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  • Welcome to the ASHRM Patient Safety Portal

    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. 

    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:

    ASHRM Patient Safety Quiz

    Click here to take the quiz.

    10 Core Patient Safety Topics

    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:

    1. Adverse Drug Events
    2. Catheter-Associated Urinary Tract Infections (CAUTI)
    3. Central Line Associated Blood Stream Infections (CLABSI)
    4. Injuries from Falls and Immobility
    5. Obstetrical Adverse Events
    6. Pressure Ulcers
    7. Preventable Readmissions
    8. Surgical Site Infections
    9. Venous Thromboembolisms
    10. Ventilator Associated Event/Ventilator Associated Pneumonia

     

    ASHRM Patient Safety Programs

    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 Leadership Series: TeamSTEPPS for Risk Managers
    TeamSTEPPS, a key driver in transforming the healthcare culture, has adapted key
    principles and tools for risk management professionals. The curriculum incorporates
    sessions in communication, teamwork and techniques, tools and strategies to help risk
    managers optimize team performance. Read more.

     

     

    ASHRM Educational Offerings

    ASHRM Academy
    Patient Safety Certificate Program

     

    ASHRM Patient Safety Articles

    White Papers
    Enterprise Risk Management: A Framework For Success (PDF) (August 2014)

    Value-Driven ERM: Making ERM an Engine for Simultaneous Value Creation and Value Protection (PDF) (October 2010)

    Journal Articles
    Patient Safety: Improved obstetric safety through programmatic collaboration

    Patient Safety: Vacuum Assisted Vaginal Delivery (VAVD)

    Patient Safety: This is Public Health

    Patient Safety: Fall Prevention in Our Healthiest Patients: Assessing risk and preventing injury for mom’s and babies

    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

    Patient Safety: Using inpatient hospital discharge data to monitor patient safety events

    Patient Safety: Why are autopsy rates low in Japan? Views of ordinary citizens and doctors in the case of unexpected patient death and medical error

    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.

     

    Patient Safety Resources

    ASHRM has identified these Patient Safety Resources to assist you in identifying useful information and helpful contacts. Click here for more information

     

    Partners in Patient Safety

    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:

    • A bloodborne pathogen and safe patient injections training presentation
    • A “How to do it Right” animated video
    • A poster and a brochure demonstrating the proper use of injection devices to give diabetes medication
    • A digital press kit including an infographic, a podcast and fact sheets

    Click Here for more information about SIPC’s One and Only Campaign and to download campaign training resources.

    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:

    • Communication Checklist – Outline of quick methods your organization can use to spread the word about this report and the importance of using single-dose/single-use vials on only one patient
    • Key Messages – High-level messages to be incorporated into websites, emails, speeches, PowerPoints, etc.
    • Social Media Messages – Numerous tweets and Facebook posts to share on your organization’s (or personal) social media pages
    • Newsletter Template – Sample language that can be tailored for your organization’s newsletter

     

    Publications

     

    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.

    Click here to learn more and to purchase Pearls for Medication Safety: Part I.
    Click here to purchase a cost-saving 5-pack.

    Click here to learn more and to purchase Pearls for Medication Safety: Part II.
    Click here to purchase a cost-saving 5-pack.

    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. 

    Click here to learn more and to purchase Pearls for Enterprise Risk Management: The Foundation.
    Click here to purchase a cost-saving 5-pack.

    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.

    Click here to learn more and to purchase Pearls for Enterprise Risk Management: Applying ERM.
    Click here to purchase a cost-saving 5-pack.

    ASHRM's Enterprise Risk Management Pearls for Integrating ERM into the Healthcare Culture
    Creating an ERM culture can be challenging, especially in healthcare organizations where the Return On Investment (ROI) has often been the sole measure for decision making and capital budgeting. ERM calls for an organization to look beyond just the potential financial benefits of alternative strategies and projects.

    Click here to learn more and to purchase ASHRM's Enterprise Risk Management Pearls for Integrating ERM into the Healthcare Culture.
    Click here to purchase a cost-saving 5-pack.

    ASHRM/Aon 2014-2015 Hospital and Physician Professional Liability Benchmark Report!
    The goal of our annual study is to provide health care systems with a business intelligence tool for better estimating and understanding self-insured medical malpractice costs.  Our analysis examines trends in two dimensions - the number of claims (frequency) and the average value of claims (severity).  We show historical claim trends and forecast cost levels for the upcoming year. 
    The 2014/2015 report delivers business intelligence specific to:

    • The link between quality of care and medical malpractice claim frequency:  Results indicate that risk managers can use patient satisfaction survey scores as a “marker” for detecting and remediating areas in need of improvement.
    • A survey of claim frequency and severity by cause of loss:
      Text mining techniques were used to measure the relative frequency and severity, or average cost, of claims by the cause of loss, which brings a new level of specificity to risk managers’ ability to identify potentially costly risks.
    • Claim frequency and severity benchmarks by state:
      The 2014/2015 report provides statistical information specific to 27 states and the District of Columbia..

    The information has been developed to help healthcare professionals better understand and estimate the costs – future and past – of medical malpractice. 

    Click Here to purchase your copy of the 2014/2015 ASHRM/Aon Hospital and Physician Professional Liability Benchmark Study today.

     

     

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