY 14
WATCH YOUR STEP!BY TINA HILMAS, RN, BSNCenter for Patient Safety
For the past 3 years (2013, 2014 and 2015) falls have remained in the top 5 reported sentinel events. Despite the multitude of fall prevention toolkits, healthcare organizations continue to struggle with preventing falls.
There are many factors which contribute to falls from balance to toileting activities to confusion to medication. Medication as a contributing factor is one of the more challenging factors to assess. While medications such as anesthesia and pain medication post-operatively automatically raise red flags, many others do not.
In reviewing the data submitted to CPS, 146 falls were report-edly associated with medication. Looking at the medications most frequently cited:
1. Oxygen – 28 events2. Pain medication/Anesthesia – 26 events3. Blood thinners – 13 eventsOxygen is a major medication that automatically increases the
risk of falling. It is often overlooked because many times oxygen is not considered a medication but rather a treatment. Many of the events involving oxygen involved a patient not utilizing their oxygen as prescribed. Oxygen deprivation can lead to confusion, which can contribute to an unsteady balance and increase the risk for falls. Also the oxygen tubing is a risk for a fall. It is important to keep it out of the pathway of the patient utilizing the oxygen.
Pain medication and anesthesia post-operatively are also fac-tors that automatically increase a patient's risk for falling. While this category automatically receives the most attention in regards to increasing a person’s risk for falling, what isn’t always kept in mind is the effect that anesthesia and medication have on the el-derly. Physiological changes that occur as a person ages also affect how pain medications or anesthesia are metabolized by the el-derly. It can cause confusion, such as an elderly person who is no longer weight bearing thinking they can stand. Age and post-op status should automatically raise a patient’s risk factor for falling.
Patients who fall while taking blood thinners are at an in-creased risk for harm. If these patients fall, the caregiver must al-ways consider whether an whether an intra-cranial hemorrhage has occurred. Due to the dangerous potential consequences, this patient population should always be considered high risk for falls with appropriate precautions in place.
Be mindful if patients have any of these other medication fac-tors:
1. Four or more medications2. Anti-hypertensives such as Procardia3. Antihistamines such as Benadryl or Atarax4. Anti-platelets such as Persantine5. Anti-depressants such as Elavil6. Benzodiazepines such as Valium7. Non-benzodiazepines such as Ambien or Lunesta8. Cardiovascular agents such as Nifedipine9. InsulinIn summary, when addressing falls, while many factors play a
part and can increase a patient's risk, one of the first areas to as-sess for risk factors are the patient’s medications. It’s important to evaluate not only the top 10% of the iceberg that is visible, but also the 90% that is unseen that could truly help prevent a patient from falling!
TINA HILMAS is a project manager at the Center for Patient Safety. You can reach her at [email protected].
ONLINE: To access additional resources about preventing falls can be found on the following websites: 1. www.priorityhealth.com/provider/clinical-resources/medication-resources/~/media/documents/pharmacy/cms-high-risk-medications.pdf2. www.drugguide.com/ddo/view/Davis-Drug-Guide/109640/all/Drugs_Associated_with_Increased_Risk_of_Falls_in_the_Elderly3. www.centerforpatientsafety.org/wp-content/up-
loads/2015/12/Collaborative-Assessment-Falls-in-Missouri.pdf4. www.jointcommission.org/assets/1/18/SEA_55.pdf5. www.ahrq.gov/sites/default/files/publications/files/fallpx-toolkit.pdf6. www.centerfortransforminghealthcare.org/tst_pfi.aspx7. psnet.ahrq.gov/resources/resource/29414
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PSONEWS SPRING 2016 CENTERFORPATIENTSAFETY.ORG THE CENTER FOR PATIENT SAFETY 14 PSONEWS SPRING 2016THE CENTER FOR PATIENT SAFETY CENTERFORPATIENTSAFETY.ORG 15
FOUR PATIENT SAFETY CASES WORK THROUGH COURTSBY KATHY WIRE, JD, MBA, CPHRMCenter for Patient Safety
Cases involving the Patient Safety and Quality Improvement Act continue to work their way through state and federal courts with no major changes.
Here is a status update on the significant cases:
1. Tibbs v. Bunnell (Kentucky)The U.S. Supreme Court denied the hospital’s application for a
writ of certiorari (a request for the Court to review an issue that relates to Federal law) filed in Tibbs v. Bunnell, No. 2012-SC-000603-MR (Ky. Aug. 21, 2014). This means the Kentucky Supreme Court decision will stand, in which the Kentucky Supreme Court ruled that any work performed in order to meet State requirements could not be patient safety work product, whether or not the work itself, or other products of it, had to be reported. This decision, as it stands now, applies only to Kentucky
2. Carron v. Newport Hospital (Rhode Island)A plaintiff presented a Tibbs-type argument in Rhode Island. The
trial court simply entered an order requiring production of the pro-tected documents without any analysis. The case was appealed and the state Supreme Court has agreed to hear it. This is good news, in that the RI Supreme Court is interested in determining if the trial court inaccurately overlooked the federal protection of the docu-ments declared by the defendant as patient safety work product.
3. Charles v. Southern Baptist Hospital (Florida)The Florida Supreme Court has decided to accept the case on ap-
peal. A decision is expected this summer or fall. The (PSO-favorable) appellate court decision rejected the Tibbs rationale. The trial court had followed Tibbs and found that any document or other work produced as part of compliance with a state requirement could not be protected PSWP. The appellate court rejected that claim.
4. Baptist Richmond v. Agee (Kentucky)This is an appeal before the Kentucky Supreme Court in which
the trial court ruled that the PSQIA protections only apply to in-formation being collected for the “sole purpose” of reporting to a PSO. In other words, if being collected for any other purpose the protections would not apply. The appellate court did not accept the appeal, noting that this decision was consistent with the Tibbs Kentucky Supreme Court ruling. This case is still being briefed and is pending before the Kentucky Supreme Court.
The Center for Patient Safety has participated with other PSOs to file briefs in these cases, supporting the protections available under what the PSOs believe is the clear language of the Act and the Final Rule. Important rulings will be published with a special alert to all of the Center’s PSO participants.
THE CENTER FOR PATIENT SAFETY will continue to issue immediate legal updates about important decisions. If PSO participants or their attorneys have any questions, please contact Kathy Wire at [email protected].
LEGAL UPDATE | IMPACTING THE PATIENT SAFETY WORLD
PSONEWS SUMMER 2016
PSONEWS SPRING 2016 CENTERFORPATIENTSAFETY.ORG THE CENTER FOR PATIENT SAFETY 16
NEW CPS REPORT SEEKS TO RAISE EMS AWARENESSBY LEE VARNER, MSEMS, EMT-PCenter for Patient Safety
Emergency Medical Services (EMS) is a special and unique profession with many dedicated men and women. These professionals bring compassion, enthusiasm and dependability in often very challenging environments. The Center for Patient Safety (CPS) is committed to provide support, resources and tools to improve safety in the EMS setting. In light of that, CPS published the PS-10 Report to raise awareness of
patient safety concerns in EMS.
EMS FORWARD | IN THE COMMUNITY
Ten Safety Topics for EMSThe ten selected safety topics are reflective of
those most often identified as risks to patient and provider safety and are forecasted to be of greater concern for EMS in 2016. This report is not an all-in-clusive list of the patient safety concerns in EMS, but complements current patient safety and quality pro-grams and provides resources to take proactive steps to eliminate harm.
It would be difficult for an organization to ef-fectively and efficiently address all ten topics in a 12-month period. Since many topics overlap, leaders are encouraged to select one or two areas to imple-ment change and monitor improvement, which will result in secondary benefits in other areas.
The topics in this report were selected following a review by CPS experts and a review of leading EMS
industry publications and journals. CPS also ana-lyzed the PSO’s database of actual event information from EMS providers nationwide. As one EMS leader shared, “There is an illusion that EMS is so safe now - [we] have forgotten how inherently dangerous it is”. This PS-10 should be shared with frontline providers, middle managers, and executive leaders. Click here to download the PS-10: EMSForward report.
THE CENTER FOR PATIENT SAFETY is a private not for profit organization that works across the continuum of care to improve quality as well as greater patient and provider safety. To learn more contact Lee Varner at [email protected].
#EMSFORWARD SAFETY TOPICS• Airway Management• Behavior Health Encounters• Crashes: Ambulance and Helicopter• Device Failures• Medication Errors• Mobile Integrated Healthcare• Pediatric Patients • Safety Culture• Second Victim Inter-vention• Transition of Care
PSONEWS SUMMER 2016
PSONEWS SPRING 2016 CENTERFORPATIENTSAFETY.ORG THE CENTER FOR PATIENT SAFETY 16 PSONEWS SPRING 2016THE CENTER FOR PATIENT SAFETY CENTERFORPATIENTSAFETY.ORG 17
PATIENT SAFETY IN EMS | EMS SAFETY CONVERSATIONS
PUT THE FOCUS ON SAFER CARE IN EMS COMMUNITYEarly this year the CPS team started a pilot program to introduce the safety huddle concept to PSO
participants. One group that started the huddle pilot program was a select group of EMS medical directors. What are huddles and how can they improve patient safety as well as the quality of care?
Huddles are timely, structured, secure and confidential conver-sations that allow for discussions in a rapid-fire format that explore real-time safety concerns. These virtual meetings provide an op-portunity to assess risk and share ways that mitigate future safety concerns. Huddles are offered through the Center’s Patient Safety Evaluation System, so conversations are protected by the federal Patient Safety and Quality Improvement Act. The huddles have in-cluded timely conversation on current issues with input to improve event investigations and action planning.
AREAS OF RECENT DISCUSSION INCLUDE: Airway Management: the importance of utilizing capnography
for airway monitoring as well as confirmation of airway placement.Time Critical Diagnosis: early identification and transportation
to appropriate destinations for this patient population.Transition of Care: Improving the hand-offs between providers
so that important information is not lost or omitted which might contribute to an unsafe event reaching a patient.
Steps are underway by CPS staff to support process improve-ments around these areas as well as collaborating with providers, leaders and other stakeholders to improve and standardize the hud-dle process. The CPS team looks forward to continuing the huddles with EMS medical directors -- stay tuned for more opportunities in the future. For more information, contact Lee Varner.
PSONEWS SUMMER 2016
The Center for Patient Safety (CPS) is proud to announce the launch of its newly revamped website. The site offers quick and easy access to essential information, resources and features while providing a more comprehensive understanding of the critical role that the Center plays in helping promote safe and quality healthcare through the reduction of medical errors.
The site, which went live on June 6, also features comprehensive sections with news, events and educational resources, as well as a blog and corporate information.
As a PSO participant, we know your access to resources is important. We’ve worked to improve your access by provid-ing you with your own login information to easily access the toolkit and partici-pant-only resources.
The new website boasts a clean design aimed at improving functionality with enhanced content and improved security measures focused on helping CPS fulfill its mission to promote a safe and just culture.
CPS’ new website will be updated on a regular basis with news, resources, and safety alerts and a newsletter aimed to help healthcare organizations reduce med-ical errors.
Visitors are encouraged to explore the
website and sign up for the Safety Snap-shot at www.centerforpatientsafety.org.
NEW CPS WEBSITE REQUIRES REGISTRATION
PARTICIPANTS ONLY: DON'T MISS OUT ON ACCESS TO SPECIAL RESOURCES
1. Visit www.centerforpatientsafety.org2. Select Members in the top right corner3. Click on “Not A Member” to register a username
and password4. Once approved, you’ll receive confirmation via
QUESTIONS about the new website? Contact Jennifer Lux at [email protected].
CPS UNVEILS NEW WEBSITE
PSONEWS SPRING 2016 CENTERFORPATIENTSAFETY.ORG THE CENTER FOR PATIENT SAFETY 18
PSO PARTICIPANTS | DATA UPDATE
PSONEWS SUMMER 2016
IMPORTANT UPDATE! FOR PSO PARTICIPANTS...
ANNOUNCEMENTSThe Center for Patient Safety's PSO
continues to grow with new organizations joining regularly. Participating organiza-tions have reported thousands of events in 2016 so far. The reported information is used for sharing and learning purposes.
Following review and analyses of the reported events, CPS has issued more than a half dozen watches and alerts as mecha-nisms to raise awareness about the patient safety trends reported to the PSO.
CPS is excited to announce several new services and features for PSO participants:
1. We have made an investment in an-alytical software, SAS, to expand on current analyses and provide more robust reporting to participants. You'll see more on this soon!
2. VergeSolutions is preparing to roll out enhanced options within their data collection portal. One new feature will allow for secure communication about events from participant to PSO and vice-a-versa. Stay tuned!
3. We've launched a new website with specific member access for you. When logged in, you'll have direct access to your toolkits, huddle report-outs, and more, as well as a new Q&A area to ask and answer questions from other participants. See the page 17 for details about setting up your access!
2016 DATA UPDATEData submitted to the Center for Patient
Safety's PSO for 2016 reveals an increase in the number of reported medication events.
Of the medication events reported:• 60 events were associated with
opioids• 36 were associated with benzodi-
azepines• 3 events were associated with a
handoff to or from another unit • The most commonly cited contrib-
uting factor was the human factor
of inattention with communication among staff and team members being the second most commonly cited contributing factor.
Please see our 2015 Annual PSO Report for resources to improve communica-tion and tools for decreasing medication events.
2016 EVENTS (JAN-JUN)
PATIENT SAFETY ALERTS AND WATCHES
ISSUED1. AHRQ Guidance2. Contaminated Supplies3. Home Health Medica-
tion Management4. Patient Destination
Decisions5. EKG Strips6. Intranasal Medication
Administration 7. Find more online
Type of Event # of EventsBlood 20Device 71Falls 826HAI 24Medication 1156Perinatal 101Pressure Ulcer 23Surgery 303VTE 2Other 2906
Harm Level # of EventsDeath 8Severe 9Moderate 43Mild 384No harm 3668Unknown 1370
PSONEWS SPRING 2016 CENTERFORPATIENTSAFETY.ORG THE CENTER FOR PATIENT SAFETY 18 PSONEWS SPRING 2016THE CENTER FOR PATIENT SAFETY CENTERFORPATIENTSAFETY.ORG 19
PATIENT SAFETY INSIDER | SAFETY CULTURE SURVEY
TAKE ADVANTAGE!Anyone can use CPS safety culture survey services, but CPS PSO Participants receive a 20% discount!
REQUEST A PROPOSAL TODAY!
Benefits of CPS Safety Culture Survey Services:• Deepest feedback reports in the industry!
• Comprehensive reports at the organization and
department-level!
• SAVE TIME & MONEY! Save 30+ hours of
administrative time. You'll need about 2 hours for
the entire process and we'll take care of the rest!
• ACCESSIBLE - online, anonymous survey with
access via computer, smart-phone, tablet, etc
• DATA ANALYSIS - data is analyzed for you
• SUPPORT - we'll talk with you about your results
and guide you to your next steps
We want you to be successful! PRICING IS AFFORDABLE FOR ORGANIZATIONS OF ALL SIZES
Culture surveys now available for:• Hospitals• Ambulatory Surgery Centers• Long Term Care• Home Health• Medical Offices• Pharmacies• EMS - NEW!
PSONEWS SUMMER 2016
2410A HYDE PARK RD. JEFFERSON CITY, MO. 65109
PHONE: 1.888.935.8272
www.centerforpatientsafety.org
The Center for Patient Safety, established in 2005, is an
independent, not-for-profit organization dedicated to
promoting safe and quality healthcare through the
reduction of medical errors.
FOR MORE INFORMATION, CONTACT ANY MEMBER OF THE PSO TEAM:
ALEX CHRISTGEN, BS, CPPS Interim Executive Director
EUNICE HALVERSON, MA Patient Safety Specialist
KATHRYN WIRE, JD, MBA, CPHRM Project Manager
LEE VARNER, MS-EMS, EMT-P Project Manager - EMS Services
TINA HILMAS, RN, BSN Project Manager
MICHAEL HANDLER, MD, MMM, FACPE Medical Director
AMY VOGELSMEIER, PHD, RN, GCNS-BC Researcher/Data Analyst
JENNIFER LUX Office Coordinator
Find us. Follow us. Like us.
Visit www.centerforpatientsafety.org for additional information on the Center’s PSO activities, resources,
toolkits, upcoming events, safety culture resources, and more.
If you have questions about any Center resources or articles within this newsletter, please contact the
Center for Patient Safety at: [email protected]
or call 888.935.8272
The information obtained in this publication is for informational purposes only and does not constitute legal, financial, or other professional advice. The Center for Patient Safety does not take any
responsibility for the content of information contained at links of third-party websites.
NOTE: Some articles contained within this newsletter may reference materials available to Center for Patient Safety PSO participants only.
WELCOME NEW STAFF!AIMEE TERRELL
Administrative Assistant [email protected]
