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.

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

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!

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.

 Video from the  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.

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

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

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