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

Click here for more.

 

 

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