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General Patient Safety Discussion
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NPSF has merged with IHI 0 P. McTiernan It's official: the National Patient Safety Foundation merged with the Institute for Healthcare Improvement (IHI) effective May 1, 2017. Read more about the merger at    
by P. McTiernan
Monday, June 26, 2017
RCA - Calling in to the meeting 3 D. Strong Our event reporting solution has functionality that can be used to facilitate RCA data collection and collaboration, but also to broadly disseminate investigatory findings (causal and contributory factors) and actions taken to reduce the frequency and/or severity of similar events in future.   To facilitate collection of information from remote staff/non-users of our system, an editable PDF document can be sent via email, which upon completion will automatically populate into the RCA record. Chatter is a built-in communication and collaboration tool with social media-like functionality. In addition to allowing cross-functional teams to collaborate in-system on investigations, RCAs, and more, organization-wide groups can be created -- both public and private -- for wider communication. In one example, a number of reported falls were determined to be caused by patient-transfer errors related to diagnostic imaging (radiology techs were improperly trained in transfer protocols). The health system safety team had created a system-wide "Patient Safety Champion" group in Chatter and used this venue to not only thank front-line staff for reporting these falls, but -- as a result of the related investigations -- to also release an updated protocol for review.   Lastly, our advanced analytics allow for the tracking/trending of RCAs & corrective actions to ensure compliance and success.  Configurable alerts will notify key stakeholders if the implemented corrective action is not proving effective over time or in a specific location, etc.   Brian Stromberg Riskonnect
by B. Stromberg
Monday, March 19, 2018
Hospital Acquired Pressure Injuries-Present on Admission 0 C. Bow A recent discussion with our Pressure Injury management team brought this question forward. Do you consider pressure injuries to be Hospital Acquired if they are not documented on admission or do you have a time frame of 24 Hours to document on a PI before it becomes Hospital Acquired? How is this handled in other organizations?
by C. Bow
Tuesday, February 20, 2018
Timely removal: Ureteral stents and/or IVC filters 0 D. Dorman Greetings,    My name is Daniel Dorman. I am a graduate student at the Marcella Niehoff School of Nursing at Loyola University, Chicago, Illinois.   I am working on a project focused on timely removal of ureteral stents and inferior vena cava filters. I am specifically interested in learning about processes that organizations have implemented to track patients with a temporary device over time.    Thank you,    Dan Dorman             
by D. Dorman
Sunday, February 18, 2018
Patient Safety Awareness Week 2018 - Activities and Ideas Sharing 1 N. Universal Login Hi,  IHI/NPSF is still formulating plans for Patient Safety Awareness Week 2018, March 11-17, and we will be posting some ideas on the United for Patient Safety website soon (http://www.unitedforpatientsafety) but if you are interested in seeing what some organizations did last year, you can view some activity here 
by P. McTiernan
Wednesday, January 17, 2018
Implications of Promising to Do Better 0 W. Hyman I have been intrigued by the Patient Safety Movement Foundations (not to be confused with NPSF) accumulation of hospitals promising to let fewer people die unnecessarily, and giving specific numbers of patients that will be saved. Isn't this a direct admission of not only having allowed patients to die unnecessary, but that you know exactly how many such deaths there were? And if you know how many does that mean you know exactly who they were? Is there a list of such patients? Do the patient's families know their family member is on that list? What is the disclosure rate of unnecessary (preventable) deaths? How do you handle the idea of past and future preventable deaths?
by W. Hyman
Tuesday, January 16, 2018
Deadline Extended: Submit Speaker Proposals by October 23 0 P. McTiernan Have you been involved in a successful patient safety initiative in your organization? Submit a speaker proposal by October 23 and you may be invited to share your work at the 20th IHI/NPSF Patient Safety Congress, May 23-25, 2018, in Boston.   Visit the website for details and download the abstract form outline to help plan your abstract before submission,
by P. McTiernan
Friday, October 13, 2017
Moving Beyond Safety I to Safety II 0 P. McTiernan Moving Beyond Safety-I to Safety-II to Transform Patient Safety IHI/NPSF Professional Learning Series Webcast Traditional patient safety efforts have been designed and implemented under the premise that our systems are well understood, well designed, and predictable. Therefore, when things go wrong, individuals are usually identified as the cause and focus for developing actions to prevent future error and harm. Unfortunately, the vast majority of preventable health care errors are due to systems issues that are often overlooked. This "new view" of addressing and improving safety is captured by the term "Safety-II." This presentation will provide a practical model for thinking about systems, define Safety-I and –II, and explore the relationship between Safety-I and –II, with suggestions for applications by safety teams. What You'll Learn At the conclusion of this program, participants will be able to: Describe the need to understand and address systems issues that contribute to preventable health care harm Differentiate between the concepts of Safety-I and Safety-II Apply the concepts of Safety-I and Safety-II to their safety strategy in their individual organizations Register or learn more.
by P. McTiernan
Thursday, October 12, 2017
ISMP Launches First High-Alert Medication Safety Self Assessment 0 P. McTiernan The Institute for Safe Medication Practices (ISMP) has introduced a new tool to help hospitals, long-term care facilities, and certain outpatient facilities evaluate their best practices related to high-alert medications, identify opportunities for improvement, and track their experiences over time. The ISMP Medication Safety Self Assessment® for High-Alert Medications focuses on general high-alert medications and 11 specific medication categories--including opioids, insulin, neuromuscular blocking agents, chemotherapy, and moderate and minimal sedation.   Participants who submit assessment findings to ISMP anonymously via a secure internet portal will be able to obtain their weighted scores so they can compare themselves to demographically similar organizations. Participation also can help organizations meet requirements for managing high-alert medications from regulatory and accrediting agencies, such as the Centers for Medicare & Medicaid Services and The Joint Commission.   To access the self assessment workbook, go to:
by P. McTiernan
Wednesday, October 4, 2017
Call for Speakers: 2018 IHI/NPSF Patient Safety Congress 2 P. McTiernan Hi, the link has been fixed! Thanks for letting us know. You can also copy and paste this into your browser, Proposals are being accepted through 10/16/17.
by P. McTiernan
Wednesday, October 4, 2017
Public Opinion Survey on Medical Error and Patient Safety 0 P. McTiernan The vast majority of Americans are having positive experiences with the health care system, but 21 percent of adults report having personally experienced a medical error, according to a new national survey released today by the IHI/NPSF Lucian Leape Institute and NORC at the University of Chicago. The survey further finds that, when errors do occur, they often have lasting impact on the patient’s physical health, emotional health, financial well-being, or family relationships. The nationwide survey of more than 2,500 adults was conducted by NORC from May 12–June 26, 2017. The survey expands on a 1997 survey conducted by the National Patient Safety Foundation (NPSF), which merged with the Institute for Healthcare Improvement (IHI) earlier this year.   Read the press release and download the survey report or fact sheets,   Read a related article from FierceHealthcare,
by P. McTiernan
Thursday, September 28, 2017
Kaiser Permanente Fellowships for Young Physicians 0 P. McTiernan The Kaiser Permanente Northern California Patient Safety Fellowship is a one-year program offered by the Regional Graduate Medical Education Office and Regional Quality and Safety Leadership, and may be located at any number of our KP medical centers. The purpose of the Interprofessional Fellowship Program in Patient Safety is to provide post-residency trained physicians an in-depth education in patient safety practice, leadership and research. Up to two positions are offered each year.   The program is currently seeking candidates for the 2018-2019 year. Learn more at
by P. McTiernan
Wednesday, September 27, 2017
AHRQ Antibiotic Stewardship Project 0 P. McTiernan AHRQ Safety Program for Improving Antibiotic Use: A National Program for Antibiotic Stewardship Join the Project at The Agency for Healthcare Research and Quality (AHRQ), in conjunction with the Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality and NORC at The University of Chicago, created the AHRQ Safety Program for Improving Antibiotic Use to develop and implement a bundle of interventions designed to improve antibiotic stewardship and antibiotic prescribing practices across acute care, long-term care, and ambulatory care facilities across the United States. Antibiotics are a precious resource and can be critical for improving the outcomes of patients with serious infections. However, antibiotics also have the potential to cause patient harm, including allergic reactions, Clostridium difficile infections, and antibiotic resistance both at the individual patient level and for society as a whole. We want antibiotics to be effective for future generations, and that is only possible if we use antibiotics judiciously.   Hospital Registration Now Open Acute-care hospitals across the United States and Puerto Rico can now register for this 12-month project, which begins in December 2017. Learn about Participating. Future cohorts are planned for long-term care facilities (beginning December 2018) and ambulatory and urgent care facilities (December 2019).   Learn more about how to participate in this project or sign up for an informational webinar to get your questions answered,
by P. McTiernan
Monday, September 25, 2017
Device and Drug Off Label Use 1 W. Hyman I am interested in learning more in regards to concerns over using drug delivery systems in a manner that was not intended.  Namely, oversight for practice and reporting of AEs and SAEs.   Regards, Sam M
by S. Mangiamele
Thursday, September 14, 2017
Handoff Communications 1 W. Hyman Just to note, the above link goes to an infographic that accompanies the new Sentinel Event Alert and summarizes its main recommendations. The full text of the alert, which includes background discussion and supporting references, can be accessed here:
by A. Spielman
Wednesday, September 13, 2017
AHRQ Medical Office Survey on Patient Safety Culture 1 J. Carmona Now we just need a proven relationship between surveyed safety culture and actual safety. But at least you get MIPS points.
by W. Hyman
Wednesday, September 6, 2017
New IHI/NPSF Report: Patient Safety in the Home 0 J. Carmona   Patient Safety in the Home: Assessment of Issues, Challenges, and Opportunities   With support from the Gordon and Betty Moore Foundation, IHI/NPSF contracted with Westat to evaluate research on patient safety in the home and identify gaps. This report examines safety issues in the home, including challenges, funding mechanisms to support safe home care, and conceptual frameworks that seek to structure these disparate issues. It concludes with opportunities for research to advance the science of patient safety improvement in the home. Read more and download the report.        
by J. Carmona
Tuesday, September 5, 2017
What to do when improvement plateaus 2 W. Hyman An interesting challenge of bench marking and trending is when the standard is set at some level above zero. This means that someone has decided that some non-zero level of unsafety is OK, and that as long as we stay below that level we are doing well. (There is also the question of OK with who since the injured party has rarely agreed.) But where did that non-zero number come from? And would you really be happy to explain to someone (eg the patient, a lawyer) that yes the patient was injured but their injury was within our acceptable rate of injuries.
by W. Hyman
Wednesday, August 30, 2017
Nurse Sensitive Outcomes Crosswalk/ Dashboard Examples 0 C. Blalock Hello,     Does anyone have a crosswalk comparing different reporting programs for Nurse Sensitive/Driven Outcomes such as Falls, Pressure Injuries, Medication Errors, etc. I was requested to compare NDNQI, CalNOC, PfP, Leapfrog, and AHRQ to determine which program to use for benchmark.   Also, if anyone has an example of a dashboard they use for reporting this information, I'd appreciate see it for ideas. I think we have some opportunity to improve our reporting and make it more meaningful. I was thinking we could have different dashboards by program such as VBP, Nurse Sensitive Outcomes (include nurse staffing ratio & pt experience on it for reference), NHSN, and a separate report for our BHU and IRFs.   Thank you very much.   Casey
by C. Blalock
Monday, August 28, 2017
Projects in Safety: How Teamwork and Research Push Patient Safety Forward 0 J. Carmona     Throughout the month of August we are celebrating ASPPS Member Appreciation Month and are highlighting patient safety projects from ASPPS members. These initiatives remind that real change is possible when teams come together. Take a look at a few of these initiatives in this recent post on 
by J. Carmona
Wednesday, August 23, 2017
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