PSONEWS From the Center for Patient Safety
FALL 2014 EDITION
IN THIS EDITION PSO Safety Alert.1 Are Healthcare Providers Missing Out.2 What Can Your Service Protect.2 Patient Safety Culture Survey.3 PSO Safety Watch: Stretchers.3 EMS PSO & The Law.3 National EMS Patient Safety Conference.4-5 CPS Joins AAA.6 Certificates Available.6 What is a PSO.6 CPS Staff Head to Austin.7 PSO Case Law Update.7 PSO Data Snapshot.7 Center Welcomes Newest Staff.8 Upcoming Events.8
PSO SAFETY ALERT ISSUED based on trends from medication events
Reports of medication errors to the PSO are not uncommon, however, when a trend is noticed we want to notify you. Recently, there have been medication errors pertaining to the administration of the incorrect medication involving Morphine and Midazolam. Recently, there has been a trend of medication errors pertaining to the administration of the incorrect medication involving Morphine and Midazolam. Specifically, confusing the two medications and administering the wrong medication. As a Patient Safety Organization (PSO), the Center for Patient Safety collects incident, near miss, and unsafe condition information on multiple types of healthcare related cases, including EMS medication events.
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The Center for Patient Safety would like to thank the many participants that are actively submitting data. Your concern about safety, quality and improving the care in our communities is evident in your level of participation. Furthermore, taking the time to enter data and safely share a near miss, adverse event, or unsafe condition might help prevent another event taking place. If it wasn’t for these many loyal participants supporting the EMS PSO we would not be able to share this valuable information with others. (continued on page 3)
CENTER FOR PATIENT SAFETY Have you noticed this icon?
Look for this icon to find additional resources in the articles. You’ll find links to downloadable templates, websites and other resources. Available in the electronic version of this newsletter.
ARE HEALTHCARE PROVIDERS MISSING OUT?
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(continued from Safety Alert, page 1)
Specifically, confusing the two medications and administering the wrong medication. Possible reasons for the error: •
Similar names of medication
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Similar packaging or container
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Similar route of delivery
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Medications were locked together
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No cross check process in place or time out taken before administration
How to Mitigate Risk The Center recommends you review your medication administration policy and discuss this with your medical director or safety director. For more information, visit these links with helpful information: •
JEMS – Bad Medicine
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Preventing Medication Errors in EMS, John Gallagher, MD, Phoenix Fire Department
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EMS Insider – Tracking Medication Errors
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EMS1 – Medical Errors
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Medication Administration Cross Check with No Error, Wichita/Sedgwick County EMS
his summer, the well-known health care attorneys at Horty, Springer & Mattern, published an excellent summary of a recent federal district court opinion on a PSO case entitled Tinal vs. Norton Healthcare, Inc. The lawsuit was filed by a pharmacist alleging that Norton unlawfully terminated her employment in violation of the Americans with Disabilities Act. The health system contended that the pharmacist was terminated because she made a series of errors in dispensing medications. The law firm has given us permission to share their views on the importance of being actively involved with a PSO.
“Would you ride in a car without a seat belt? Would you drive without auto insurance?
It would be foolhardy – and perhaps dangerous – not to protect yourself by taking those simple steps. The same is true about hospitals and health systems that are not taking advantage of the protection for peer review information and quality data that is available under the Patient Safety and Quality Improvement Act of 2005 (“PSQIA”). They are needlessly placing themselves at risk!” Quote from Horty, Springer & Mattern, P.C. (July, 2014)
WHAT CAN YOUR SERVICE PROTECT?
• Call review documentation (for example: communication/ feedback to your staff about their performance; focused reviews of high risk or other specific concerns) • Documentation and conversations related to investigations of incident reports • Internal studies on medication and other types of errors • Case reviews by your agency’s Medical Director • Regional quality committee meetings (certain conditions must be present)
• Most any electronic or paper documentation, notes, and data related to your agency’s safety and quality improvement processes
“EMS agencies can become members of PSOs and not only achieve protection of their own processes but also benefit from the collective knowledge and understanding provided by the PSO and its members.” – The National Association of Emergency Medical Technicians (NAEMT)
www.centerforpatientsafety.org
SUMMER 2014
PATIENT SAFETY CULTURE SURVEY
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he safety culture survey provides feedback on your organization’s communication, teamwork, patient safety, leadership, and staff engagement. The Center for Patient safety (CPS) recognizes your commitment to safety as a CPS PSO participant. Therefore, CPS offers a 20% discount to participants utilizing CPS’ culture survey services for Hospitals, LTC, Home Care, Pharmacies, Medical Offices and EMS. Contact us today to receive a free estimate for your 2015 culture surveys.
CPS PSO ISSUES EMS SAFETY WATCH FOR STRETCHERS
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ultiple stretcher-related incidents have been reported to the Center’s Patient Safety Organization. The following areas of concern are from real events: • Stretcher collapsed while a patient was on it • Stretcher rolled out of control with a single attendant guiding it • Head of the stretcher collapsed while in upright position • Bolts or screws were missing from stretcher • Power function was not operational and manual mode was not engaging • Unable to raise or lower stretcher using power function
How to Mitigate Risk
The Center advises you to take appropriate actions to prevent events from occurring at your organization. Please follow the manufacture recommendations and guidelines for maintenance as well as usage of the equipment. It is also recommended you conduct a refresher on the device and all supporting equipment. For more information, contact your manufacture and have the serial number available. Ferno- 877-733-0911 Stryker-800-327-6511 Additional information is available on our website or contact the EMS Project Manager, Lee Varner, lvarner@mocps.org.
EMS PSO AND THE LAW
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he Center for Patient Safety would like to thank the many who joined us for the EMS PSO Webinar on October 1, “Ask the Lawyer: PSOs and the Law”. The webinar drew a very wide group of EMS and other healthcare professionals from around the country. Kathy Wire, JD, MBA, CPHRM, led the presentation then opened up the remainder of the program to questions. Kathy outlined the 2005 Patient Safety Quality Improvement Act and how participation would provide federal protection around much of the quality and safety efforts that EMS was already doing. Kathy said “EMS is great to work with; they have a keen interest in quality and safety”. The webinar focused on what a PSO is and how it supports the needs of quality and safety work.
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Watch the recording:
Lee Varner, BS, EMS, EMT-P, EMS Project Manager at the Center for Patient Safety, was impressed with the diversity of those who participated with the webinar. Lee said “the topic attracted both ground and air EMS as well as many leaders in our industry”. The goal of the webinar was to help raise awareness to the importance of reporting unsafe conditions, near misses, and adverse events. Participating with a PSO and sharing information in a safe way allows EMS to learn one another and drive best practices in our industry.
CENTER FOR PATIENT SAFETY
THE NATIONAL EMS PATIENT SAFETY CONFERENCE
JEFFERSON CITY, MISSOURI ON NOVEMBER 12, 2014
AUDIENCE
The 2014 EMS Patient Safety Conference is expected to be bigger and better than previous years, bringing national EMS experts together to share strategies to improve patient safety, highlight successful practices and provide broad networking opportunities to share successes and challenges.
AGENDA
What’s in the Data? A look at the Center’s EMS and Hospital event reports, presented by Center for Patient Safety staff: Eunice Halverson, MA, Patient Safety Specialist and Lee Varner, BS EMS, EMT-P, Project Manager Plan-Do-Study-Act presented by David Williams, Institute for Healthcare Improvement Faculty, Using the Improvement Model for Impact in EMS
SPONSORSHIP & VENDORS
Breakout Sessions:
We encourage and welcome your involvement as a Safe Care sponsor and/or vendor! To reserve your sponsorship and/or vendor space: • Complete the 2014 Conference Sponsor and Vendor Form • Return it to the Center by Friday, September 12, 2014, to receive recognition in preconference promotional materials that are expected to reach over 10,000 people. NOTE: After September 12 2014, sponsorship and vendor applications are welcome, however recognition in preconference promotional materials cannot be guaranteed.
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PSO Safe Tables (PSO Participants only), presented by the Center for Patient Safety
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Just Culture Case Scenarios, presented by Mark Alexander
Safety Culture and Management of Risk presented by Tom Judge, Executive Director, Lifeflight of Maine Coordination of Patient Safety in Mobile Integrated Healthcare presented by Michael Bachman, Wake County EMS, Raleigh, NC
Visit www.centerforpatientsafety.org/2014-ems-conference/ for more information.
VENUE Capitol Plaza Hotel 415 W McCarty St. Jefferson City, MO 65101
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SUMMER 2014
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CENTER FOR PATIENT SAFETY
CPS JOINS AAA
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he Center for Patient Safety is excited to announce its membership with the American Ambulance Association. Membership with the AAA will support the opportunity to connect with EMS leaders from diverse organizations around the country. The Center will also be exhibiting at the AAA Annual Conference and Trade Show November 17-19 in Las Vegas. For more information about the American Ambulance Association, visit their website.
CERTIFICATES AVAILABLE (CPS Members only)
Each PSO member can print a certificate that recognizes its participation with the Center for Patient Safety (CPS). Just answer a few questions to confirm your participation and you’ll receive immediate access to a printable certificate. Complete the PSO Participation Validation survey.
WHAT IS A PSO?
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atient Safety Organization’s (PSOs) support the collection, analysis, sharing and learning about what medical errors occur, why and how to prevent them. By reinforcing a safety culture that allows healthcare providers to safely report and share information about vulnerabilities within the healthcare system, PSOs are pivotal in the crusade to prevent medical errors and patient harm. Still interested in learning more? Contact Lee Varner at the Center for Patient Safety at lvarner@mocps.org or call 888.935.8272.
www.centerforpatientsafety.org
SUMMER 2014 Have you noticed this icon?
Look for this icon to find additional resources in the articles. You’ll find links to downloadable templates, websites and other resources. Available in the electronic version of this newsletter.
CPS STAFF HEAD TO AUSTIN IN OCTOBER TO SPEAK
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ee Varner and Kathy Wire will be guest speakers at the upcoming ESO Solutions’ Wave 2014 Conference in Austin, Texas, on October 21 and 22. They will have EMS PSO 101 - a session on EMS Patient Safety Organizations (PSO). This conference includes lectures by industry experts on the latest trends and best practices in data, EMS and the continuum of care.
PSO CASE LAW UPDATE LATE DEVELOPMENT
Two new cases (from Florida and Kentucky) have applied restrictive definitions to "Patient Safety Work Product" that arise from unique features of state law in those states. The Center for Patient Safety has summaries of both cases on its website.
PSO DATA SNAPSHOT
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he Center for Patient Safety continues to receive EMS data through the ShareSuite PSO Database, powered by Verge Solutions. Participating EMS servicies are commended for their role in improving patient safety through the sharing of these events. • Nearly half of all EMS entries in the platform consist of STEMI and Stroke time collection information. • About one-fourth of the entries are “Other” which indicate there are many events occurring beyond the main categories. • About one-fourth of the entries are categorized safety concerns, including airway management, ambulance crash, device or medical/surgical supply, and medication or other substance. • Of the categorized entries, 81% of reported events reached the patient. 21% of those events resulted in some level of harm: mild harm, moderate harm or death.
The Center for Patient Safety regularly releases information about the data submitted to the PSO. For information on the data from the Center’s hospital PSO database, see the Spring 2014 PSONews.
CENTER FOR PATIENT SAFETY
UPCOMING EVENTS..
2014
CENTER WELCOMES NEWEST STAFF!
NOVEMBER 12 - EMS Patient Safety Conference – Jefferson City, Missouri
The Center is pleased to announce the newest members of our team.
Tina Hilmas, RN, BSN Project Manager thilmas@mocps.org
BE A SAFETY SPONSOR: How you can help!
The Center for Patient Safety values partnerships with organizations and individuals who want to support improvement in healthcare quality and patient safety. Because the Center is a not-for-profit organization, donations are tax-deductible. There are three ways to join the effort to spread safety culture throughout the healthcare community: individual donation, organizational sponsorship levels, and/or supporters can sponsor an event or initiative.
Jennifer Lux Office Coordinator jlux@mocps.org
Opportunities include: • Education and training activities • Patient Safety Awareness Month activities and events • Clinical collaboration • Surveys, analysis, and reports • Adverse event reporting system • Research and analysis • Publications and reports The Center makes the process easy; you can donate online in minutes. And, of course, any of the Center staff can answer your questions and provide more information.
FOR MORE INFORMATION, CONTACT ANY MEMBER OF OUR PSO TEAM Executive Director, BECKY MILLER, MHA CPHQ, FACHE, CPPS, bmiller@mocps.org Patient Safety Specialist, EUNICE HALVERSON, MA, ehalverson@mocps.org Project Manager, KATHRYN WIRE, JD, MBA, CPHRM , kwire@mocps.org Project/Operations Manager and Analyst, ALEX CHRISTGEN, BS-BA, achristgen@mocps.org Project Manager, EMS Services, LEE VARNER, BS, EMS, EMT-P, lvarner@mocps.org Medical Director, MICHAEL HANDLER, MD, MMM, FACPE Researcher/Data Analyst, AMY VOGELSMEIER, PHD, RN, GCNS-BC Office Coordinator, JENNIFER LUX, jlux@mocps.org Administrative Assistant, DIANA PHELPS, dphelps@mocps.org
For additional information on the Center’s PSO activities, resources, toolkits, upcoming events, safety culture resources, and more, visit our website at www.centerforpatientsafety.org or follow us on Twitter @PtSafetyExpert for the most up-to-date news.
NOTE Some articles contained within this newsletter may reference materials available to Center for Patient Safety PSO participants only. If you have questions about any Centerresources or articles within this newsletter, please contact the Center for Patient Safety at info@mocps.org or call our office at 888.935.8272. The information obtained in this publication is for informational purposes only and does not constitute legal, financial, or other professional advice. The Center for Patient Safety does not take any responsibility for the content of information contained at links of third-party websites.
ABOUT THE CENTER: The Center for Patient Safety, was founded by the Missouri Hospital Association, Missouri State Medical Association and Primaris as a private, non-profit corporation to serve as a leader to fulfill its vision of a healthcare environment safe for all patients and healthcare providers, in all processes, all the time.
www.centerforpatientsafety.org