A publication for hospitals, ASCs and medical officesPSONEWS

FALL 2015 EDITION

IN THIS EDITIONAligning Culture with Strategic...1

Culture Stats.2

Culture Measurement as Key...3

LTC Update.4

EMS Update.5

Pointers for Implementing Change.6

PSO Legal Update.6

Patient Safety Insider.8

PSO Co-Sponsors National Webinar.9

PSO Data Update.10-11

Upcoming Events.12

CPS Speakers: On-the-Circuit.12

ALIGNING CULTURE with the STRATEGIC PLANA success story shared from SSM Health

Patient safety is a top priority for SSM Health, which owns and operates 20 hospitals, more than 60 outpatient care sites, a pharmacy benefit company, an insurance company, two nursing homes, comprehensive home care and hospice services, a technology company and two Accountable Care Organizations in four states.

SSM Health has used the patient safety culture surveys to measure its progress and identify areas for improvement since 2007. While all hospital staff was surveyed in early years, SSM Health limited the survey to caregivers and added home care and long-term care facilities in 2014. Its many medical group practices across all four states were added in 2015 utilizing the medical practice survey tool. All caregivers are now encouraged to share their opinions about patient safety by completing the survey administered by the Center for Patient Safety (CPS).

PARTICIPATION IS UP

Participation in the 2015 survey increased to 62.9%, with some units achieving 100% participation. When asked why participation has steadily increased over the years to such a high level, Debby Vossenkemper, System Director/Patient Safety Officer, credited a consistent senior leader focus with leadership accountability, survey communication process and a strong rollout process.

“Our caregivers as well as leaders are serious about improving patient safety,” Vossenkemper said. “Action is

taken based on input from the front-line caregivers. In addition, we have a process to systematically communicate within each department details about the surveys, review department specific improvements from prior surveys and distribute the surveys to leaders through the use of a communication tool kit”.

“Our System CEO, Bill Thompson, sent a letter in January to all employees setting expectations and explaining that the patient safety survey and employee partnership survey are closely aligned and equally important. Our System Vice President of Patient Safety and Quality, Dr. Kevin Johnson, sent a similar message to all clinicians. System Communications and Human Resources are also very involved in the process, which makes a big difference.”

The weekly participation reports by department from CPS were also instrumental in driving up participation, enabling SSM Health to meet its participation goal.

THE RESULTS

Survey results are aggregated by CPS, who provides reports at the department level. This is helpful, as similar services across the system can compare results with each other. A toolkit including the results, a primer on how to read

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“The Center for Patient Safety has been a pleasure to work with on the safety surveys – this is our second year of doing so. Nothing is too much to ask and it’s always done with a smile! Changes to customize the surveys and reports for SSM Health made a huge difference to our staff’s buy-in.” DEBBY VOSSENKEMPER SYSTEM DIRECTOR/PATIENT SAFETY OFFICER

CENTER FOR PATIENT SAFETY

www.centerforpatientsafety.org

them and comparisons with previous survey results is distributed to all senior and clinical leaders. Leaders are expected to review, and discuss with their teams, improvements that have been made based on the staff’s input from previous surveys. In addition, the results are shared with senior leaders and System/Regional/Entity Patient Safety Councils to ensure a consistent understanding of the results across the organization and by facility.

The top improvement opportunities are identified, and teams of front-line staff develop action plans, which are aligned with the organization’s strategic plan and goals. Each department is expected to have a patient safety goal which is posted on a SharePoint website for transparency across SSM. Each facility’s senior leadership team defines an action plan related to two areas of focus related to the survey results which is reviewed quarterly at the Patient Safety Quality Council. In addition, the action plan addresses both areas of focus related to patient safety and employee partnership.

OPPORTUNITIES FOR IMPROVEMENT AND SUCCESS

While each facility selects areas of improvement based on its specific results, during the prior survey cycle the hand-off process between units, especially between the Emergency Department and nursing floors, was identified as an opportunity in several of the entities. Therefore, CQI teams are working to further study and improve the hand-off process. Last year, one hospital identified an opportunity to increase its event reporting rate to better understand where and why events or near-misses were occurring. This year they celebrated a 28% increase! The senior leadership team “owned” the event report goal and made it happen by reinforcing the goal in various ways, including conversations during senior leader rounding, No Harm Team meetings and distribution of talking points, and daily safety briefs.

RECOMMENDATIONS

Vossenkemper shared two learnings from SSM’s survey experiences: First, identify one or two areas that need improvement and drive change, as opposed to trying to improve everything at once. Second, use quality improvement techniques to achieve incremental improvement and set stretch goals to achieve results.

Congratulations to SSM Health for their focus and successes in improving patient safety!

FOR MORE INFORMATION

Contact Debby Vossenkemper at Debby_Vossenkemper@ssmhc.com or 314-989-2197.

CULTURE STATSWHAT IS CULTURE?

Culture is the way we do things. It is a group personality, created by the actions and behaviors of leaders, that has its own beliefs, values and norms.

WHAT IS PATIENT SAFETY CULTURE?

Patient safety culture is important in healthcare because the beliefs of employees drive their behaviors. If shortcuts are tolerated, they become the norm. Those shortcuts can lead to mistakes that result in patient harm.

Strong communication is a key component of a positive safety culture. If a culture doesn’t support open communication, staff may fear retribution if they speak up about their mistakes.

MEASURING PATIENT SAFETY CULTURE

Of the 30,000+ healthcare survey responses collected by the Center for Patient Safety (CPS), results suggest a focus on communication is still lacking:• 70% feel things “fall between the cracks” when

transferring patient from unit to another;• 68% feel problems often occur in the exchange of

information across hospital units;• 60% feel units do not coordinate well with each other.

Additional analysis reveals an ongoing need to support a “just” culture to support open discussion of mistakes in a non-punitive environment. In addition, staff commonly indicate they fear reporting their mistakes:• 60% worry the mistakes they make are kept in their

personnel file;• 60% feel when an event is reported, it feels like the

person is being written up, not the problem.

Measuring culture using a standardized safety culture survey offers a snapshot of the values and beliefs of the clinical staff in an organization. High-performing areas can be celebrated and rewarded. CPS finds regularly high-performing areas include:• Teamwork within units• Supervisor/Manager expectations and actions promoting

patient safety.Any organization can use the CPS survey services, but PSO participants receive a 20% discount. Interested in scheduling your next survey for your hospital, ASC, medical office, pharmacy, long-term care, or home care locations? Submit a request for a free estimate.

FOR MORE INFORMATION

If you are interested in the Center administering your next survey, contact Alex Christgen at achristgen@centerforpatientsafety.org.

CONTINUED FROM PAGE 1, “ALIGNING CULTURE...”

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Have you noticed this icon? Look for this icon to find additional resources in the articles. You’ll find links to downloadable templates, websites

and other resources.Available in the electronic version of

this newsletter.

FOR MORE INFORMATION

For more information, contact the CoxHealth Office of Patient Safety at 417-269-6589.

CULTURE MEASUREMENT AS KEY IMPROVEMENT TOOLA success story shared from Cox Health

The survey of patient safety culture has become a key improvement tool for CoxHealth, a health system across 5 campuses with 954 licensed beds. CoxHealth spans 83 clinics and serves 25 counties across southwestern Missouri. They have used the survey administered by the Center for Patient Safety (CPS) since 2010. All clinicians in the inpatient and outpatient settings as well as the clinics and EMS agency are encouraged to participate. While participation is a challenge, it has steadily increased over the years to 47% average due to improved communication. The surveys are discussed in the corporate newsletter as well as at leader meetings. Senior leaders discuss the surveys with staff during their regular rounding and encourage participation.

RESULTS

Survey results are aggregated and distributed by CPS, including department level reports for those units large enough to ensure anonymity. Vice presidents and department leaders are responsible for discussing results at staff meetings and identifying opportunities for improvement. Departments using the TeamSTEPPS module use the survey results to identify needs and focus education. Rachel Wells, Patient Safety Officer, advised, “The survey is used as a tool. It helps open the door for us to guide patient care departments and can assist them in focusing their priorities.”

SUCCESSES

There have been many successes at CoxHealth!

• The Radiation Oncology department had significant improvement, going from zero survey areas scoring above the 90th percentile, to seven survey areas above the 90th percentile in the last survey.

• The overall non-punitive response to error score was above the 90th percentile in 2014, which shows a high level of staff trust with management. Patient safety culture has been nurtured as management is supportive and consistently improves processes when opportunities are identified. Jeff Robinson, Radiation Oncology Director, reveals, “Safety Surveys tend to turn the invisible into the visible. Once we saw where we are at, we came together to make the needed improvements.”

• Cox Monet Hospital stands out as a benchmark within the system. It is a critical access hospital, and the staff’s access to senior leaders is outstanding. When opportunities for patient safety improvement are identified, teams work together to make improvements, which are communicated across the hospital to close the loop. The system is working to replicate this workflow model across all facilities.

LESSONS LEARNED

Wells’ words of advice based on her experience with the culture surveys: “Patient safety is a journey and the survey is a tool to measure our progress and help us focus along the way. Doing the survey once is not enough. It needs to be routinely offered to see how we’re doing.”

Congratulations to CoxHealth for their focus and improvements in patient safety!

What ’s the pulse of your organization?

?

CENTER FOR PATIENT SAFETY

www.centerforpatientsafety.org

LONG TERM CARE SAFETY IMPROVEMENT PROGRAMThe Center for Patient Safety (CPS) is excited to announce that PSO services are now available for long-term care (LTC) providers. Better yet, participation is FREE for all licensed Missouri providers.

CPS staff explored the options for LTC PSO participation and felt that targeted activities would be the best way to bring providers into this program. Working with Primaris to identify the right issues, two significant safety areas floated “to the top”: serious falls and adverse drug events involving high risk medications.

FALL PREVENTION

The falls project will collect data from participants in the PSO’s protected and confidential workspace about falls with injury or other serious or potentially serious fall events the provider chooses to report. CPS will aggregate the information, identify trends or patterns, look for potentially great solutions and push information back to the participants. Possible broad hazards, such as a type of equipment or medication that significantly increases the risk of falls, can be brought forward much sooner to the manufacturer and the LTC community. In addition, participating facilities have an opportunity to evaluate their facilities safety culture and have access to an easy tool to help perform investigations of adverse events that occur within the facility.

ADVERSE DRUG EVENTS

Participants in the drug project will report actual adverse events and near misses involving a selected group of high risk medications, which will include anti-coagulants, insulin and opioids.

It is estimated that reporting each event through the Center’s online system will take less than 5 minutes. Participants will be required to sign a contract with the Center and enact appropriate policies; CPS provides templates. CPS staff are available to provide support with both implementation and data entry.

Long Term Care

SAFETY Improvement Program

TAKE5MINUTES... to help prevent the next serious FALLorMEDICATION event.

DON’T MISS THIS FREE OPPORTUNITY!FOR MORE INFORMATION

If you are interested in participating, contact Kathy Wire at kwire@centerforpatientsafety.org.

FALL 2015

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EMS AGENCIES FOCUS ON BEHAVIORAL HEALTH PATIENTSThe Center for Patient Safety works closely with many EMS services around the United States to improve patient safety and reduce preventable harm. Over the past year EMS leaders have expressed interest to better serve the needs of the mental health population. In the process many of these leaders have discovered there is little data around these encounters and transports, including emergency calls, or scene encounters as well as inter-facility transfers between hospitals.

Earlier this year, the Center’s EMS data committee began exploring the opportunity to collect data to better understand encounters with behavioral health patients. This includes understanding what happens at the emergency scene as well as during inter-facility transfers. Recently the committee finalized the data collection formats for this project. Starting this month a pilot program was initiated to collect data and, so far, participation has been strong.

The behavior health pilot is collecting data around several key areas including provider and patient safety as well as resource utilization. Many leaders would like to understand the frequency and dynamics of specific high risk events such as patient elopement from an ambulance. The data will also support better understanding of a community’s mental health resources, as this often determines the destination for this patient population.

WHY THROUGH A PSO?

The EMS data committee chose to collect and analyze the behavioral health patient data within the Center’s patient safety evaluation system. As such, the information is confidential and protected under the Patient Safety Quality Improvement Act of 2005. Many EMS services have been hesitant to share data due to fear of litigation and concern about their public image. Therefore, the PSO is the perfect vehicle to allay these fears since the data and analysis are confidential and protected. Event information is aggregated, de-identified and shared with participants who can use it to improve their care of patients.

EMS leaders are hopeful that this new area of study will help everyone more clearly understand the current status. The Center and its many PSO participants are excited to be involved with this project. Ultimately, the goal is to use the data to drive greater patient and provider safety as well as to save healthcare resources.

Annual EMS Patient Safety ConferenceO C T O B E R 3 0 , 2 0 1 5

FOR MORE INFORMATION: Visit www.centerforpatientsafety.org/2015-EMS-Conference

FOR MORE INFORMATION

For more information, contact Lee Varner at lvarner@centerforpatientsafety.org.

www.centerforpatientsafety.org

CENTER FOR PATIENT SAFETY

POINTERS FOR IMPLEMENTING CHANGEHealthcare is currently in a constant state of flux or change. With pressure to reduce costs, improve quality and provide safe care, implementing change has become constant with the phrases “evidence-based practice” and “evidence-based care” becoming the new buzz words.

But how can changes be implemented? What can be done to ensure that the change is successful? Will there be a starting point and an ending point? These are all questions that surface whenever an organization undertakes changing a process. Although organizations are very different regarding resources, staff and implementation of daily routine, all seem to be looking for further tips on how to implement change.

The Sinclair School of Nursing recently held its 8th Annual Evidence-Based Practice on the Frontline conference which focused on “Building a Culture of Quality, Safety and Nursing Professionalism”. Dr. Marita Titler from the University of Michigan, keynote speaker, shared useful information regarding change and evidence-based practice. She shared illusions to implementing change:

• “We just need to tell them what to do and they will do it.”• “Clinicians just need to be told the change one time.”• “There is one right way to implement change.”• “We just need to hand out trustworthy guidelines and everyone will get on

board.”• “Clinicians always care about the topic where processes are being changed

– i.e. falls/infections.”

PSO LEGAL UPDATECases interpreting the Patient Safety and Quality Improvement Act (PSQIA) continue to wind their way slowly through the courts. Two new Florida trial court orders have recently reinforced the strength of PSQIA protections in that state: the cases are:

Loyless v. Flagler Hospital et al., No. CA12-24017th Judicial Circuit, St. Johns County, FLPETRASKIEWCHZ v. Laser Spine Institute et al., No. 13-CA-1439413th Judicial Circuit, Hillsborough County FL (August 10, 2015)

The Loyless order is very short. The court conducted an in camera review of the documents requested by the plaintiff and held that the documents were protected PSWP. It reinforces earlier advice from CPS that participants should anticipate that a judge may want to look at the materials for which they claim protection.

The Laser Spine Institute (LSI) court produced a more extensive order that analyzes the intricacies of Florida law. Florida courts have produced some challenging decisions in the past. The opinion discusses the history of the PSQIA, including quotes from the Final Rule and Congressional Hearings leading up to the law.

Briefly, the LSI court held that 1) the PSQIA supersedes Florida’s Amendment 7 and 2) a provider can prepare PSWP separate from the mandatory state reporting system and claim PSQIA protection for its PSWP.

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Highlights of the LSI case:

• The Vice President for Nursing and Surgical Services submitted an affidavit and also testified at the evidentiary hearing about the organizations Patient Safety Evaluation System (PSES) and procedures for generating PSWP. This was the key evidence that convinced the court about protections; preparation for this step is vital, as is having a sound PSES and related policies.

• LSI initiated a separate process (“Code 15 reports”) for investigating and reporting state-reportable events as soon as they were identified within the PSES. That work proceeded independently of ongoing work inside the PSES. Only the work conducted inside the PSES generated protected PSWP. Everyone acknowledged that the Code 15 information generated outside the PSES was discoverable under the terms of the PSQIA. The opinion notes that the only information the provider was required to report to the state was an Annual Report that included aggregated and summarized information about reportable incidents, and that the Annual Report contained nothing defined by LSI as PSWP.

• LSI had a very broad process for gathering information about adverse events, incidents and variances. The process for each type of information inside the PSES was well-defined. The information gathered at this stage was much broader than the information that must be reported under Florida law, which only includes selected serious events. The broad scope of review within the PSES seemed to influence the court, which contrasted it to the narrow reporting under state law. The court specifically noted that PSWP can be protected as soon as it is created within the PSES or reported to the PSES, and that protection does not depend on the specific data having been reported to the PSO.

CPS has always recommended that participants have clear pathways for information within and outside their PSES. The LSI case reinforces the need for that clarity, and also supports the availability of PSQIA protection for work that takes place in a well-defined PSES.

In contrast, the realities to implementing change include:• Implementing change is an ongoing process• Leaders and facilitators need to have an understanding of

the research AND be able to articulate it• Leaders need to CREATE interest and excitement regarding

the topic• Change needs to be compatible with work flow and make

the work easier, whenever possible• Use quick and handy reference guides/EMR electronic

reminders

Dr. Titler highlighted an important principle: “It is the interaction of the characteristics of the process change, the intended users and the context of the process change that determines the rate and extent of adoption.”

With technology changing on a daily basis, communication factors and style have become a huge part in influencing adoption of evidence-based practice and processes and there are so many components :

• Interpersonal communication channels• Multiple methods of communication• Social networks of users

Other communication factors to consider when implementing cultural change:

• Interactive education is more effective than didactic alone• Clinicians need knowledge as well as the skills to carry out

evidence-based practice change• Healthcare providers must keep patient and family values,

culture and preferences as top priorities when promoting process change

• Share key messages in the setting of the process change

Organizational factors that could affect adoption of change:• What is the learning culture? Does the organization

promote learning and stay on top of latest techniques/evidence-based practice?

• Is leadership implementing the change themselves and also promoting it?

• Is the climate receptive to change?• Is the change a good fit with the values of the intended

users and the culture of the organization?• How will you evaluate the impact of the process change?

With new standards and change becoming an every day occurrence, it is necessary to develop a healthy organizational culture that promotes patient safety and quality of care which is evidence-based. These pointers may help organizations adjust and build that healthy culture!

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CONTINUED FROM PAGE 6, “POINTERS FOR IMPLEMENTING CHANGE”

CENTER FOR PATIENT SAFETY

www.centerforpatientsafety.org

DREADED RCAsOne of the most important tools to improve the culture of patient safety is the cause analysis process. Yet, most organizations have not implemented a standardized process to complete a credible and effective root cause analysis (RCA) after an event. Common failures include lack of a standardized approach, failure to identify system level causes, superficial solutions, poor implementation of solutions and lack of follow-up. Earlier this summer the National Patient Safety Foundation presented RCA2: Improving Root Cause Analyses and Actions to Prevent Harm by Dr. James Bagian from the University of Michigan and Doug Bonacum, Kaiser Permanente.

The slides, webinar audio and full report are available at http://www.npsf.org/?RCA2

ALERT FATIGUEAuditory and visual warnings for clinicians to prevent or act on unsafe conditions have dramatically increased with implementation of technology. While these warnings are well intended and in isolation may be helpful, they can be overwhelming and irritating. Often clinicians override them, ignore them, or turn them off resulting in harmful events. A 2014 study found that the physiologic monitors in an academic hospital’s 66 adult intensive care unit beds generated more than 2 million alerts in one month, translating to 187 warnings per patient per day. Read more:

http://psnet.ahrq.gov/primer.aspx?primerID=28&utm_content=buffer250e2&utm_medium=social&utm_source=linkedin.com&utm_campaign=buffer

CALL TO ACTION - STOP THE SPREAD OF ANTIBIOTIC RESISTANCEThe CDC released a Vital Signs Report, Stopping the Spread of Antibiotic Resistance addressing the increasing number of germs that are no longer responding to drugs designed to kill them, causing more than 2 million illnesses and at least 23,000 deaths each year in the US. The report recommends that CEOs, administrators and clinicians work together on antimicrobial resistance prevention activities including antimicrobial stewardship programs and infection control actions to address these threats to patient safety.

http://www.cdc.gov/vitalsigns/stop-spread/index.html

FOCUS ON CREATING SAFER WORKPLACESIf your facility collects only reports of adverse events and ignores near misses, you are missing out on the most valuable source of data for identifying patient safety priorities and for measuring progress on fixing problems. Near misses are defined as an error that happened but did not reach the patient. These errors are captured and corrected before reaching the patient, either through chance or purposefully designed system controls that have been put in place. Thus, reporting near misses can help better evaluate whether your processes to ensure patient safety are effective.

Philip LaDuke has identified nine reasons why employees do not bother to report near misses. Are you missing an opportunity?

http://ehstoday.com/safety/management/9-reasons-near-miss-reporting

PATIENT SAFETY INSIDER

Did you miss any of these hot resources and articles the first time around? Here’s another chance to check them out...

FALL 2015

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On July 16, CPS was pleased to collaborate with the North Carolina Quality Center PSO and the Midwest Alliance for Patient Safety and host Dr. Bill Munier from AHRQ and Michael Callahan from Katten, Muchin, Rosenman, LLP on the first of a two-part series for participants of the three PSOs. Some key points shared by these national presenters included:

• The partnership between PSOs and providers is that of a social contract for national learning; PSOs accelerate learning, produce generalizable lessons for improvement and allow for comparisons and benchmarking

• The social contract supports a two-way, vertical system for quality improvement: Providers get protections from PSOs, providers share experience (data) with PSOs, PSOs share data nationally, national learning is shared with PSOs, providers, and the nation, and quality and safety are improved nationwide – starting from the ground up

• Benefits of working with a PSO include protections, specialized experience, and focused aspects of quality & safety

• Benefits of PSOs also include safe tables among providers, faster aggregation of larger volumes of information & richer analysis, shared learnings

• Over 5,000 healthcare providers are currently working with a Patient Safety Organization (PSO) across 29 states

• Critical questions to ensure protections under Patient Safety & Quality Improvement Act: Are your policies in place? Did you report to PSO?

• Healthcare providers cannot afford to miss out on the opportunity to participate in Patient Safety Organizations

• Section 1311 (h) of the Affordable Care Act will be effective January 1, 2017 requiring hospitals with more than 50 beds to participate with a PSO. AHRQ is providing information and resources to help providers select a PSO. Visit www.ahrq.gov for more information.

The recorded versions of these webinars are available to participants or their attorneys.

On July 30, the 2nd session of the series provided a deeper dive into the legal challenges to the PSO related protections. Michael Callahan delved further into the PSQIA definitions for what data can be protected and how to do that to maximize the benefits of PSO participation. Key issues shared by Mr. Callahan:

• PSO protections can benefit any licensed provider, and have particular value for sharing across system-based entities, for organizations operating across state lines and for integrated provider groups such as those within ACOs.

• PSO protections apply in both state and federal proceedings, providing reliable protection at the federal level for the first time. They can never be waived. If they are greater than protections offered under state law, the PSO protections supersede state law.

• Plaintiff attorneys are studying PSO protections and are developing arguments for release of PSO-related and protected documents. The best defense against this development for PSO participants starts with a valid contract with a PSO as well as appropriate policies and actual reporting to their PSO.

• Court interpretations of the law were discussed, including plaintiff arguments and responses for the Walgreens appellate court decision upholding PSO protections and PSO trial court decisions relating to medical malpractice cases in Florida, Pennsylvania, Kentucky, Illinois.

• A Kentucky case (Tibbs vs. Bunnell) which is pending before the US Supreme Court was based on what PSOs believe to be an incorrect interpretation of protections.

• Court decisions to-date only reflect the law within the state of the decision; providers and their counsel should not be hesitant in any state to actively participate in a PSO and gain the protections, sharing and learning that is possible through PSO participation.

CPS CO-SPONSORS NATIONAL WEBINAR

Visit www.centerforpatientsafety.org/second-victims for more information.

REGISTER NOW!SPACE IS LIMITED

September 24, 2015

Annually, the majority of events submitted to the Center for Patient Safety’s PSO result in no harm to the patient, however, there is a steady increase in events reported to the PSO which supports continued learning. With nearly 35,000 events from healthcare organizations, medication events continue to be the highest reported event type, followed by falls.

LESSONS FROM THE DATABASEMEDICATION ERRORS:Accurate medication reconciliation is a challenge. There are near misses and patient events reported to the Center’s database related to errors which occurred because the reconciliation process was either skipped or not done properly. In one case, a patient received another patient’s medications in error because they had been entered in the wrong medical record. Due to the patient’s underlying renal failure, the incorrect medications exacerbated the condition, resulting in death. Lesson Learned: streamline the reconciliation process as much as possible, but ensure that staff understand the importance of completing it accurately for every patient and follow the “5 Rs”:

• Right Medication• Right Patient• Right Time• Right Dosage• Right Route of Administration

FALLS:Patients on anti-coagulants who fall or hit their head are at a greater risk for a poor outcome. A high fall risk and high bleed risk patient fell when the therapist left the patient’s side while doing therapy. The patient initially appeared to have no injury; he was alert and oriented. He later developed a headache and had difficulty performing therapy. A cat scan indicated a cranial bleed. The patient was transferred to ICU and intubated, but the bleed was deemed inoperable and the plan of care was changed to comfort measures. Lesson Learned: Implement a process to indicate patients taking anticoagulants and ensure complete hand-offs when patients leave the nursing floor for treatments or therapies.Also with handoffs, ensure that a process for face-to-face handoff is in place. A patient requiring oxygen and Bipap was transferred between floors with no face to face report and left on tank oxygen which eventually emptied. The patient expired and it was noted that the patient had never been switched from the tank oxygen. Lesson Learned: A process for face-to-face handoff and standardized report would have set up a process for a thorough and complete transfer of care.

CENTER FOR PATIENT SAFETY

www.centerforpatientsafety.org

PSO PARTICIPANTS-ONLY: PSO Dashboards were delivered via secure email to primary contacts in early August. Watch for the next

PSO Dashboard release in October 2015.

PSO.DATA.UPDATE

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PROCEDURES:Several events occurred when patients were having diagnostic tests or dialysis. A patient was undergoing an outpatient CT guided lung biopsy in the imaging department. While in recovery, he became short of breath. The patient’s underlying respiratory illness had not been identified. His condition rapidly declined to unresponsive. CPR was started and the patient was transferred to the ED. Due to his condition, IV access could not be obtained and the patient expired. Lesson Learned: Consider requiring an IV line for all patients undergoing biopsies. Ensure ancillary staff are aware of all medical conditions. Consider requiring baseline oxygen saturation of 95% on room air.Several patients undergoing an MRI did not have their pre-procedure questionnaires completed accurately or they were not reviewed by the staff prior to the MRI. Examples include patients with an insulin pump, artificial heart valve, pacemaker, and a cerebral artery metal clip. Lesson Learned: Stress importance of staff ensuring the pre-procedure questionnaire is completed accurately and completely by reviewing it carefully with the patient when planning/scheduling procedure to ensure appropriate diagnostic procedure ordered.

REMINDERPSO adverse event reporting cannot be used for comparison of individual organizations. The purpose of PSO adverse event reporting is to learn what events occur and why, and to use that information to prevent future occurrence and patient harm. The value is in the quantity, quality, and details. The more reports obtained by the PSO containing detailed information about errors, near misses, and unsafe conditions, the greater potential for learning, sharing, and proactively preventing future harm, costs, and liability exposure

ELECTRONIC SUBMISSION IS AVAILABLEElectronic submitters can now simply export selected data fields from their event reporting system for mapping into the ShareSuite platform. Benefits of electronic reporting include:

• no duplicate event entry;• no dedicated IT resources needed;• initial set up takes about two hours; consecutive

submissions take only minutes, and;• send more information to PSO to increase learning

opportunities.Interested in electronic submission? Contact Eunice Halverson at ehalverson@centerforpatientsafety.org.

SHARE ROOT CAUSE ANALYSESPlease consider submitting your completed RCAs to the Center so information can be shared with other participants. All information is de-identified and factors changed to ensure anonymity. It’s easy to upload your documents to the ShareSuite platform. Need assistance sharing your RCAs? Contact Eunice Halverson at ehalverson@centerforpatientsafety.org.

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Harm Levels

FOR MORE INFORMATION, CONTACT ANY MEMBER OF OUR PSO TEAMBECKY MILLER, MHA CPHQ, FACHE, CPPS, Executive Director, bmiller@centerforpatientsafety.orgEUNICE HALVERSON, MA, Patient Safety Specialist, ehalverson@centerforpatientsafety.orgKATHRYN WIRE, JD, MBA, CPHRM, Project Manager, kwire@centerforpatientsafety.orgALEX CHRISTGEN, BS-BA, Project/Operations Manager and Analyst, achristgen@centerforpatientsafety.orgLEE VARNER, BS, EMS, EMT-P, Project Manager, EMS Services, lvarner@centerforpatientsafety.orgTINA HILMAS, RN, BSN, Project Manager, thilmas@centerforpatientsafety.orgMICHAEL HANDLER, MD, MMM, FACPE, Medical DirectorAMY VOGELSMEIER, PHD, RN, GCNS-BC, Researcher/Data Analyst JENNIFER LUX, Office Coordinator, jlux@centerforpatientsafety.orgDIANA PHELPS, Administrative Assistant, dphelps@centerforpatientsafety.org

For additional information on the Center’s PSO activities, resources, toolkits, upcoming events, safety culture resources, and more, visit our website at www.centerforpatientsafety.org or follow us on Twitter @PtSafetyExpert for the most up-to-date news.

ABOUT THE CENTER:The Center for Patient Safety, was founded by the Missouri Hospital Association, Missouri State Medical Association and Primaris as a private, non-profit corporation to serve as a leader to fulfill its vision of a healthcare environment safe for all patients and healthcare providers, in all processes, all the time.

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.

NOTESome articles contained within this newsletter may

reference materials available to Center for Patient Safety PSO participants only. If you have questions about any

Center-resources or articles within this newsletter, please contact the Center for Patient Safety at

info@centerforpatientsafety.org or call 888.935.8272.

SEPTEMBER 24 SECOND VICTIM TRAIN-THE-TRAINERMid-America Transplant ServicesSaint Louis, MissouriREGISTER NOW - SPACE IS LIMITED

OCTOBER 30EMS PATIENT SAFETY CONFERENCEHollywood Hotel & Convention Center & CasinoSaint Louis, MissouriREGISTER NOW - EARLY BIRD REGISTRATION ENDS 9/18

UPCOMING EVENTS...

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CENTER FOR PATIENT SAFETY

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CPS SPEAKERS on the circuitCPS staff are always on the go, sharing their expertise at national, state, and local conferences, events, and meetings. If you see them at an upcoming event near you, stop and say hello!• Becky and Dr. Keith Starke, with Mercy, will be presenting to

the Missouri Chapter of the American College of Physicians in Osage Beach, Missouri in September

• Kathy presents twice in Texas this Fall, first on Patient Safety Organizations and then Just Culture

• Kathy will conduct a half-day pre-conference session for LeadingAge in St. Louis, Missouri and again in Kansas City, Missouri on Root Cause Analysis: Fertilizer for a Safe and Just Culture

• Becky and Kathy will be presenting, “PSO’s: Your Partners for Managed Care Success” at the Annual Conference of the American Society of Healthcare Risk Managers in Indianapolis, Indiana in October

• Lee will present Protecting Learning and Preventing at the Air Medical Transport Conference (AMTC) in Long Beach, California in October

• Becky and Dr. Handler will be presenting at the Missouri Academy of Family Physicians in November