APSS Educational Resources

Dr. Donna Prosser is joined by Martin Hatlie, JD, Co-Director, MedStar Institute for Quality and Safety, Timothy McDonald, MD JD, Chief Patient Safety and Risk Officer, RLDatix, Aimee Samuels, DNP, RN, CPHRM, Patient Safety Officer, Director of Patient Safety & Clinical Risk, and Julie McCoy, PharmD, JD, Senior Manager of Pharmacy, Quality, & Medication Safety,   Providence St. Joseph Health; Partner, Pacific Apex Law Group, LLP, to provide the second of a three part series around the CANDOR (Communication and Optimal Resolution) model. Here, the group will discuss the background of the AHRQ CANDOR program, domains, and toolkit and assess a current state and gaps analysis process through the Samaritan Health Services case study. Thereafter, discussion will focus on the evidence for the effectiveness or impact of a Gap Analysis process. Recommendations for using a Gap Analysis process to assess organizational readiness, strengths and challenges will follow.

CANDOR AHRQ Modules and Implementation Guide

Making communication and resolution programmes mission critical in healthcare organizations

The “Seven Pillars” Response to Patient Safety Incidents: Effects on Medical Liability Processes and Outcomes

De-identified CANDOR Gap Analysis

Misplacement of a nasogastric tube can lead to harm and even death. Routinely leveraging clinical best practices is essential for all placing and verifying tubes. This article serves to review updated techniques for nasogastric tube placement based on latest evidence. See also “Nasogastric Tube Placement and Verification” APSS Blueprint.

The Patient Safety Movement Foundation is joined by Pryanka Relan, MD, MPH from the World Health Organization. Dr. Relan will deliver a comprehensive global update on COVID statistics, vaccine distribution rates, country-specific metrics, and recommendations for safe reopening.

Moderator: Donna Prosser, Chief Clinical Officer, Patient Safety Movement Foundation

Speaker: Pryanka Relan, MD, MPH, World Health Organization

Webinar Presentation: https://patientsafetymovement.org/wp-content/uploads/2021/04/PSMF-Webinar-Presentation_WHO-Covid-19-Updates.pdf?utm_source=Youtube&utm_medium=Link&utm_campaign=WHO-Covid-Update-Webinar-Presentation

Additional WHO COVID-19 Updates: https://patientsafetymovement.org/wp-content/uploads/2021/04/WHO-Covid-19-Vaccine-and-Immune-Response-Update.pdf?utm_source=Youtube&utm_medium=Link&utm_campaign=WHO-Covid-Vaccine-Immune-Response-Update

PSMF COVID-19 Resources: https://patientsafetymovement.org/helpful-coronavirus-covid-19-resources/?utm_source=Youtube&utm_medium=Link&utm_campaign=PSMF-COVID-Resources

If you haven’t already, please take the time to complete this survey: https://www.surveymonkey.com/r/386TZLB?utm_source=Youtube&utm_medium=Link&utm_campaign=Youtube-Survey

Comprehensive textbook around key areas for quality improvement in hospitals and healthcare organizations around the world. Topics include, but are not limited to, Patients for Patient Safety, Risks in Oncology and Radiation Therapy, Digital Technology and Usability and Ergonomics of Medical Devices, and Non-Technical Skills in Patient Safety.

“Many medication errors can be prevented through safe medication practices, however, sometimes these errors — including those involving “smart” infusion pumps — are caused by a combination of human and technical risk factors, including fatigue, distraction, and drug library overrides, deficiencies or misuse. Smart infusion pumps combine computer technology and drug libraries to limit the potential for dosing errors. Smart pump errors can result in harm to patients that could be avoided by using built-in dose error reduction software (DERS).”

Dr. Donna Prosser, Chief Clinical Officer at the Patient Safety Movement Foundation, is joined by Thankam Gomez, Founder & CEO, Cygnia Healthcare, Mark Graban, Author of “Lean Hospitals: Improving Quality, Patient Safety, and Employee Engagement”, Management Consultant, Coach, Professional Speaker, Podcaster, Senior Advisor to KaiNexus, and Beth Beswick, Retired Vice President, Human Resources, Carteret Healthcare to discuss the background of accountability in healthcare, the history of healthcare culture, and the current organizational barriers to implementing an environment of shared learning. Additionally, panelists will discuss stepwise recommendations for implementation of a Just Culture and propose strategies for evaluating the impact of the shift from a blaming culture to a systems analysis approach.

Moderator: Donna Prosser, Chief Clinical Officer, Patient Safety Movement Foundation

Panelists:

• Beth Beswick, BSN, MPH, Retired VP Human Resources and Community Relations, Carteret Health Care
• Mark Graban, Author of “Lean Hospitals: Improving Quality, Patient Safety, and Employee Engagement”, Management Consultant, Coach, Professional Speaker, Podcaster, Senior Advisor to KaiNexus
• Thankam Gomez, RNRM, BSN, Founder & CEO, Cygnia Healthcare

Webinar Presentation: https://patientsafetymovement.org/wp-content/uploads/2021/04/PPT_-Sharing-Accountability-for-Patient-Safety.pptx.pdf?utm_source=website&utm_medium=Link&utm_campaign=Sharing-Accountability-Webinar-PPT

Webinar FAQ’s: https://patientsafetymovement.org/wp-content/uploads/2021/04/Sharing-Accountability-for-Patient-Safety-FAQ.pdf?utm_source=website&utm_medium=Link&utm_campaign=Sharing-Accountability-Webinar-FAQs

Resources:

• The Incident Decision Tree: Guidelines for Action Following Patient Safety Incidents https://www.ahrq.gov/downloads/pub/advances/vol4/meadows.pdf?utm_source=website&utm_medium=Link&utm_campaign=Incident-Decision-Tree
• Mark Graban: My Favorite Mistake podcast https://www.markgraban.com/my-favorite-mistake-reflections-from-business-leaders-podcast/?utm_source=website&utm_medium=Link&utm_campaign=Mark-Graban-My-Favorite-Mistake-Podcast
• Just Culture: It’s More Than Policy https://psnet.ahrq.gov/issue/just-culture-its-more-policy?utm_source=website&utm_medium=Link&utm_campaign=Just-Culture-Journal-Article
• Case discussed in webinar: Wisconsin pharmacist arrested on charges of sabotaging COVID vaccine doses https://www.reuters.com/article/us-health-coronavirus-usa-pharmacist-idUSKBN2961YF?utm_source=website&utm_medium=Link&utm_campaign=US-Health-Pharmacist-Vaccine-Article
• Creating a Foundation for Safe and Reliable Care Actionable Patient Safety Solution (APSS) https://patientsafetymovement.org/clinical/creating-a-foundation-for-safe-and-reliable-care/?utm_source=website&utm_medium=Link&utm_campaign=Creating-a-Foundation-for-Safe-and-Reliable-Care-APSS

If you haven’t already, please take the time to complete this survey: https://www.surveymonkey.com/r/386TZLB?utm_source=website&utm_medium=Link&utm_campaign=Youtube-Survey

There are so many organizations that are doing great work related to Patient and Family Advisory Councils (PFACs) but an astounding number are not and this work is crucial to performance improvement. Meaningful and sustainable incorporation of the patient and family perspective is no longer optional for organizations that strive for high reliability. The panelists will discuss the background of person-centered care, the history of its incorporation in the clinical setting, and the introduction of PFACs, current organizational barriers to implementing and sustaining PFACs, recommendations to nurture involvement in and meaningful use of PFACs, and strategies for participant onboarding into PFACs and organizational introduction to PFACs on the journey toward high reliability.

See the webinar’s FAQ here for a full list of resources, with a handful of examples below:

Lessons Learned from a Systems Approach to Engaging Patients and Families in Patient Safety Transformation

See the Patient Safety Movement Foundation’s Person and Family Engagement Actionable Patient Safety Solution (APSS) series for more recommendations around meaningful performance improvement for person-centered care.

https://patientsafetymovement.org/clinical/person-and-family-engagement/

Survey: https://www.surveymonkey.com/r/386TZLB

The Patient Safety Movement Foundation is joined by Kathleen L. Mosier, PhD, Emeritus Professor of Psychology, San Francisco State University; President, International Ergonomics Association; Founder & Principal Scientist, TeamScape LLC., to discuss human factor and ergonomic considerations for foundational performance improvement in healthcare. Conducting current state assessments, considering cognitive heuristics, and discussing recommendations for user-friendly systems design are among the key points discussed.

Please view our Workplace Safety Actionable Patient Safety Solutions: https://patientsafetymovement.org/cli…​ and our other Workplace Safety video interviews within this playlist.

See here for Ergonomic Checkpoints in Health Care Work Prepared by the Human Ergology Society In collaboration with the International Ergonomics Association.

The Patient Safety Movement Foundation (PSMF) is joined by Cristine Lacerna, DNP, MPH, RN, CIC, CPH, Regional Director, Infection Prevention & Control and HEROES Program, Kaiser Permanente, to discuss healthcare worker safety and infection control in hospitals and healthcare organizations. Recommendations discussed include translating policy to practice, incorporating mechanisms for ongoing feedback from the frontline, implementing meaningful education, and ensuring support from leadership. If you haven’t already provided feedback, please leave it here:

https://www.surveymonkey.com/r/386TZLB

El Dr. Steven Barker, MD, PhD, miembro de la junta directiva de Masimo Corporation y Patient Safety Movement Foundation, brinda de forma muy completa una descripción general sobre la incidencia, los factores de riesgo individuales, institucionales y de procesos, así como las causas más comunes e implicaciones clínicas, organizacionales y financieras de la embolia gaseosa. Ofrece estrategias para reducir la incidencia de esta enfermedad a través de la priorización, detección temprana y la participación por parte del personal de primera línea en el manejo de esta complicación. La presentación incluye numerosos estudios de casos, ejemplos e ilustraciones con fines educativos multifacéticos. Nos encantaría saber de ti, deja tus comentarios aquí: https://www.surveymonkey.com/r/386TZL…

Dr. Donna Prosser, Chief Clinical Officer at the Patient Safety Movement Foundation, is joined by Katlyn Jackson RN, BSN, Circulating Nurse, Puget Sound Lakewood Surgery Center, to discuss the special needs for patient safety and healthcare worker safety in the operating room, the need for interdisciplinary collaboration, environmental, electrical, and radiation safety considerations. Recommendations for organizational current state assessments are outlined.

Podcast from Vizient:

“Sepsis is a life-threatening infection that kills nearly 270,000 Americans annually.  Another 1.7 million people develop sepsis but survive the experience.  In this podcast, we dive into the work of patient and family advisory councils and why the collaboration between patients, families and their providers can mean the difference between life and death.”

With, Armando Nahum, Director, Center for Engaging Patients as Partners, MedStar Institute for Quality and Safety, and Jeanne DeCosmo, BSN, MBA, CPHQ, Director, Clinical Quality, MedStar Health.

La resistencia a los antibióticos causa 23.000 muertes al año tan solo en los Estados Unidos (CDC, 2020).

Tobias Gilk, MRSO, MRSE, MArch., Founder, Gilk Radiology Consultants, Kansas City, Missouri, explains the unique safety concerns of MRI for both patients and healthcare workers, discusses the accumulation of radiation exposure as a determining factor to transition to MRI, and provides recommendations for healthcare safety as it relates to radiology.

Other relevant resources include:

Radiation Dose Chart

American College of Radiology Manual on MR Safety

Patient Safety Movement Foundation is joined by Katie Ann Blanchard, MSN, RN, WVTS, CEO and Co-Founder of WPV Solutions, and a PhD candidate at the University of Washington, School of Nursing, to discuss workplace violence, her testimony, and offer recommendations for how how healthcare organizations can recognize and eliminate violent behavior.

Video Resources:

1. Patient Safety Movement Foundation’s Workplace Safety Actionable Patient Safety Solution (APSS): https://patientsafetymovement.org/cli…​

2. WPV Solutions: https://wpvsolutions.org/

Our November 2020 webinar, titled “Pressure Ulcer Prevention and Management,” (link below) was met with great success amongst our global audience. To further our pressure ulcer education, we were able to collaborate with one of the panelists, Robin Betts, MBA-HM, RN, CPHQ, Vice President, Quality, Clinical Effectiveness & Regulatory Services Kaiser Foundation Health Plan & Hospitals, Northern California, and DeAndre Turner, Clinical Practice Consultant and Hospital-Acquired Pressure Injury Performance Improvement Expert, to illustrate the gaps in pressure ulcer detection and tracking across organizations. The group discusses the current gaps in practice, proper protocols for current state assessments, and recommendations for organizational pressure ulcer tracking and detection improvement.

This production and editing of this video was made possible thanks to the generous in-kind donation made by Kaiser Permanente.

Resources:

1. Pressure Ulcer Tracking and Detection November 2020 Webinar Recording

2. Pressure Ulcer Actionable Patient Safety Solutions

Las variaciones de la glucosa son un riesgo para la salud y bienestar del paciente hospitalizado. Contar con un protocolo para el control adecuado de la glucosa tanto en pacientes diabéticos como no diabéticos permite reducir complicaciones relativas a hipo y a hiperglucemia. A continuación compartimos un plan de acción que actualizamos regularmente para el control adecuado de glucosa en sangre

Sarah Miller, MS, Director of Partnerships, Patient Safety Movement Foundation, is joined by Edwin Loftin, Jr., DNP, MBA, RN, NEA-BC, FACHE, Senior Vice President, Integrated and Acute Care Services and CNO, Parrish Medical Center, and Armando Nahum, Patient Advocate, to discuss the meaningful incorporation of the patient and family perspectives in all organization-wide improvement work, particularly in the resolution process after a medical error. The group discusses Patient and Family Advisory Committee (PFAC) implementation and sustainment along with the impact of PFAC incorporation.

Dr. Donna Prosser, Chief Clinical Officer at the Patient Safety Movement Foundation, is joined by David Ha, PharmD, BCIDP, Pharmacist in Infectious Diseases and Antimicrobial Stewardship, Stanford Healthcare, to discuss the implementation and sustainment of antimicrobial stewardship programs across health systems. The team discusses the multifaceted implications of poor antimicrobial stewardship, the realistic expectations around effective implementation of performance improvement projects, and the importance of current state and future state mapping for meaningful tracking and optimization.

Blood glucose management is essential for every patient and often, when patients are admitted to the hospital, glucose is difficult to manage due to the psychological and physiological stress. This table highlights the basics of recognition, risk factors, treatment, and monitoring for hypoglycemia, hyperglycemia, DKA, and HHS.

Join Dr. Donna Prosser as she interviews Chuck Stokes, Former President and CEO of Memorial Hermann Health System and Founding Partner with Relia Healthcare Advisors, about what it means to be a highly reliable organization and the steps his organizations have taken to become part of the impact. Recommendations are offered for sustainable implementation of performance improvement initiatives.

Q&A: https://patientsafetymovement.org/wp-content/uploads/2021/01/Stokes-High-Reliability-FAQ.pdf

The use of restraints should be restricted to situations in which they are absolutely clinically necessary. However, interpretations of clinical necessity vary in practice and this range has significant implications for patient safety. This simple decision making tree serves as a visual for consideration.

Dr. Donna Prosser, Chief Clinical Officer at the Patient Safety Movement Foundation, is joined by a group of experts, including anesthesiologists, respiratory therapists, and nursing leaders, to explore the patient safety priorities of sedation, opioid therapy, and respiratory depression. The group discusses frequently encountered safety issues, explores organizational processes to reduce sedation safety events, and assesses the role patients and family members can play in reducing harm.

The objectives for this webinar included:

1. Describe the different levels of sedation across the continuum according to the ASA

2. Analyze the relationship between routine opioid therapy and respiratory depression

3. Discuss the most frequent safety issues encountered during the sedation process

4. Summarize organizational processes that healthcare leaders can implement to reduce sedation safety events.

5. Discuss the role patients and families can play in reducing the risk of harm from sedation.

Link to the HQI Toolkit pdf

Link to Q&A

Let us know what you think! https://www.surveymonkey.com/r/LXZ62GP

CE provided only for the live event.

How does your antibiotic prescription impact those around you? More than you may think. This infographic breaks down the basics to ensure antibiotic safety for you and those around you.

“Today’s article was guest authored by Donna M. Prosser, DNP, RN, NE-BC, FACHE, BCPA, Chief Clinical Officer at Patient Safety Movement Foundation. This article is the first in a series of four from the Patient Safety Movement with tips on how to effectively use clinical simulation to hardwire a foundation for patient safety and reliable care to make safety the number one priority of all providers. The next article, to be published in March 2021, will focus on how to use simulation to hardwire a person-centered culture of safety.”

Dr. Steven Barker, MD, PhD, Masimo Corporation and Patient Safety Movement Foundation Board Member, provides a comprehensive overview of air embolism incidence, individual, procedural and organizational risk factors, common causes, and clinical, organizational, and financial implications. He offers strategies to reduce air embolism incidence through organizational prioritization, early detection, and frontline involvement. The presentation includes numerous case studies, examples, and illustrations for multifaceted educational purposes.

We would love to hear from you, leave your comments here: https://www.surveymonkey.com/r/LXZ62GP

“In this episode, I talk with Priya Parker – a master facilitator, strategic advisor, and the author of The Art of Gathering: How We Meet and Why it Matters. We dig into what it means to come together, why connection requires intention, and the often-invisible structures inside our most meaningful gatherings. Priya even helps me deconstruct my wedding and why, decades later, people still tell me how different and fun it was!”

This podcast is applicable to patient safety and performance improvement, as a priority goal in any organizational initiative is the effective and meaningful incorporation of perspectives from multiple individuals and teams.

Dr. Donna Prosser, Chief Clinical Officer at the Patient Safety Movement Foundation, is joined by a multidisciplinary group of experts, including clinicians, administrators, and patients and family members, to understand the background of pressure ulcer prevention and management, discuss multi-faceted opportunities for organization-wide improvement, and explore mechanisms for improved patient and family member involvement in prophylaxis. The group will tailor aspects of the dialogue to assess the COVID-19 impact on pressure ulcer prevalence and management.

Here’s the link to our slideshow presentation: https://docs.google.com/presentation/… 

Full Responses to Live Questions from Panelists and Current Research: https://patientsafetymovement.org/wp-content/uploads/2020/12/QA-Full-Responses.docx

Patient advocate Vonda Vaden Bates interviews Brandyn Lau, MD, DrPH, MPH, Assistant Professor of Radiology and Health Sciences Informatics, Johns Hopkins School of Medicine, around the importance of VTE prophylaxis for hospitalized patients. The team addresses the following questions:

1) What are typical organizational protocols for requiring formal risk assessments?

2) What factors should be considered that may change the patient’s risk profile and how can clinicians parallel this change with appropriate reassessment and prophylaxis adjustment?

3) What is the current discrepancy between attitudes versus evidence regarding prophylactic efforts? (Particular emphasis on ambulation)

4) What information can be shared between patients and clinicians, and between healthcare settings to improve VTE prevention?

5) What are the barriers to objective reporting and reporting the all too common VTE events post-discharge?

Repetidamente, le preguntó a los médicos si su hija se encontraba bien. Repetidamente, sus preocupaciones fueron desestimadas por el equipo de salud, lo que, eventualmente llevó a la muerte evitable de su hija, Gabby Galbo. Desde entonces, Tony ha trabajado incansablemente para aprobar la legislación sobre los protocolos de sepsis en los hospitales y comparte sus ideas para otros de su viaje legislativo personal.

The Standardize 4 Safety (S4S) initiative is the first nationwide, interdisciplinary movement toward devising standardized medication concentrations with the goal of reducing medical errors related to the misinterpretation of non-standardized drug concentrations, particularly during transitions of care.

“This course begins by exploring the principles on which syringe systems operate. This reveals nuances of their operation that may lead to unexpected medication delivery. The course concludes with a discussion of best practices for ensuring the desired infusion. This includes adopting ASHP’s Standardize4Safety recommendations, optimizing dispensing practices and syringe size selection, and developing protocols for syringe change-over. Applying this knowledge will help clinicians use syringe pumps in a manner that ensures patients receive their medication in a timely, stable, and continuous manner.”

CE credit is provided for physicians, nurses, and pharmacists.

During the delivery of an infusion, there are important considerations related to how infusion pumps operate and the complex fluid dynamics of IV tubing setups. While you may be aware of these, they may not be explicitly taught in education curricula or training programs. Furthermore, they are often invisible to the naked eye and when discussed, are often expressed using complex technical jargon. The content available on this site attempts to make the invisible visible by presenting these topics in a graphic, animated, and interactive way.

Dr. Donna Prosser, Chief Clinical Officer at the Patient Safety Movement Foundation, interviews Deborah Milewski, PT, DPT, Adjunct Faculty, Department of Physical Therapy, Chapman University, around the importance of considering mobility management as a care intervention equal in importance to many other interventions we tend to assign higher priority. While the current state of mobility management in hospitals is fragmented, lacks standardization, and often sends the patients mixed messages, the team offers suggestions for improvement, including setting realistic goals, emphasizing the importance of mobility, and prioritizing it as an intervention.

Dr. Donna Prosser is joined by John James, Dr. John James, a patient safety advocate, and the author of A New, Evidence-Based Estimate of Patient Harms Associated with Hospital Care. The team discusses the meaning of informed consent for clinicians and patients, the steps to a genuine shared decision making dialogue, and the components that should be addressed in the decision making process. Informed consent cannot be separated from the person-centeredness of an organization. While the shared decision making between clinicians and patients and loved ones does require time, attention, and attentiveness to the patient’s wishes and goals, it should be a priority for all healthcare organizations.

Alicia Cole discusses the unique viewpoint offered by patients in the healthcare system and notes that patients are the only individuals who can see and experience the healthcare system from a 360 degree angle.

Here is an example of what your completed home-based plan of care can look like.

This plan of care form is intended for family members and caregivers coordinating their loved one’s care, especially from a distance. Use this form to keep track of the patient’s medications, treatments, changes in plans etc. You can download as a Microsoft Word document or print and write in pencil!

Dr. Donna Prosser, Chief Clinical Officer at the Patient Safety Movement Foundation, interviews Robyn Begley, Chief Executive Officer, AONL, and Senior Vice President and Chief Nursing Officer, AHA, around her most recent discoveries in the COVID-19 pandemic. The team conducted a study with over 1,800 participants, ranging from nursing staff to hospital administrators, on the effects of COVID-19 and the challenges and fallbacks that occurred during three periods of the pandemic. After discussion of results, recommendations are proposed for supporting hospitals and healthcare workers.

This article describes conceptualization and application of High Reliable Organization (HRO) principles to guide practice and culture.

This peer-reviewed study has found a relationship between comfort speaking English and medical errors in children. Hospitalized children with parents uncomfortable speaking English are twice as likely to experience a preventable medical error, highlighting the need for strategies to improve communication for this vulnerable group.

Dr. Donna Prosser, Chief Clinical Officer at the Patient Safety Movement Foundation, interviews Deborah Milewski, PT, DPT, Adjunct Faculty, Department of Physical Therapy, Chapman University, around the importance of considering mobility management as a care intervention equal in importance to many other interventions we tend to assign higher priority. While the current state of mobility management in hospitals is fragmented, lacks standardization, and often sends the patients mixed messages, the team offers suggestions for improvement, including setting realistic goals, emphasizing the importance of mobility, and prioritizing it as an intervention.

We would love to hear from you, leave your comments here: https://www.surveymonkey.com/r/LXZ62GP

Dr. Donna Prosser, Chief Clinical Officer at the Patient Safety Movement Foundation, is joined by a multidisciplinary group of patient advocacy experts and clinicians to understand the various meanings of the term ‘patient advocacy’ and to evaluate how an empowered patient can improve healthcare delivery, experience, and outcomes for all involved. The group will discuss the history and current state of patient advocacy, and will propose recommendations regarding the extent to which various healthcare disciplines and patients and their families can improve patient advocacy.

National Patient Advocate Services

www.npaf.org

www.patientadvocate.org

Professional Patient Advocate Directories and Services

https://www.gnanow.org

https://bcpa.pacboard.org/search/custom.asp?id=5640

https://www.nahac.com/find-an-advocate#!directory/map

https://whitleyptadvocates.com

https://getcaribou.com

Let us know what you think! https://www.surveymonkey.com/r/LXZ62GP

CE provided only for the live event.

Join Dr. Donna Prosser, CCO, and Dr. Edward Kelley, Director of Integrated Health Services Department at World Health Organization (WHO) Headquarters, Geneva, for our October COVID-19 Update. Topics discussed include our current climate of the COVID-19 pandemic broken down by region, influenza season amidst COVID-19, the reopening of schools across the globe, and Dr. Kelley’s speculations on how we will be able to overcome this crisis in the upcoming future.

For Access to COVID-19 Tools Accelerator (ACT-A), a global collaboration to accelerate the development, production, and equitable access to COVID-19 tests, treatments, and vaccines, see https://www.who.int/initiatives/act-accelerator.

Resources and references for the video can be found down below.

1. https://www.sfgate.com/news/article/UN-Europe-s-pandemic-restrictions-are-15649526.php

2. https://www.wsj.com/articles/as-second-covid-19-wave-rolls-through-europe-deaths-and-hospitalizations-rise-11601919564?mod=searchresults&page=1&pos=1S

3. https://www.wsj.com/articles/europes-second-covid-wave-starts-to-spill-over-from-young-to-old-11601982003

4. https://edition.cnn.com/2020/09/19/europe/europe-second-wave-coronavirus-intl/index.html

5. https://www.bbc.com/news/health-54417547 6. https://extranet.who.int/dataformv3/index.php/729445?lang=en

Dr. Donna Prosser is joined by Dr. Steven Deeks, Professor of Medicine, University of California, San Francisco, and Dr. Jake Suett, Staff Grade Anaesthetist and Intensive Care Doctor, United Kingdom, to discuss the long term implications of COVID-19 from clinical and personal perspectives. Dr. Deeks shares the research around long COVID-19 symptoms and Dr. Suett provides a personal anecdote of his experience with symptoms that have lasted months. Dr. Suett shares with the PSMF information about the COVID symptom study, which consists of an international mobile app to track COVID-19 symptoms over time.

In the first part of the NAHQ Virtual Conference, Mike Ramsay opens with his keynote speech. In the second half, viewers will learn about the history and impact of patient safety, and discuss the characteristics of highly reliable organizations. The relationship between patient safety and human factors and recommendations for the future will also be explored.

In this Part 2, viewers will learn how the process of care coordination has evolved over time, and analyze the multiple roles that have been created both in and out of hospitals. The effectiveness of current efforts to improve care coordination and the impact on outcomes when patients and families are involved will be examined.

In Part 3 of the NAHQ Virtual Conference, viewers will learn the differences and similarities between person-centered care (PCC), patient and family-centered care (PFCC), and patient and family engagement (PFE). The many advances that have been made over the past several decades and the opportunities for healthcare organizations to truly place the patient at the center of their care will be discussed.

Originating from efforts by the Centers for Medicare & Medicaid Services (CMS) Partnership for Patients, Safety Across the Board (SAB) emphasizes the need for safety as a priority in all healthcare institutions. When an organization invests in one population-specific improvement project, they develop the expertise and capacity to take on others without having to start from scratch, and so accelerate improvement on all patient safety challenges.

Dr. Edwin Loftin is interviewed by AHRQ regarding “Safety Across the Board” (SAB), a concept originating from the Centers for Medicare and Medicaid Partnership for Patients. Dr. Loftin describes a culture of healing, culture within institutions, and the ever-evolving process of improvement.

Dr. Donna Prosser, Chief Clinical Officer at the Patient Safety Movement Foundation, is joined by a group of health technology experts and patient advocates to discuss the movement for data sharing in healthcare and the current level of transparency in the US and internationally. The barriers to patient data sharing, as well as the implementation of actionable solutions, are discussed from the unique perspectives of the panelists to provide a rich dialogue around a timely issue.

For more information around this topic, please read the Lancet article “Public Perceptions on Data Sharing: Key Insights from the UK and the USA“.

This 2017 OECD report outlines the global burden of patient safety and medical errors, makes predictions for patient safety in the future, and offers recommendations for areas of focus for the future.

You can print out this pdf form and get the necessary information from the care team. If you use pencil, you can easily update it each day; just take pictures to keep a record!

See PSMF’s Example Template for a guide to get started.

Here is an example of what your completed home-based plan of care can look like.

The team at HealthySimulation.com welcomes Dr. Donna Prosser, Chief Clinical Officer at the Patient Safety Movement Foundation (PSMF), in an interview around the history of patient safety, its current recognition in the healthcare space, and recommendations to improve outcomes in the future for all patients. Dr. Prosser discusses the hallmark events of improvement over the last several years and describes the free tools and resources from the PSMF to help hospitals in their improvement endeavors.

HealthManagement.org features PSMF’s Chief Clinical Officer, Donna Prosser, in their spotlight of pandemic prevention strategies. Dr. Prosser offers insight regarding the unprecedented level of public scrutiny of patient care. Healthcare leaders are now challenged to implement new cultures focused on sustaining safe, person-centered care for both patients and health workers.

The Patient Safety Movement Foundation is joined by Thomas Murray, MD, PhD, Associate Professor, Yale School of Medicine; Associate Medical Director, Infection Prevention, Yale New Haven Children’s Hospital, and Sarah Kandil, Assistant Professor, Yale School of Medicine; Deputy Quality and Safety Officer, Yale New Haven Children’s Hospital, to discuss the new research around Multisystem Inflammatory Syndrome in Children (MIS-C). The group discusses the typical MIS-C specific symptoms, the importance of accurate diagnosis, and typical treatments and therapies. MIS-C has been reported in children in relation to COVID-19 so the prevention measures for MIS-C are often the same as the standard COVID-19 prevention measures.

The medication cascade often begins when drug-induced side effects are mistaken for symptoms of another disease that warrants even more drugs. Polypharmacy increases a patient’s risk for adverse events and makes it increasingly difficult for patients and providers to predict drug interactions.

The hub is a platform to share learning for patient safety. It offers a powerful combination of tools, resources, stories, ideas, case studies and good practice to anyone who wants to make care safer for patients. Its communities of interest give people a place to discuss patient safety issues or concerns. Membership is free, you can register at www.pslhub.org

Patient Safety Learning is a charity and independent voice for improving patient safety.

Patient Safety Learning acknowledges the theme for 2020’s World Patient Safety Day with resources around staff members for staff safety in the healthcare space. This webpage includes blogs, interviews, and videos emphasizing the importance and steps to create this culture of safety for everyone. There is no patient safety without healthcare worker safety.

The Collaborative for Accountability and Improvement devised an infographic outlining the components needed for successful and effective patient and family member integration into the care team and into the solution upon the occurrence of a medical error.

PSMF is joined by Dr. Lori Stromness of Intermountain Healthcare to discuss the frequently-encountered barriers to CAUTI prevention. The objective of the performance improvement project was decreasing infectious and non-infectious harm to patients with education around evidence-based guidelines. This project was particularly successful due to the proactive reflection of potential for improvement after an adverse event or near miss, thus contributing to the culture of safety overall and improving urinary catheter procedures.

PSMF is joined by Dr. Bob Hyzy, MD, Medical Director, CCMU Critical Care Medical Unit. CLABSI prevention has been a priority initiative for organizations across the globe but we are still not yet at zero. Dr. Hyzy provides a case study of his organization’s CLABSI bundle and checklist and provides insight into the typical gaps hospitals and healthcare organizations fail to acknowledge with any population-specific improvement project.

The Patient Safety Movement Foundation published a white paper on September 8, 2020 assessing the feasibility of creating a National Patient Safety Board to reduce preventable medical errors in facilities across the country.

Airway Safety Panel Webinar: Speaking Up and Getting Started: Dr. Donna Prosser is joined by Arthur Kanowitz, MD, FACEP, Founder, Airway Safety Movement, Lauren Berkow, MD, FASA, Professor of Anesthesiology, University of Florida College of Medicine, Anne Lyren, MD, MSc, Clinical Director, Children’s Hospital’s Solutions for Patient Safety, Kevin McQueen, MHA, RRT, Regional Director of Respiratory Therapy, University of Colorado Health, Memorial Hospital, Sarah Kandil, MD, Deputy Quality and Safety Officer, Yale New Haven Children’s Hospital, David Hughes, President, Do It For Drew Foundation, and Edwin Loftin, DNP, RN, MBA, FACHE, Chief Nursing Officer, Parrish Medical Center. Although airway safety is known to be one of the key components in safe care, thousands of patients lose their lives each year to poor airway management and unplanned extubations. The team discusses starting an unplanned extubation project without buy-in from others, multi-institutional collaboration, pushback from leaders, colleagues, or other organizations, the future of interventions, clinicians who have experience with unplanned extubations as key advocates, and cross checking pediatric and adult safety efforts. The panel ends with Drew Hughes’ story and the team emphasizes taking a moment to ground yourself in your practice and the importance of speaking up when you think the patient is at risk.

Dr. Donna Prosser is joined by Dr. Ronald Wyatt, MHA, Vice President and Patient Safety Officer, MCIC Vermont, Dr. Marcus Robinson, Executive Director, Collaboraction Theatre Company, Dr. Daria Terrell, Medical Director of Clinical Programming and Health Outcomes, St. Bernard Hospital and Healthcare Center, and Patricia Merryweather Arges, PDG, Executive Director, Project Patient Care. The panel follows the insights of the Social Disparities Part I webinar and highlights the institutional racism in our healthcare systems and how these conditions create disproportionate outcomes for the most vulnerable populations. 

• Find the powerpoint presentation here.

Dr. Steve Barker is joined by Ronald Weinstein, MD, FCAP, FATA, Director/Founder, Arizona Telemedicine Program, and Jeffrey Dunn, DO, MBA, Founder/CEO, Redivus Health to discuss the future of telemedicine within the patient safety and quality improvement space. Telemedicine has become a significant area of investment in recent years and the panelists predict that, in the future, user experience, consolidation, customization based on relevance to the user, robotics, and health literacy will become top priorities.

Dr. Donna Prosser interviews Helen Hughes, Chief Executive of Patient Safety Learning in the UK. The team reviews system issues that are fundamental contributors to medical error. 

Dr. Donna Prosser interviews airline pilot Martin Bromiley about the human factors contributing to medical error and discusses what the healthcare space might be able to learn from the airline industry.

Dr. Donna Prosser is joined by a panel of experts to discuss how the COVID-19 pandemic is affecting mental health across the globe and share some tips for effectively managing these challenges.

Expert presenters explore how a culture of safety is foundational for all improvement efforts thereafter and investigate how the CANDOR process can facilitate a culture of safety. 

Expert presenters investigate the root causes behind why hand-offs are the source of so many errors in hospitals and the steps healthcare organizations can take, from executive leadership to frontline staff, to improve hand-offs consistently. 

Expert presenters explore data collection tips, measurement strategies, applying measurement techniques throughout quality improvement processes, and visual management. 

Expert presenters investigate ergonomic factors and behavioral heuristics that create gaps in processes and lend to medical errors.

Expert presenters share the importance of patient safety curriculum in universities and teaching hospitals and illustrate examples of modules to effectively implement patient safety education.

Expert presenters describe the burden of extended boarding hours in the emergency department, identify barriers to timely throughput, and assess the effect of real-time throughput dashboard on emergency department boarding time and inpatient mortality.

Dr. Steve Barker discusses the importance of hand-off communications within hospitals, key components within hand-offs, mnemonics, where common gaps in communication may be, and how we can improve hand-offs in all circumstances in our systems.

If you or a loved one is hospitalized right now and has a patient safety story to share, tell us about it!

CARDMEDIC is a free communication tool to allow clinicians to communicate with patients effectively through the PPE in times of COVID and beyond.

 The World Health Organization’s white paper explores health literacy, treatment decision-making, and self-management of chronic conditions as areas for improvement in healthcare systems across Europe.

The World Health Organization’s white paper explores strategies to bolster patient engagement and how it can be leveraged to improve quality of care globally.

This website walks the user through creating their own advance care plan and provides thought-provoking prompts throughout the way.

Dr. Donna Prosser and Vonda Vaden Bates lead a panel of chaplains, physicians, and family members through a reflective discussion around managing end of life care.

Resource outlines what a thorough evaluation of life-prolonging treatment would look like and what aspects should be considered in the decision-making process.

Death with Dignity outlines the various options for end of life care and advanced directives and delineates by state.

Centers for Disease Control and Prevention provides a comprehensive outline of end of life care and advanced directive considerations for various types of patients and situations.

 Talking about end of life care is tough. Family Caregiver Alliance provides tips to start and navigate the conversation in a productive and sensitive manner.

Expert presenters explore maternal mortality globally, hemorrhage prevalence, and maternal risk factors.

Expert presenters explore the prevalence and recognition of pre- and post-operative anemia, its associated complications, and the use of safety transfusion protocols and strategies to optimize patient safety. 

Expert presenters share guidance for arrest prevention, arrest resuscitation, critical care, and airway management in this Advanced Resuscitation Training (ART). 

The PSMF team is joined by Edwin Loftin, DNP, MBA, RN, NEA-BC, FACHE, Senior Vice President of Integrated and Acute Care Services and Chief Nursing Officer, Parrish Medical Center. Dr. Loftin provides a detailed application of the guidelines within PSMF’s #8: Airway Safety Actionable Patient Safety Solution. Dr. Loftin describes Parrish Medical Center’s background and unique barriers to airway safety. With this root cause analysis and background assessment, Dr. Loftin illustrates how their team applied and tailored the general principles of airway management and patient safety to their specific environment. 

The PSMF team is joined by Sarah Kandil, MD, Yale School of Medicine, who provides a background on Yale’s journey to zero unplanned extubations. She describes the collaboration necessary to determine root causes and key drivers. The case study provided by Dr. Kandil highlights the challenges, opportunities, and outcomes associated with Yale’s project improvement plan.

• See Children’s Hospitals’ Solutions for Patient Safety’s Unplanned Extubation Real Time ACA Event Investigation form, as referenced in the presentation.

PSMF is joined by Arthur Kanowitz, MD, FACEP, Founder, Airway Safety Movement; Chair of the Airway Safety Workforce, Patient Safety Movement Foundation; Founder, Chairman, CMO, Securisyn Medical. Dr. Kanowitz explains the incidence and significant costs, both clinical and financial, associated with unplanned extubation. He then discusses specific action items hospitals must take in order to improve quality processes around unplanned extubation. These specific points are followed up with a discussion of the fundamental components necessary for healthcare improvement as a whole, including accurate measurement and tracking, and a culture of safety.

PSMF is joined by Lauren Berkow, MD, FASA, Professor of Anesthesiology, University of Florida; President, Society for Airway Management. Dr. Berkow presents evidence of the extent to which unplanned extubations occur in healthcare organizations and explains the significant clinical and financial implications associated. Dr. Berkow elaborates on the factors that contribute to unplanned extubations and proposes recommendations to prevent it from occurring, with specific examples from her own work, projects, and collaboratives. 

Several clinical trials are currently being performed to further the development and research of antiviral drugs against SARS-CoV-2 virus. This PSMF research provides a table of a variety of investigated therapies, their mechanism of action, and detailed information about the clinical trial itself.

This infographic outlines what patients, families, and advocates can do to manage a hospitalization during this pandemic.

Dr. Donna Prosser interviews a panel of experts in a discussion around social determinants of health that lend to less favorable outcomes for marginalized populations. The panel offers a reflection on current state, ideal future state, and how to get there.

Resource provides information around respecting choices and conversation guides for patients and clinicians.

This resource provides a quick overview of Mind Body Stress Reduction techniques so they can apply these concepts on the frontline, right now. It is also an excellent resource for anyone who is under stress right now due to the coronavirus.

Dr. Donna Prosser is joined by Dr. Danielle Ofri to discuss the history of medical errors and how they have greatly impacted hospitals during this time of COVID-19. Dr. Ofri serves as an attending physician at Bellevue Hospital and Clinical Professor of Medicine at New York University, School of Medicine and as Editor-in-Chief at the Bellevue Literary Review.  In this video, Dr. Donna Prosser explores more in depth about Dr. Ofri’s latest opinion piece, Nightingale in the Year of the Nurse.

CDC provides guidance for best practices in using alcohol-based hand rubs.

Centers for Disease Control and Prevention demonstrates the proper technique for hand hygiene.

Video from the World Health Organization demonstrates the proper technique for hand hygiene.

 Tips from the Centers for Disease Control and Prevention on how to protect yourself and others around you from the COVID-19 virus.

Tips from the World Health Organization on how to protect yourself and others around you from the COVID-19 virus.

Expert presenters introduce complications associated with poor airway management, describe how unplanned extubations occur, and explore strategies to get to zero preventable deaths related to airway management. 

Expert presenters share the current state of falls prevention in hospitals, where these interventions fall short, and how we can improve in the future.

Experts from University of Vermont Children’s Hospital share their CLABSI quality improvement initiative, including planning, steps taken, and outcomes.

This blog outlines the importance of oral care to prevent NV-HAP and brings this key point to life by reviewing the VHA oral care implementation plan and its efficacy.

 The Lily Hospitals IPC team in Nigeria improved hand hygiene practices and reduced infection rates using a simple mnemonic. This tool ensures clinicians, patients, and visitors wash their hands correctly – without missing any spots.

Expert presenters highlight the lack of awareness of sepsis, associated complications, it’s burden on the full healthcare system, and strategies for early recognition and treatment.  

PSMF has compiled research regarding the prominent drugs being tested for COVID-19 prevention and treatment. Updated July 2020.

Expert presenters explore the adverse drug event roadmap, technologies available to help mitigate the gaps, and how clinical ‘silos’ lend to medication errors.