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Ju., 29, 2007
Four new online patient safety improvement resources are now available:
* The Agency for Healthcare Research and Quality has released `Mistake-Proofing the Design of Health Care Processes`, a synthesis of practical examples on the use of process or design features to prevent medical errors or the negative impact of errors. This free resource, written by J.R. Grout, includes over 150 examples of mistake-proofing techniques that can be applied in health care. Go to: www.ahrq.gov/qual/mistakeproof/
* `Infection: Don't Pass It On` is a public health campaign established through a collaboration between the Veterans Health Administration and various public health organizations. The goal of the campaign is to involve staff, patients, and visitors in taking basic steps to preventing infection, whether occurring daily, seasonally, or occurring during infectious disease emergencies. The major message of the campaign is to wash your hands and cover your Go to: www.publichealth.va.gov/infectionDontPassItOn/Default.htm
* In June 2007 the American College of Radiology (ACR) published an update to its 2004 white paper on MR safety, the `ACR Guidance Document for Safe MR Practices.` This document covers every aspect of MR safety, from the design of the MR suite and the qualification of staff to screening patients and what to do in an emergency. Go to: www.acr.org/SecondaryMainMenuCategories/quality_safety/MRSafety/safe_mr07.aspx
* The Food and Drug Administration has a free educational kit that nurses, midwives and other educators can use to make presentations on food safety for pregnant women. The kit contains an Educator`s Resource Guide with background and facts on food safety, reproducible handouts and a 20-minute video. The materials are available in English and Spanish. Go to: www.cfsan.fda.gov/~pregnant/tools.html
Jul. 8, 2007
The Agency for Healthcare Research and Quality has released a handbook to help providers set up patient registries for the purpose of improving the quality of care. Included in this handbook are recommendations for designing the database and elements of quality to consider when setting up and maintaining the registry. Also discussed are ethical and privacy considerations. The complete handbook, Registries for Evaluating Patient Outcomes: A User's Guide, is available online at www.effectivehealthcare.ahrq.gov. Free print copies are available by calling 800-358-9295. Ask for AHRQ Publication Number 07-EHC001-1.
Jun. 11, 2007
Taming the Measurement
Monster, an article by Patrice Spath, was published in the June/July 2007
issue of Frontiers of Health Services Management. This article is also available
on our website in the Web Links (www.brownspath.com/weblinks.htm). A link
to the article is in the Performance Measurement and Improvement section. While you
are there, be sure to check out other new links we have recently added. The
Department of Community and Family Medicine at Duke University
Medical Center has developed online patient safety-quality improvement
training modules for physicians. You can access these modules
at: http://patientsafetyed.duhs.duke.edu/index.html
May 14, 2007
Handout materials from the March 2007 Michigan Patient Safety Best Practices Conference are now available on the website of the Michigan Health and Safety Coalition. To download the handout materials go to: www.mihealthandsafety.org/patientsafety.html
May 3, 2007
Handout materials from the Maryland Patient Safety Conference in March are now available for downloading on their website. Speakers included Dr. Lucian Leape and Patrice Spath. To download the handout materials go to: www.marylandpatientsafety.org/html/education/032307/presentations.html. The Royal College of Surgeons of Edinburgh and the National Health Service in Scotland have collaborated on a project designed to evaluate the non-technical skills of surgeons. The tool allows attending surgeons to give feedback to colleagues and trainees based on structured observations of four categories of performance: situation awareness, decision making, communication & teamwork, and leadership. The system is intended to be used in the intra- operative environment. To learn more about this project and the evaluation tools go to: www.abdn.ac.uk/~psy296/dept/Aberdeen%20NOTSS%20project%20home.htm
Apr. 23, 2007
Children’s Hospital of Minnesota has created a short training video entitled, “Asking for Help: Calling the Rapid Response Team.” The video depicts a caregiver’s interactions with a worried mother of a hospitalized infant. The training video illustrates the confluence of factors that influence the decision to call the Rapid Response Team. The message conveyed to the viewer is that any and all concerns regarding a patient who may be deteriorating merits such a call. A post-view discussion guide and parent brochure explaining the Rapid Response Team process is also available. The video and accompanying materials can be found online at: www.childrensmn.org/ForHealthProfessionals/ForHealthProf.asp. Click on “rapid response team video and discussion guide” in the resource section on this page.
Mar. 8, 2007
Hospital violence is a significant and growing concern and it's no wonder. Consider the types of patients that may enter the hospital: * patients who have active psychiatric diagnoses * patients high on drugs * patients having adverse reactions to illegal drugs and/or alcohol * gang members with a history of violent behavior * family members in the midst of abusive situations * incarcerated prisoners (forensic patients). Emergency departments and clinical areas must develop appropriate security policies and procedures to reduce the negative impact violence can have on the quality of patient care and staff working in these areas. A 2-part article on hospital security and forensic patients is available online at Securityinfowatch.com. Included with the article is a "Forensic Patient Action Plan." You can find this article at: wwww.securityinfowatch.com/article/article.jsp?siteSection=&id=9811. The healthcare security guidelines recently published by the International Association for Healthcare Security and Safety are another useful hospital security resource. These guidelines are available in PDF format at: http://www.iahss.org/pdf/guidelines/IAHSSGuidelines0107.pdf
Feb. 13, 2007
The Society of Hospital Medicine has compiled a variety of quality improvement tools to enhance patient safety and quality of inpatient care. The tools include order sets, guidelines, templates, and worksheets. They are for use in a variety of clinical settings and serve as a resource for institutions seeking to make improvement in inpatient care. The tools cover a wide variety of clinical topics, including: * acute myocardial infarction * anticoagulation * catheter associated bloodstream infections * discharge planning * pain management * skin and wound care * venous thromboembolism prophylaxis. The tools can be downloaded from the SHM website. Go to: http://www.hospitalmedicine.org/ Click on "Quality & Patient Safety" (on the left side of the home page). Then Click on "Quality Improvement Tools"
Feb. 2, 2007
Improving Chronic Illness Care (ICIC), a national program of The Robert Wood
Johnson Foundation, has developed the "Chronic Care Model" designed
to improve care for patients with chronic conditions such as diabetes, asthma
and depression. In addition to facilitating regional learning collaboratives,
the ICIC has
gathered together a variety of tools that can be used by clinicians to implement
changes in the six Chronic Care Model elements. Several of these tools can
be downloaded from the ICIC website at: www.improvingchroniccare.org/tools/criticaltools.html
Jan. 17, 2007
Medication management in long-term care involves careful reconciliation of the resident's prescribed medication regimen whenever a resident is transferred in or out of the long-term care facility, regardless of the reason or length of time away from the facility. Effective medication reconciliation depends upon the cooperative efforts of pharmacy, nursing, clerical, and physicians. The University of Pittsburgh Institute on Aging has developed several tools that caregivers in long term care can use to facilitate medication reconciliation for residents. These tools can be found at: www.aging.pitt.edu/health-care-professionals/resources-med-mgmt.htm. On this site you'll also find policies for Labeling & Storage of Drugs and Biologicals in a LTC facility and a link to a resource entitled, "A Systems Approach to Quality Improvement in Long-Term Care: Safe Medication Practices Workbook" developed by the QIO in Massachusetts.
Jan. 6, 2007
Handouts and presentations from the National Association of Health Data Organizations' 21st Annual Meeting held December 2006 are now available on their website. Topics covered at the conference included: * Quality Measurement and Reporting: Challenges and Opportunities * Enhancing Administrative Data for Quality Reporting * Healthcare-Acquired Infection Reporting Standards and Practices * Translating Data into Action * The impact of CMS DRG Modifications on claims data quality. To view or download the conference materials go the NAHDO website: http://www.nahdo.org and click on the link to meeting materials.
Nov. 18, 2006
The Department of Defense, in collaboration with the Agency for Healthcare Research and Quality, has created a team training toolkit for healthcare organizations. This toolkit, entitled TeamSTEPPS, is an evidence-based teamwork system aimed at improving communication and other teamwork skills among healthcare professionals. TeamSTEPPS includes a comprehensive suite of ready-to-use materials and training curricula necessary to successfully integrate teamwork principles into all areas of the healthcare system. The multimedia TeamSTEPPS curriculum kit is available for free. Contained within the kit are training modules (text and powerpoint format), video vignettes illustrating key concepts, workshop materials, and implementation recommendations. All TeamSTEPPS tools, except for the video vignettes, can be accessed online at: www.usuhs.mil/cerps/teamstepps.html (click on " Preview TeamSTEPPS materials"). Ordering information for the complete kit can also be found on this site, as well as the TeamSTEPPS site maintained by AHRQ: www.ahrq.gov/qual/teamstepps/
Oct. 31, 2006
The Utah Department of Health has created a Microsoft Access tool designed to help health care organizations track adverse drug events. This tool is free to anyone who is interested. You can obtain the tool and user guide at: http://health.utah.gov/psi/adereporter.htm The National Academy for State Health Policy has developed a patient safety toolbox that includes several data analysis tools used by states to evaluate the thoroughness of root cause analyses submitted to the state health department. To access these tools, click on "Data Analysis Tools" on the patient safety toolbox page: ttp://www.pstoolbox.org/_catdisp_page.cfm?LID=111
Oct. 16, 2006
The Washington State Hospital Association (WSHA) has developed two tools for sharing performance data with hospital boards. One is a model dashboard report - a one page informational sheet with color coding to assist in performance analysis. They've also developed PowerPoint templates for quality measure trend reports which can be used to present to the Board benchmark data along with explanatory information. In addition to the tools for Board communication, on the WHSA" tools" website you'll find various patient safety leadership resources. To view and download these resources go to: http://www.wsha.org/page.cfm?ID=PSCommunicationTools
Sep. 18, 2006
Conducting patient safety culture surveys have been likened to describing the water to a drowning man; in other words, they tell you how bad things are, but provide little assistance in identifying the solutions. The Delmarva Foundation in Maryland has created a resource that includes many different solutions. "Improving Your Hospital Culture: A Guide to Understanding, Measuring, and Changing your Most Important Asset" can help you improve the patient safety culture in your hospital. Topics covered in the guide include: * What culture is and why it matters to your hospital * How to assess the culture and see whether it is changing * What can be done to change your culture. The guide is designed to help you quickly find information and materials you may need. The powerpoint and PDF files that can be accessed from the Delmarva website allow you to link to lots of additional information and tools. To access this free guide, go to: www.delmarvafoundation.org/providers/hospitals/culture.html
Sep. 7, 2006
Minnesota's Quality Improvement Organization, Stratis Health, has a extensive list of health care performance improvement and information management tools and resources on their website. This searchable list offers a wide variety of practical resources for hospitals, home health agencies, long term care, and outpatient clinics. The resources (pdf files, document files, etc.) are yours to download! Go to the Stratis site: www.stratishealth.org and click on" Tools & Resources" at the top of the home page.
Jul. 31, 2006
The Health Disparities
Initiative is a program designed and supported by the Health Resources and
Services Administration's Bureau of Primary Health Care to eliminate disparities
in the delivery of healthcare to all individuals living in the U.S. The
program invited provider organizations to participate in collaboratives
on various topics with the goal of improving their healthcare delivery systems
and measuring the effectiveness of changes. The collaboratives
cover asthma, cancer, management of depression, prevention of diabetic and
cardiovascular disease, general disease prevention, and business redesign. Organizations
participating in the collaboratives agreed to adopt national, as well as local
measures of quality based on proven guidelines. The measures used in these collaboratives can be
found on the program website. In April 2006 the business
redesign collaborative published a
guide for leaders entitled,"Leaders' Guide to Developing the
Business Case for Planned Care." The Leaders' Guide PDF
document includes a framework and guidance that health center
leaders and staff can use in their efforts to drive their
business case. Also included in the Leaders' Guide are a
series of Toolkits that evolved from the work of the pilot
collaborative group. These Toolkits include resources and
specific tools that can also be accessed through links to the
website Library. All of the above resources can be found
online at:
http://www.healthdisparities.net/hdc/html/home.aspx
Jul. 11, 2006
The Next of Kin Education
Project is a non-profit effort dedicated to improving patient care and safety
in hospitals. This group has developed a toolkit of materials for health
care professionals. This Seven Steps Information kit provides hospitals
with concise training tools and sample chart pages that can be adapted for
use in patient's charts. The kit gives patient care staff tools they can use to locate an
unconscious patient's emergency contact information, perform next of kin communications,
and obtain informed consent quickly and easily. The kit can be downloaded
from the Project website at: http://nokep.tripod.com/nokep.htm
Jun. 6, 2006
The Pharmacy Association of Wisconsin has posted a collection of medication reconciliation tools used at seven Wisconsin hospitals on their website. You can find these downloadable tools at: www.pswi.org/reconciliation2.htm
May 28, 2006
In April 2006 the Minnesota Hospital Association sponsored a Fall Prevention "Day of Sharing" for participants to share and discuss successes, barriers, models, tools, and other resources regarding hospital falls prevention. Participants addressed six topical areas related to falls prevention, which included: * Assessment * Communicating High Risk for Falls * Moving Assessment into Prevention * Communicating Prevention Plans * Documenting Plans * Post-Falls Action. The fall prevention tactics shared by participants are now available on the MHA website at: http://www.mnhospitals.org/index/fallprevention
May 18, 2006
The University Hospital
Consortium (UHC) is assisting its members in implementing the performance
improvement initiatives of the Institute for Healthcare Improvement (IHI) 100,000 Lives Campaign:
* Rapid response teams * Acute myocardial infarction care * Prevention of
adverse drug events * Prevention of central line-associated bloodstream infection *
Prevention of surgical site infection * Prevention of ventilator-associated
pneumonia. Included on the public area of the UHC website
are examples of
tactics that UHC members are using to achieve performance goals.
To view these tactics go to:
http://public.uhc.edu/uhcmail/ihi/IHI.htm
Apr. 12, 2006
Handouts from the
presentations at the Maryland Patient Safety Center's 2nd Annual Patient
Safety Conference held on March 30, 2006 are now available for downloading
on their web site. Topics include:
* A system wide approach to obstetrical risk reduction * Rapid implementation
of tight glycemic control * Medication management in the long term care setting *
Don't forsake accountability (presentation by Patrice Spath)
* Suicide: predicting the unpredictable. Go to: http://www.marylandpatientsafety.org/
and click on the
conference presentation link.
Mar. 26, 2006
With funding from the John A. Hartford and Robert Wood Johnson Foundations, the Care Transitions Program in the Division of Health Care Policy and Research at the University of Colorado Health Sciences Center has designed tools to support patients as they make the transition from hospital to home. These tools include: * A patient-centered record that consists of the essential care elements for facilitating productive interdisciplinary communication during the care transition. * A structured discharge preparation checklist of critical activities designed to empower patients. * A 15-item uni-dimensional measure to assess the quality of care transitions. The tools and instructions for their use are available on the Care Transitions Program website at: www.caretransitions.org/
Mar. 11, 2006
The Center on Aging, Kansas State University and the Kansas Department on Aging is collaborating on a project designed to change the culture within nursing home environments. The goal is to encourage implementation of progressive, innovative approaches to care that make a significant difference in the quality of care and the quality of life for those living and working in long-term care environments. The PEAK (Promoting Excellent Alternatives in Kansas) nursing home initiative includes a series of educational modules featuring information about changing culture within nursing home environments. These modules are intended to be used by providers as they work to implement change among clients and staff. Excerpts from the training modules are available online and you can also order the complete modules. Modules are free of charge to facilities in Kansas. Requests outside Kansas are charged a modest fee. Also on the PEAK project site are newsletters describing the project and progress to date. The project website is: http://www.k-state.edu/peak/index.htm
Feb. 27, 2006
GeroNurseOnline is a comprehensive website providing current best practice information on care of older adults. The website is maintained by Nurse Competence in Aging, which is a collaboration between the American Nurses Association, the American Nurses Credentialing Center, and the John A. Hartford Foundation Institute for Geriatric Nursing. Currently on the GeroNurseOnline site there is a training program on managing urinary incontinence (CEUs available) plus a large number of patient assessment tools. Go to the resources page on the site (http://www.geronurseonline.org) to find these tools.
Feb. 6, 2006
The Muskie School
of Public Service maintains a database of information on quality measures
that have been developed for home and community based services. You may
search the database in a number of ways to find indicators of interest.
To learn more about this database go to: http://webapp.usm.maine.edu/MuskieQualityIndicators/. The National Inventory of Mental Health Quality Measures provides
a searchable database of process measures for quality assessment and improvement
in mental health and substance abuse care. To learn more about this database
go to: http://www.cqaimh.org/quality.html
Jan. 22, 2006
StratisHealth has developed a discharge planning quality resources tool kit. The resources in the tool kit will help hospital case managers identify and facilitate patients' post-hospital needs. The resources will also help you assess your facility's strengths and identify areas for improvement in the transitioning of patient care. The StratisHealth discharge planning tool kit can be found online at: http://www.stratishealth.org/Tools_Kit_discharge_planning.html
Dec. 29, 2005
Patients with multiple conditions receive care from health care professionals from a variety of disciplines. Studies show that patients with complex needs do better when every person involved in their care (including the patient) work together as a team to develop a smart plan of care. The geriatric interdisciplinary team training program, sponsored by the John A. Hartford Foundation, is designed to improve teamwork and improve patient outcomes. Included on their website (http://www.gitt.org/) are a variety of free materials including: * Team fitness test * Team observation tools * Sample team training exercises and teaching tools. Be sure to fully explore the site - you'll find lots of useful teamwork training resources.
Dec. 2, 2005
Norvatis Pharmaceutic
has developed a number of reference manuals
of interest to health care professionals caring for seniors. The
senior care manuals currently available are: * Healthcare Practitioner Reference
Manual for Use in Long-Term Care Facilities * Healthcare Practitioner's Guide
to Risk Management in Long-Term Care Facilities * Healthcare Practitioner's Guide to Drug Interactions in the
Elderly * Healthcare Practitioner's Guide to Alternative Oral Dosage Forms for
the Geriatric Patient. These manuals are available for
download (PDF) on their website: www.novartisvin.com/seniorcare/hps/default.jsp. To
access this area on their website, you may be required to sign- up as a Novartis
VIN
member (there is no charge).
Nov. 7, 2005
The Victorian (Australia)
Quality Council has developed several patient safety improvement tool kits.
One is
a guideline pack entitled, "Minimizing the risk of falls and falls injuries:
Guidelines for acute, sub-acute and residential care settings." Included
in the guideline pack is a framework and supporting
resources to support falls prevention activity in hospital and residential
care settings. The fall prevention guideline pack can be found at:
www.health.vic.gov.au/qualitycouncil/plans/falls_5d.htm
Because both staff and patients have a role to play in pressure ulcer prevention,
the Council developed two patient information publications aimed at engaging
patients in pressure ulcer prevention. These publications are available in
eleven different languages. These patient publications can be downloaded at:
www.health.vic.gov.au/qualitycouncil/plans/pupps_patients.htm
Oct. 12, 2005
A national study of more than 1,700 nurses, physicians, clinical-
care staff and administrators found that fewer than 10 percent address behavior
by colleagues that routinely includes trouble following directions, poor
clinical judgment or taking dangerous shortcuts. In all, the study pinpointed
seven
categories of problems that are frequently encountered, yet rarely addressed.
In response to this study, the American Association of Critical Care Nurses
issued a set of national standards to promote skilled communication and
collaboration among nurses and other caregivers. The recommendations emphasize
the urgent
need for hospitals to implement initiatives, especially communication training
and education, to ensure that healthcare professionals deliver safe, high
quality care to their patients. The study results, survey tools, and other
informative materials can be found on the website: http://www.silencekills.com/
Oct. 6, 2005
The Partnership for Clear Health Communication is a coalition of national organizations that are working together to promote awareness and solutions around the issue of low health literacy and its effect on health outcomes. The Partnership has developed a new "Ask Me 3 Presentation Tool Kit" designed to be used in teaching clinicians and patients how to communicate with one another. To learn more about the Partnership and the tool kit, go to: www.askme3.org/PFCHC/
Sep. 19, 2005
Authors of a newly published study of patient safety educational materials found that these materials may not always be effective or appropriate. The study, published in the Sep. 2005 issue of the `Joint Commission Journal on Quality and Patient Safety`, analyzed materials published by national patient safety organizations, including those of the Joint Commission. Several recommendations for improving the materials are offered by the study authors. The study was funded by the Commonwealth Fund and a complete copy of the article can be downloaded from their website: http://www.cmwf.org/publications/
Sep. 8, 2005
The UK National Patient Safety Agency has undertaken a major patient safety initiative aimed at improving caregivers' hand hygiene. The initiative, entitled "Cleanyourhands," is based on positive results identified during a pilot project held in 2003-04. On the Agency's website (www.npsa.nhs.uk/cleanyourhands) you'll find all the information and resources you need to implement a similar initiative in your health care facility.
Aug. 23, 2005
Looking for some good resources on quality management in transfusion services? Look no further. The British Columbia Provincial Blood Coordinating Office maintains a website for the TraQ Program. The goal is to promote quality improvement among transfusion medicine professionals through timely access to and sharing of education and quality management information related to current practices and guidelines in transfusion medicine. On the site you'll find guidelines, training and educational material related to the administration of blood products. The materials have been developed by transfusion medicine professionals throughout Canada, the UK and the US. Most are available for free on the site. You'll need to register on the site to access some of the materials, but registration is also free. Check it out! You can find the site at: http://www.traqprogram.ca
Aug. 11, 2005
The University of Pittsburgh Medical Center (UPMC) McKeesport has developed three Quality Safety Teaching/Learning Packets to provide physicians, nurses, and therapists with a common language to address complex patient safety issues. These Packets teach caregivers how to keep patient safe: * by calling for help early (rapid response) * from hospital acquired infections * from falls and contusions. The rapid response training packet is a PDF file. The other two are powerpoint files. You can view and download these training packets at: http://mckeesport.upmc.com/KeepingPatientsSafe.htm
Jul. 18, 2005
Child Health Corporation of America, the National Association of Children's Hospitals and Related Institutions, and National Initiative for Children's Healthcare Quality (NICHQ) have partnered to bring resources to the children's health care community as part of the Institute for Healthcare Improvement 100K Lives Campaign. The webcasts are being offered free of charge. On July 20 at 2 PM Eastern time the topic of the webcast is: Preventing Ventilator-Associated Pneumonia. Future webcasts are on preventing central line infections and surgical infections. In June webcasts were held on how to deploy rapid response teams and medication reconciliation. Powerpoint presentations and audio from these two webcasts are available for download on the CHCA web site. Registration for the webcasts is limited so if you are interested in joining in, sign up ASAP. If you can't join the webcasts, be sure to check out the presentations and audios from past webcasts. To learn more go to: http://www.chca.com/news/index.html
Jul. 7, 2005
Looking for a `fill-in-the-blank` failure mode and effects analysis? The Utah Patient Safety Steering Committee's Adverse Drug Effects (ADE) User Group has created one that you can use to analyze anticoagulation usage within your hospital. The tool is based on the VA HFMEA model, however it could be adapted to whatever FMEA model you might be using. The Utah ADE group created a FMEA table that covers all aspects of anticoagulation use - from ordering to patient education. The process steps, possible failure modes, effects, and suggested risk reduction strategies have been added to the table. All your caregivers need to do is review the template, adjust to fit your situation, apply probability and severity ratings, and identify the best risk reduction strategies for your facility. Of course, it is also up to you to implement these strategies and monitor effectiveness. The Utah ADE group`s FMEA tools and instructions for use can be found online at: http://www.uha-utah.org/ADEpublications.htm
Jun. 27, 2005
What quality tool is best to use during the various steps of a process improvement project? What tools are used during a Six Sigma project? Are they different from the tools employed in the PDCA cycle? If you are looking for answers to these questions you'll find the Quality Tools and Techniques Selector Chart on the website of De La Salle University a handy resource. The common and not-so-common quality tools used during the PDCA Cycle and during two Six Sigma improvement models (DMAIC & DMADV) are listed. Click on the name of the tool and you'll be taken to another webpage that describes the tool and how to use it. Both beginners and "seasoned" quality professionals will find the Quality Tools and Techniques Selector Chart to be a useful resource. Be sure to check out the other quality-related information on the site. http://quality.dlsu.edu.ph/tools/tool_chart.html
Jun. 7, 2005
Many healthcare organizations are investigating ways of improving
information flow. A recent study of surgery scheduling coordination
illustrates how to analyze systems in a complex environment. The
study, conducted at the University of Maryland in Baltimore,
involved the use of sampling techniques to uncover subtle factors
that influence human performance in complex systems. The
study was published in a special issue of the IEEE Transactions
on Systems, Man, and Cybernetics, November 2004. The link below
will take you directly to the PDF file of the journal article. http://www.ctlab.org/pdf%20files/SurgicalScheduling.pdf. In
the same special issue of the IEEE Journal issue you'll find
a study on "Failure to Respond to Alarm" Problems. The link below
will take you directly to the PDF file of this journal article. http://www.ctlab.org/pdf%20files/AlarmProblems.pdf
May 14, 2005
The mission of the Center for Health Sciences Interprofessional
Education and Research located at University of Washington is to
promote health of individuals and the public by advancing
interprofessional collaboration. The Center's Faculty Leadership in Interprofessional
Education to Promote Patient Safety (FLIEPPS) project developed a curriculum
that can be used by educators of
health care professionals to promote the development of practical approaches
to developing patient safety. The "Best Practices
in Patient Safety Education" module
handbook
was developed by the FLIEPPS project participants. This handbook
consists of modules about the core elements of patient safety and
interprofessional teaching, readings and other reference resources,
and interactive exercises to apply the principles outlined in the
handbook. The 3rd edition of the handbook is now available online at:
http://interprofessional.washington.edu/fliepps/curriculum.asp
Apr. 21, 2005
The Maryland Patient Safety Center held their first annual Patient
Safety Conference at the Baltimore Convention Center on March 31.
Robert Wachter, M.D., author of "Internal Bleeding: The Truth
Behind America's Terrifying Epidemic of Medical Mistakes" delivered
the keynote presentation and a notable line up of leading experts conducted
concurrent
breakout sessions that highlighted key
patient safety issues. The very informative handout
materials from this conference are
now available on the Patient Safety Center`s web site:
http://www.marylandpatientsafety.org/
Apr. 12, 2005
The Agency for Healthcare Research and Quality (AHRQ) has just launched
their new online Patient Safety Network (PSNet), featuring the latest news
and essential resources on patient safety. On
the site, in "What's New", you'll find
an annotated, carefully
selected compilation of the most recent and important news, tools,
and conferences in patient safety. "The Collection" is your gateway
to thousands of patient safety resources. If you're new to the field and want
to see the most enduringly important articles and books on patient safety,
you'll find them under "Classics". You can also customize the site
around your own interests and sign-up to receive the PSNet newsletter, which
highlight what`s new each week. Visit the AHRQ PSNet at http://psnet.ahrq.gov
Apr. 3, 2005
Boston University Medical Center is involved in a project to
re-engineer the hospital discharge process. The project, developed
through the efforts of the Patient Safety Center, includes an
in-depth analysis of the discharge process and the adequacy of
discharge plans to link patients to their sources of primary care.
Errors in discharge related to medication, support services,
follow-up of abnormal findings, and discharge recommendations have
been identified. The root causes are being analyzed, including an evaluation
of the patient characteristics predictive of errors and the financial
consequences of the errors. Based on
this work, a revised discharge and follow-up system is
being developed and subjected to clinical trial. The details of
the project, including the process map, FMEA and re-engineering
discharge guidelines can be found on the project web site at:
http://www.bu.edu/familymed/projectred.html
Mar. 11, 2005
The Australian Council on Healthcare Standards (ACHS) annually hosts
an award program for health care improvement projects or strategies that
demonstrate outstanding achievements. The award
is sponsored by Baxter Healthcare and the ACHS. A summary of all entries
for the ACHS Quality Improvement Awards is published each year. These summaries
are now available online. The projects can be adapted for use by other health
care facilities or inspire ideas for new projects. To
download the project summaries, go to:
http://www.achs.org.au/content/Screens/file_download/QIa.htm
Mar. 3, 2005
On the website of Physicians Insurance, a liability insurance carrier for
physician practices in Oregon and Washington, you'll find a wide variety
of risk management and quality improvement resources. There are articles,
sample
documents, forms, and brochures intended to improve quality and reduce liability
risks in outpatient clinics. The index page for all of these resources is:
http://www.phyins.com/pi/risk/index.htm Once you are at the index page,
use the navigation bar on the left to navigate to other pages containing
various resources.
Feb. 27, 2005
In response to growing pressures from payors to reduce length
of
stay, the neonatologists throughout Connecticut have developed NICU
Discharge Guidelines. The guidelines represent evidence- and consensus-
based recommendations for judging the appropriateness of an infant`s
discharge from NICU. While the guidelines are broad enough to allow physician
discretion, they are specific enough to be meaningful in discussions
with payors and case managers. The guidelines
can be found online at the website of the Hezekiah
Beardsley Connecticut Chapter of the American Academy of Pediatrics
http://users.rcn.com/ctaap/main.html. The link to the guideline
word document is on the right. Scroll down the home page to find
the link. There is also a link to the cover letter that was
included with the guidelines when they were disseminated to
pediatricians in Connecticut.
Feb. 10, 2005
In January 2005, the American College of Endocrinology and the American Association
of Clinical Endocrinologists convened a consensus conference to discuss patient
safety in patients with
diabetes and other endocrine diseases. The conference brought together experts
from diabetes and endocrinology, general internal medicine, anesthesiology,
surgery, pediatrics, nursing societies,
governmental and regulatory agencies and key national organizations focused
on healthcare quality and safety. Following the conference a consensus statement
based on the discussions was published. This report, `Patient Safety and
Medical System Errors in Diabetes and
Endocrinology Consensus Conference: Position Statement` is now available
on the AACE website: http://www.aace.com/pub/PSCC/PatientSafetyPositionStatement.pdf
Feb. 7, 2005
Getting patients more involved in managing their medications is an important
aspect of patient safety. The Joint Commission has addressed this topic
in one of their 2005 patient safety goals that
requires implementation of a medication reconciliation process by hospital
providers. Some hospitals and outpatient providers are conducting medication
reviews with patients to identify and resolve problems(e.g. interactions,
unwanted effects, dosing irregularities, etc.) If you
are looking for examples of medication review forms and
patient information materials that can be used to conduct
medication reviews, check out what`s available on the website of the National
Prescribing Service, an Australian organization. Their Medimate program includes forms that patients can use to
record their medications and a cover letter that can be mailed to patients
to schedule a medication review appointment. For clinicians
the site includes lots of information about
medication management and guidelines for prescribing and
monitoring patients` medications. Much of the information on
the site is applicable to the U.S. health care system. I
encourage you to explore the website of the National
Prescribing Service (http://www.nps.org.au/) to discover all
they have to offer consumers as well as health care
professionals.
Jan. 23, 2005
The potential for home health patients to have a medication error is
high. Some studies suggest that up to 30% of home health patients have
experienced a possible medication error. A 2002
research study showed that collaboration between pharmacists, nurses and the
patient`s attending physician, can reduce medication
errors for home health patients. The home health Medication Management
Model consists of advice from a consultant pharmacist to the attending
nurse based on established guidelines. If appropriate, the nurse or
pharmacist brings the identified problem to the physician`s attention
for resolution. The Model can help home health agencies meet federal
standards for medication review and improve clinical outcomes by
identifying and preventing medication errors in their patients. A
comprehensive Toolkit for implementing the home health Medication
Management model is available online at:
http://www.homemeds.org/tools/toolkit1.htm
Jan. 2, 2005
Here`s a website where you`ll find lots of resources for health care quality
professionals. The Healthcare Quality Improvement Organization of New Jersey
has developed many tools that health
care facilities can use to improve performance. Go to their web site (http://www.pronj.org/info.php)
and click on the intervention tools under Resources. There you`ll discover
many improvement tools for physician offices, nursing facilities, home health
agencies and hospitals.