Patient Safety Toolbox
Medical errors are the eighth leading cause of death in the United States, with the number of deaths exceeding those associated with motor vehicle accidents, breast cancer, or AIDS. Medication errors represent the largest single cause of errors in the hospital setting, accounting for more than 7,000 deaths annually -- more than the number of deaths resulting from workplace injuries
|In 2006, the State of Vermont enacted Act 215, 18 V.S.A. Ch. 45A, the Patient Safety Surveillance and Improvement System (PSSIS). This statute required the Vermont Department of Health to establish a comprehensive patient safety surveillance and improvement system for the purpose of improving patient safety, eliminating adverse events in Vermont hospitals and supporting and facilitating quality improvement efforts by hospitals.
Key components of the system include:
Hospital Engagement Network (HEN)
- internal hospital reporting and analysis of all adverse events and near misses
- external hospital reporting of the National Quality Forum's twenty-eight (28) serious reportable events and intentional unsafe acts to the PSSIS
- hospital disclosure to patients of adverse events that result in patient death or serious bodily injury
- analysis of reportable events and compliance monitoring by the PSSIS.
The Center for Medicare and Medicaid Innovation (CMMI) awarded a contract to Intermountain Healthcare and it’s partner delivery systems to lead the way in improving safety and quality across the country. We are recruiting hospitals to join our learning community in beating the drum for change.
Patient Safety Surveillance & Improvement System (PSSIS)
Slide Show Presentation at the QIO Conference in Lebanon, NH on March 14, 2012
By Avril Cochran of Vermont Program for Quality in Health Care
Mount Ascutney Hospital and Health Center
An Example of a Leadership Rounding Policy
IHI: Respectful Management of Serious Clinical Adverse Events
After the Institute of Medicine released its sentinel report, To Err is Human: Building a Safer Health System, the Agency for Healthcare Research and Quality (AHRQ), in conjunction with its Federal partners and non-Federal stakeholders and at the direction of Congress, started the process of building the foundation to better understand patient safety challenges and how effective solutions could be rapidly implemented.
AHRQ: Advancing Patient Safety
The Commonwealth Fund: Five Years After To Err Is Human: What Have We Learned”
AHIP: Health plan joins partnership to promote patient safety, lower hospital readmissions.
AHIP: Innovations in Reducing Preventable Hospitals Admissions, Readmissions, and Emergency Room Use.
The SBAR (Situation-Background-Assessment-Recommendation) technique provides a framework for communication between members of the health care team about a patient's condition. SBAR is an easy-to-remember, concrete mechanism useful for framing any conversation, especially critical ones, requiring a clinician’s immediate attention and action. It allows for an easy and focused way to set expectations for what will be communicated and how between members of the team, which is essential for developing teamwork and fostering a culture of patient safety.
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IHI:Global Trigger Tool for Measuring Adverse Events
IHI: SBAR Guidelines for Communicating with a Physician
IHI: Template: Using SBAR to Report to a Physician about a Critical Situation
This toolkit is designed to help your hospital understand the Quality Indicators (QIs) from the Agency for Healthcare Research and Quality (AHRQ), and support your use of them to successfully improve quality and patient safety in your hospital. The toolkit is a general guide to using improvement methods, with a particular focus on the QIs. It focuses on the 17 Patient Safety Indicators (PSIs) and the 28 Inpatient Quality Indicators (IQIs).
AHRQ: Quality Indicator Toolkit for Hospitals
AHRQ: Improving Health Care Quality
Addressing Medication Errors in Hospitals: A Framework for Developing a Plan
Addressing Medication Errors in Hospitals-Ten Tools
Human factors engineering is the discipline that takes into account human strengths and limitations in the design of interactive systems that involve people, tools and technology, and work environments to ensure safety, effectiveness, and ease of use.
Usability testing is also essential for identifying workarounds—the consistent bypassing of policies or safety procedures by frontline workers. Workarounds frequently arise because of flawed or poorly designed systems that actually increase the time necessary for workers to complete a task. As a result, frontline personnel work around the system in order to get work done efficiently.
AHRQ: Nursing Workload and Patient Safety-A Human Factors Engineering Perspective
AHRQ: Patient Safety and Quality: An Evidence-Based Handbook for Nurses
A checklist is an algorithmic listing of actions to be performed in a given clinical setting, the goal being to ensure that no step will be forgotten. Although a seemingly simple intervention, checklists have a sound theoretical basis in principles of human factors engineering and have played a major role in some of the most significant successes achieved in the patient safety movement.
Changes in Safety Attitude and Relationship to Decreased Postoperative Morbidity and Mortality following Implementation of a Checklist-Based Surgical Safety Intervention.
AHRQ: Central Line Insertion Care Team Checklist
AHRQ: Your Project Checklist: How to Manage your Quality Reporting Project
Top 10 Health Technology Hazards for 2011
Top 10 Health Technology Hazards for 2012
The Health Research & Educational Trust (HRET), an affiliate of the American Hospital Association (AHA), has been awarded a contract by the Centers for Medicare and Medicaid Services to support their Partnership for Patients (PfP) campaign. PfP is a public-private partnership that intends to help improve the quality, safety and affordability of health care for all Americans. The project assists hospitals with adopt new practices that have the potential to reduce inpatient harm by 40 percent and readmissions by 20 percent.
Hospital Engagement Network to Improve Patient Care