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Feb. 15, 2010
Are you looking for some new information on root cause analysis? Here are some resources you may find useful:
In the Maryland, all hospital-acquired Stage III/IV pressure ulcers or deep tissue injuries must be reported to the state and a root
cause analysis submitted. To streamline this process, a form for reporting the RCA has been developed. It covers the important
issues that should be considered when evaluating a pressure ulcer incident. The form is available in two formats (document and pdf
at the sites below:
www.dhmh.state.md.us/ohcq/download/hospforms/short_rca_hapu.doc
www.mdahq.citymax.com/f/Short_RCA_for_HAPU_revised.pdf
The National Patient Safety Agency of the NHS in the UK has recently redesigned their site. The section on root cause analysis now includes several report-writing tools and templates. These resources can be found at: www.npsa.nhs.uk/nrls/improvingpatientsafety/patient-safety-tools-and-guidance/rootcauseanalysis/
Oct. 21, 2009
There has recently been a lot of interest in high reliability organizations and what healthcare organizations can do to create processes that consistently operate as expected. While there are many mistake proofing techniques that can be applied to health care processes, it is also important to understand the environment/ culture that is needed to support high reliability. At the link below you’ll find a presentation on high reliability and mindfulness – an important attribute of an organization committed to improving the reliability and safety of health care processes. Link: http://cahmi.org/ViewDocument.aspx?DocumentID=275
Sep. 10, 2009
Hospitals are being challenged to
reduce readmissions and Medicare is upping the ante through changes in reimbursement. A report just
released by the California Health Foundation outlines some relatively inexpensive
strategies hospitals can use to sharply reduce readmissions. The report, available
for download at the link below, describes nine programs that are addressing
the problem and identifies important factors that influence success. Link:
www.chcf.org/topics/chronicdisease/index.cfm?itemID=134064
Aug. 31, 2009
The Kaiser Permanente department
of National Patient Care Services has created a Distance Learning Program to connect with community
health organizations to share access to learning opportunities. All resources
on this site are available at no charge to anyone interested in expanding
their knowledge. To learn more about the learning modules on the site (some related to patient safety) go to:
http://nursingpathways.kp.org/national/communityoutreach/
Genetic Alliance recently launched a free online customizable family health
history tool, "Does It Run In the Family?" The tool was developed
so anyone can create personalized booklets about health for their families and communities. Designed for organizations, but
useful for individuals and families, the tool allows users to personalize
family health history booklets with stories, photos, quotes, local resources,
interview questions, and specific health condition information. The "Does
It Run In the Family?" booklets explain why family health history is
important, how to talk about it, and outlines health conditions that run in
families. For more information go to: http://www.doesitruninthefamily.org/
Jun. 3, 2009
National Mental Health Development Unit in London recently published a workbook entitled, Strategies to Reduce Missing Patients. This workbook explains the challenges of missing patients and offers practical strategies to help facilities reduce the numbers who go missing. The PDF version of this April 2009 publication is available at: www.nimhe.csip.org.uk/silo/files/strategies-to-reduce-missing-patientspdf.pdf
The National Initiative for Children`s Healthcare Quality (NICHQ) has compiled resources related to the development and use of rapid response teams for pediatric inpatient populations. These free resources can be found at: www.nichq.org:80/patient_safety_rrt.html. On the NICHQ website you`ll also find pediatric patient safety resources related to medication use and prevention of infections and pressure ulcers.
May 28, 2009
A team training tool on Rapid Response
Systems is now available from the Agency for Healthcare Research Quality and the Department of
Defense. Designed for use by hospital teams, the training module complements the Team Strategies and Tools to Enhance Performance
and Patient Safety (TeamSTEPPST), which was published in 2006. This evidence-based
module, available in CD format, provides insight
into the core concepts of teamwork as they are applied to the Rapid Response System. The curriculum can be customized to meet your
facility’s unique needs. The Instructor Guide includes a complete course planning package, with suggested lesson plans and resources,
as well as tools for monitoring, evaluation, and ongoing coaching. The CD includes a set of vignettes in which professional actors
demonstrate rapid response system problems and their solutions and curriculum
slides that can be customized. Free copies of the Rapid Response System module
CD are available at: http://teamstepps.ahrq.gov/abouttoolsmaterials.htm or
by calling AHRQ's publication clearinghouse at 800-358-9295.
Apr. 13, 2009
“Pathways for Patient
Safety” are a new series of education tools designed to improve patient safety in physician practices. They were
developed jointly by the Health Research and Educational Trust (HRET), the Institute for Safe Medication Practices (ISMP) and the Medical
Group Management Association (MGMA). The free tools include:
* Working as a Team - outlines actions required for building high-
performing patient safety teams and techniques for effective
communications among care givers to reduce patient harm.
* Assessing Where You Stand - provides practical steps toward minimizing medical errors by assessing current patient-safety
procedures, addressing practice culture and setting goals.
* Creating Medication Safety - describes factors practices should consider when implementing or augmenting a medical reconciliation
process, and when prescribing or administering medications that may be harmful to patients.
In 2006, this group launched the “Physician Practice Patient Safety Assessment.” This self-assessment tool helps physician practices
evaluate their patient-safety processes and detect areas for improvement. All
of these tools can be downloaded for free from the MGMA sponsored website: www.physiciansafetytool.com