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:
Patient and Care Provider Tool
Effective communication between the care provider and a patient is an essential step in building an open, shared decision-making and trusted relationship. When the patient has all vital information and important questions or concerns written down for quick reference, during the limited time with the care provider, the patient leaves with better understanding of next steps and has answers to their questions. Communication is one key to the delivery of high-quality outcomes and patient satisfaction scores.
The ASHRM Patient Safety Task Force developed the Patient and Care Provider Tool to be a starting point for customizing your own tool. Customize the tool to your service line areas, population of patients served and identified patient needs. Provide the tool to new patients or as they are preparing for a follow up or next scheduled outpatient visit. Working together is key to successful patient outcomes and experience.
ASHRM Patient Safety 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:
- Adverse Drug Events
- Catheter-Associated Urinary Tract Infections (CAUTI)
- Central Line Associated Blood Stream Infections (CLABSI)
- Injuries from Falls and Immobility
- Obstetrical Adverse Events
- Pressure Ulcers
- Preventable Readmissions
- Surgical Site Infections
- Venous Thromboembolisms
- Ventilator Associated Event/Ventilator Associated Pneumonia
ASHRM Patient Safety Programs
Patient Safety Certificate Program:
The Patient Safety Certificate Program is designed to assist health care risk management and patient safety professionals apply key patient safety concepts to support improved patient care and outcomes. Participants will review patient safety concepts and learn to effectively apply them to effect positive change in their organization. The certificate program is designed in a “blended learning” approach, with attendees beginning their journey with the program with an online component prior to the in-person learning. Learn More.
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. 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. 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 Learn More
ASHRM Patient Safety Articles
Enterprise Risk Management: A Framework For Success (PDF) (August 2014)
ASHRM Members log in for free access
Different Roles, Same Goal: Risk and Quality Management Partnering for Patient Safety
Risk Management Pearls: Enhance Communication in Healthcare Settings, 2nd Edition
Serious Safety Events: A Focus on Harm Classification – Deviation in Care as a Link™
Serious Safety Events: Getting to Zero™
Patient Safety: Improved obstetric safety through programmatic collaboration
Patient Safety: Vacuum Assisted Vaginal Delivery (VAVD)
Patient Safety: This is Public Health
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.
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. Download the guide.
What is the Communication and Optimal Resolution Process?
The Communication and Optimal Resolution (CANDOR) process is a process that health care institutions and practitioners can use to respond in a timely, thorough, and just way when unexpected events cause patient harm. Based on expert input and lessons learned from the Agency's $23 million Patient Safety and Medical Liability grant initiative launched in 2009, the CANDOR toolkit was tested and applied in 14 hospitals across three U.S. health systems. For more information
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
Gawande, A. (2010). The Checklist Manifesto: How to Get Things Right. New York: Metropolitan Books.
Marx, D. (2009). Whack-a-Mole: The Price We Pay For Expecting Perfection. Minnesota: By Your Side Studios.
Reason, J. T. (1997). Managing the Risk of Organizational Accidents. England: Ashgate Publishing Ltd.
Wachter, Robert (2012). Understanding Patient Safety, 2nd Edition. New York: McGraw-Hill Professional.
Weick, K. E. & Sutcliffe, K. M. (2015). Managing the Unexpected: Sustained Performance in a Complex World. New Jersey: Wiley.