We trust that you enjoy our postings of ASHRM patient safety tips and information, aligned with the American Hospital Association (AHA)/Health Research & Educational Trust (HRET) Hospital Engagement Network (HEN). The goal of the HEN is to assist hospitals in adopting practices to reduce inpatient harm by 40 percent and readmissions by 20 percent. ASHRM and the AHA/HRET HEN will continue to serve as expert resources in working to improve patient safety in these areas.
Our work of promoting patient safety continues all year. Through our 2014 theme—Sharing in the Caring through Enterprise Risk Management—we will continue to recognize the role all healthcare professionals play in promoting patient safety year-round. Make sure to visit the ASHRM Patient Safety Portal throughout the year for updated information and resources.
We have posted patient safety tips and highlighted 10 Core Topics developed to assist healthcare professionals in reducing serious safety events. We hope you find the information about these core topics useful and relevant and share them with your colleagues.
Please click on the links below to access valuable patient safety information:
10 Core Patient Safety Topics Aligned with the AHA/HRET Hospital Engagement Network Program
ASHRM has provided important patient safety tips and information about 10 Core Patient Safety Topics in alignment with the American Hospital Association (AHA)/Health Research & Educational Trust (HRET) Hospital Engagement Network (HEN). The goal of the HEN is to assist hospitals in adopting practices to reduce inpatient harm by 40 percent and readmissions by 20 percent. ASHRM and the AHA/HRET HEN will continue to be resources to help improve patient safety in these core areas:
Patient Safety: Serious safety events: Getting to Zero™
Risk Management: TeamSTEPPS and patient safety in healthcare
Special Focus: Healthcare Risk Management in Non-Hospital Settings: Safety risks in the ambulatory setting
Risk Management: Safety and underwater birth—what every risk manager should know
Medication Safety: Anticoagulant medication errors in nursing homes: Characteristics, causes, outcomes, and association with patient harm
Medication Safety: Procedural sedation and implications for quality and risk management
For more patient safety articles, click here.
ASHRM has identified these Patient Safety Resources to assist you in identifying useful information and helpful contacts. Click here for more information
ASHRM and AHRQ Partner on TeamSTEPPS Master Training Course for Healthcare Risk Managers
ASHRM partnered with the Agency for Healthcare Research and Quality (AHRQ) and the Healthcare Research & Educational Trust (HRET) to offer the first-ever TeamSTEPPS Master Training Course for Enterprise Risk Managers. The free course which was filled to capacity with 50 participants, was held in Chicago in February.
TeamSTEPPS, or Team Strategies and Tools to Enhance Performance and Patient Safety, is a set of evidence-based, practical tools that helps hospitals and other health care providers strengthen teamwork among caregivers with the goal of improving patient safety. Teamwork is a top priority for all health care providers—hospitals, long-term care facilities, and physician office practices. However, changing culture and behavior of an organization can be challenging. Working together as an innovative partnership, the Agency for Healthcare Research and Quality and the Department of Defense (DOD) designed the TeamSTEPPS program for use in a variety of health care settings.
HRET is coordinating the efforts of a network of national TeamSTEPPS training centers, facilitating a learning network that equips master trainers to improve teamwork within their facilities, hosting annual conferences, and updating and expanding free TeamSTEPPS materials for provider use. HRET is partnering with IMPAQ International on this important initiative. Click here for more information.
Agency for Healthcare Research and Quality Guide to Patient and Family Engagement in Hospital Safety and Quality
This guide gives hospitals practical tools and step-by-step guidance to improve patient and family engagement. It includes strategies that hospitals can implement, including layperson advisors, and improving communications during admissions, at the bedside during shift changes, and with discharge planning. Click here to download the guide.
American Society for Healthcare Engineering 2012 Advocacy Report
The report includes a collection of articles and information based on the society’s unified code initiative, and details how codes that are conflicting, outdated burden the health care system. This affects patient safety due to the fact that the billions of dollars wasted on outdated or conflicting codes is money that hospitals can be used toward safe patient care. Click here to download the report.
New Injection Safety Campaign Stresses One Needle, One Syringe at One Time
The Centers for Disease Control and Prevention (CDC) and the Safe Injection Practices Coalition (SIPC) have released new training materials as part of their One and Only Campaign. The campaign aims to eliminate adverse events resulting from unsafe injection practices.
Since 2001, more than 130,000 patients in the United States have been notified of potential exposure to hepatitis B virus (HBV), hepatitis C virus (HCV), and HIV due to lapses in basic infection control practices. Many of these lapses involved healthcare providers reusing syringes, resulting in contamination of medication vials or containers which were then used on subsequent patients.
The One and Only Campaign stresses that providers must use a needle and a syringe only one time for each and every injection. This practice will greatly reduce the risk of contracting hepatitis and other infections through medical injection.
The goal of the campaign is to ensure patients are protected every time they receive a medical injection. SIPC members believe the goal can be attained by empowering patients and reeducating healthcare providers regarding safe injection practices. Targeted education and awareness campaigns focus on influencing the culture of patient safety.
A wide range of educational materials are available through the campaign including:
Click Here for more information about SIPC’s One and Only Campaign and to download campaign training resources.
Prevent Surgical Fires with Initiative Tools
National Fire Prevention Week is Oct. 5-11
ASHRM, along with 27 other organizations and the FDA, is celebrating the third anniversary of the Preventing Surgical Fires Initiative during National Fire Protection Week, Oct. 5-11, 2014. The Initiative offers surgical fire prevention tools and promotes the adoption of risk reduction practices. To learn more about the Initiative and steps you can take in your own facility, click here.
As a SIPC Member, ASHRM Draws Attention to Safe Use of Single-Dose/Single-Use Vials
A report from the Centers for Disease Control and Prevention (CDC) found that transmission of life-threatening bacterial infections, including MRSA, can occur when healthcare personnel use medication in containers labeled as single-dose or single-use for more than one patient, a practice that is against standard precautions. This report summarizes the investigation of two outbreaks of invasive Staphylococcus aureus infection confirmed in 10 patients being treated for pain in outpatient clinics. In each outbreak, healthcare personnel had used single-dose or single-use vials for more than one patient.
The Safe Injection Practices Coalition (SIPC), a partnership of patient advocacy organizations and foundations, including ASHRM, is using this report to draw attention to the importance of following safe injection practices at all times, even during times of medication shortages. SIPC has put together a portfolio of resources to assist your organization in following safe injection practices. The portfolio includes a:
Patient Safety I–Set the Framework:
Participants will be able to describe the evolution of patient safety, identify the characteristics of a Just Culture, and explain how human factors influence patient safety outcomes. For more information, click here.
Patient Safety II–Take the Lead:
Participants will be able to outline strategies to obtain actionable information from data mining efforts, professionally respond to staff reactions to adverse events, and examine the relationship between medication errors and technology. For more information, click here.
The HRM Certificate Program:
A cornerstone of ASHRM's professional development resources, the HRM Certificate Program covers key aspects of risk management while providing valuable continuing education credits. The program includes three modules: Module 1: Essentials in HRM; Module 2: Applications in HRM; and Module 3: Advanced Forum in HRM. Participants who complete all three modules will earn a certificate. Click here to learn more.
Certified Professional in Healthcare Risk Management (CPHRM)
Administered by the American Hospital Association (AHA), the Certified Professional in Healthcare Risk Management (CPHRM) is the healthcare industry’s premier certification for the risk management profession. The AHA's Certification Center determines eligibility requirements, exam content, testing procedures, and other aspects of certification and oversees the examination process. Click here to learn more.
ASHRM Healthcare Risk Management Pearls for Obstetrics:
Part I and Part II
ASHRM’s new Healthcare Risk Management Pearls for Obstetrics: Part I and Part II provide the tools for healthcare risk managers, patient safety professionals, providers, and administrators to help decrease risk and improve safety in the delivery of care to pregnant women and their babies. All of the chapters provide succinct risk management strategies that can be easily implemented.
Click here to learn more and to purchase Pearls for Obstetrics: Part I.
Click here to purchase a cost-saving 5-pack.
Click here to learn more and to purchase Pearls for Obstetrics: Part II.
Click here to purchase a cost-saving 5-pack.
ASHRM Risk Management Pearls for Medication Safety: Part I and Part II
Medication safety challenges are a priority for consumers, providers, regulatory/accreditation agencies, and healthcare leaders. Although medications are intended to benefit patients, the medication-use system is a potentially high-risk and error-prone component of the healthcare delivery system in both inpatient and outpatient delivery systems. Opportunities for harm may occur at any stage of the medication-use process, from selecting, procuring and prescribing, to storing, preparing, dispensing, administering, and monitoring. ASHRM’s new Risk Management Pearls for Medication Safety: Part I and Part II summarize medication error prevention strategies and practices that are effective in reducing and eliminating patient harm.
ASHRM Pearls for Enterprise Risk Management: The Foundation
The barrage of technological, organizational, and legal changes will continue to be commonplace in the healthcare industry. As a result, new and additional forms of risk will arise. Today’s healthcare risk manager must be able to identify and address these issues. The Enterprise Risk Management (ERM) approach efficiently and effectively addresses organizational-wide risk, especially in unpredictable and ever-changing environments, and ultimately helps improve patient safety. ASHRM’s Pearls for Enterprise Risk Management: The Foundation is designed to help you understand ERM, how it can benefit your organization, and help improve patient safety. ERM: The Foundation begins with an overview of ERM, and progresses to implementation of an ERM program and its benefits.
ASHRM Pearls for Enterprise Risk Management: Applying ERM
Enterprise risk management (ERM) requires a system-wide, integrated approach to addressing risk in your organization. The foundation for your organization’s approach is the enterprise risk management plan. ASHRM’s Pearls for Enterprise Risk Management: Applying ERM explains how to obtain buy-in from the governing body and all stakeholders; how to link the plan with other organizational initiatives; how to roll out the plan; and how to monitor and communicate your organization’s ERM effectiveness.
2013 ASHRM/Aon Hospital and Physician Professional Liability Benchmark Report
The cost of medical malpractice is growing at the slowest rate in the fourteen year history of the ASHRM/Aon Hospital and Physician Professional Liability Benchmark Report. The 2013 analysis—distributed by ASHRM and Aon Global Risk Consulting—details the professional liability costs faced by healthcare organizations.
The 2013 report includes information about:
The analysis will assist you in developing proactive strategies to reduce risk-related costs and ultimately improve patient outcomes.
Click here to learn more and to purchase your copy.