CHPSO March Newsletter

March 2013

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In this Issue:

  • CalPERS’ Doug McKeever to Speak at Annual Meeting
  • Annual Meeting Early Bird Registration Extended
  • The Impact of Health Information Technology on Patient Safety
  • March Member Call: Creating a Safe Journey for Patients — Maximizing Results from Your AHRQ Culture of Safety Survey
  • CHPSO / ECRI Webinar: ECRI Institute PSO Deep Dive™ — Health Information Technology
  • Annual Meeting Goes Green
  • Lessons Learned: Retained Surgical Items
  • Patient Safety Awareness Week is March 3–9, 2013
  • Results of Member Survey
  • Children’s National Medical Center “Keeping Our Kids Safe: You Have Our Permission” Video
  • Members-Only at CHPSO.org
  • Upcoming Patient Safety Calendar

CalPERS’ Doug McKeever to Speak at Annual Meeting

CHPSO is pleased to announce that Doug McKeever will be speaking at the Second Annual Meeting — Getting to Zero: Innovate, Collaborate, Accelerate — April 8–9, 2013 at the Hyatt Regency Sacramento. A competing commitment forced Peter Lee from Covered California to withdraw, so Mr. McKeever will step in to discuss the nexus between health care reform, financial sustainability, quality and safety.
 
Mr. McKeever is Chief of the Health Policy and Program Support Division at the California Public Employees’ Retirement System (CalPERS). He oversees development and implementation of policies relating to the health care program, leadership and program direction of the CalPERS health plans rate negotiation strategies, and implementation of health care reform efforts affecting CalPERS. Before CalPERS, he was the Director of Juvenile Programs at the California Department of Corrections and Rehabilitation, where he directed and oversaw the development and implementation of statewide medical, mental health, dental and education plans and policies.

Annual Meeting Early Bird Registration Extended

The Annual Meeting “Early Bird” registration deadline has been extended to March 14. Registration forms received through March 14 will qualify for the discounted rate. The registration rate will increase $105 on March 15.

CHPSO’s Second Annual Meeting — Getting to Zero: Innovate, Collaborate, Accelerate — April 8–9, 2013 will take place at the Hyatt Regency Sacramento. Innovative speakers, such as Carolyn Clancy, MD, Director of the Agency for Healthcare Research and Quality (AHRQ), will provide knowledge and techniques that can be immediately implemented into facility processes in order to reduce patient harm. Additional information and registration can be found at www.chpso.org/annual-meeting.

As a provider, CHPSO is approved by the California Board of Registered Nursing for 11.4 contact hours of continuing education for this program. Continuing education will also be extended for 9.5 hours of ACHE Qualified Education credit, 9.5 hours for the National Association of Healthcare Quality (NAHQ) for CPHQ credit, and is pending approval of 9.5 contact hours of CE credit toward fulfillment of the requirements of ASHRM designations of Fellow (FASHRM) and Distinguished Fellow (DFASHRM) and towards Certified Professional in Healthcare Risk Management (CPHRM) renewal. Full attendance at each day’s educational sessions is a prerequisite for receiving continuing education credit. Additional information and registration can be found at www.chpso.org/annual-meeting.


The Impact of Health Information Technology on Patient Safety

Health care providers and policymakers have embraced health information technology (IT) as an essential component of high-quality health care because it has the potential to provide multiple benefits. For many health care organizations, health IT is synonymous with electronic health records (EHRs), but it also includes bar-coded medication administration, computerized provider order entry (CPOE), medication management, laboratory information, and picture archiving and communication systems (PACS).

Significant resources are now directed at health IT. Not surprisingly, IT now represents the biggest share of many health care organizations’ capital budgets. But the nation’s multibillion-dollar outlay for health IT can only make a positive impact on health care quality if it is planned, designed, installed, and used correctly. Just being wired to enable providers to submit orders electronically or view a patient’s record from a computer screen is not a guarantee of improved patient care.

There are numerous studies to support health IT’s important role in patient safety. For example, CPOE systems can improve patient safety by eliminating transcription errors from illegible handwriting, providing clinical decision support, and alerting clinicians to potentially dangerous orders, such as a patient allergy to a selected medication. But studies also point to the unintended consequences of health IT. Continuing with the CPOE example, studies have documented that, among several possible hazards with the systems, clinicians can mistakenly select the wrong patient file when placing an order in a CPOE system if the computer screen display is confusing, resulting in a medication order for the wrong patient.

PSOs’ Role in Analyzing Health IT Events

Patient safety organizations (PSOs) across the nation are playing an important role in identifying the potential perils associated with health IT. PSOs have the unique ability to collect and analyze patient safety events associated with health IT in a non-threatening and protected manner. CHPSO is leading a workgroup with other PSOs to investigate the patient safety issues associated with EHRs in an effort to highlight these concerns to EHR vendors. CHPSO members are encouraged to continue submitting incident reports in which the EHR is a contributing factor.

CHPSO members can log into their CHPSO/ECRI portal to review to the entire report, ECRI Institute PSO Deep Dive: Health Information Technology.


March Member Call: Creating a Safe Journey for Patients — Maximizing Results from Your AHRQ Culture of Safety Survey

Monday, March 11, 2013, 10–11 a.m.

Having a culture that supports and promotes safety efforts has been identified in health care and other industries as a key element in improving safety. As required by the Joint Commission, hospitals must measure their patient safety culture on a regular basis. The AHRQ Hospital Culture of Patient Safety Survey has been the most widely used in California.

In this session, learn how to successfully implement, analyze, prioritize, communicate and develop specific interventions to enhance your safety culture. We will review the AHRQ data from one hospital and hear how they plan to move forward in 2013 to further enhance their culture of safety using a focused Culture Change Model to ensure a safe journey for patients, visitors, and staff.

Presented by Steven Savage, EdD, Director, Quality Improvement Network Facilitation, California Hospital Engagement Network (CalHEN) California Hospital Association and Kassie Waters, Director, Quality Improvement, Marshall Medical Center in Placerville, CA.

This call is for members only. Members will receive an email with call in information Thursday before the call. If you are a CHPSO member and want to ensure you are on our member mailing list, please email info@chpso.org.


CHPSO / ECRI Webinar: ECRI Institute PSO Deep Dive™ — Health Information Technology

Monday, March 18, 2013, 11:30 a.m.–12:30 p.m.

Join CHPSO and ECRI for a review of the latest PSO Deep Dive™ analysis identifying health information technology (IT) events and unsafe conditions, along with risk reduction strategies. This webinar seeks to further health care’s understanding of how health IT can improve health care quality without jeopardizing safety.

Dr. Jason Adelman from Albert Einstein College of Medicine, Montefiore Medical Center will present a health IT tool related to understanding and preventing wrong-patient electronic orders.

The goals of this webinar presentation are to:

  • Share information reported from members about health IT-related events.
  • Suggest strategies to mitigate health IT-related events.
  • Provide an example of a health IT tool.

This call is for members only. Members will receive an email with call in information Thursday before the call. If you are a CHPSO member and want to ensure you are on our Member mailing list, please email info@chpso.org.


Annual Meeting Goes Green

As a conservation effort, CHPSO's Second Annual Meeting — Getting to Zero: Innovate, Collaborate, Accelerate — April 8–9, 2013, in Sacramento, CA will be paperless. Presentations and handouts will be distributed electronically through an exclusive conference attendee section on our website. We plan to provide wireless access during the meeting so event attendees may download materials to their phone, tablet or laptop.

Attendees who have completed the registration process will receive an email within 48 hours regarding pre-approved status on our website. Users will then need to go to www.chpso.org and set up their account. Verified users will have exclusive access to all conference offerings. Attendees who are CHPSO members will also have the benefit of access to member-only information on the CHPSO website.

If you have any questions, please do not hesitate to contact Andee Thorpe at athorpe@chpso.org. We look forward to seeing you in April!


Lessons Learned: Retained Surgical Items

CHPSO and Dr. Verna Gibbs, Director of NoThing Left Behind, have been leading a multi-state collaborative with patient safety leaders in Illinois, Michigan, Missouri, North Carolina, Nebraska and Tennessee to collect and analyze events related to retained surgical items, with a particular interest in small miscellaneous items (SMI) or un-retrieved device fragments (UDF). These items are often pieces or fragments that have broken off during surgery, like screws, wires, drill bits, suction tips, and tips from tunneling devices. Because they are often small in nature and can be difficult to remove, clinicians often minimize their importance as a patient safety issue. However, these items can dislodge and migrate to other areas of the body. Metal objects can become heated when a patient undergoes a MRI.

Most of the cases involving UDFs (38%) occurred during orthopedic procedures. The second largest number (28%) occurred during vascular procedures, where pieces or entire guidewires, sheaths, and stents were retained.

Why do they occur?

Catheter and guidewire fractures may be caused by the use of inappropriate techniques, such as withdrawing a catheter through or over a needle, shaping a device to conform to the patient’s anatomy when the device wasn’t designed to be reshaped, using undue force or torque (rotational force) on insertion or withdrawal, improperly manipulating a catheter using devices that are too small or too large, or using a device for an off-label purpose. Other SMIs may be caused by manufacturer defects, worn equipment, new or unfamiliar devices or devices with multiple separable parts.

How can these be prevented?

The degree to which human factors are involved in the cause of these events remains unclear. Additional information and analysis are needed to determine the extent to which lack of training and inappropriate device usage are causal factors in these patient safety events. CHPSO members are encouraged to continue submitting information on events related to retained surgical items.

The presentation from our Feb. 1, 2013 webinar, Retained Surgical Items: The Bits and Pieces, Results from the Multi-State Collaborative Effort, led by Drs. Gibbs and Jaffe, is available to CHPSO members on our website. To obtain member access, select the “Member access login/sign up” link on the CHPSO website.


Patient Safety Awareness Week is March 3–9, 2013

Are You Ready?

Patient Safety Awareness Week is an annual education and awareness campaign for health care safety led by the National Patient Safety Foundation (NPSF). Each year, health care organizations take part in the event by creating an awareness of the need to center our patient care on quality and safety.

The theme for Patient Safety Awareness Week 2013 is Patient Safety 7/365: 7 days of recognition, 365 days of commitment to safe care. This is a week to recognize the advancements that have been made in the patient safety arena, while acknowledging the challenges that remain—and committing to work on them, every day.
Use this opportunity to promote patient safety information from the CHPSO Patient Safety News and the “Knowledge Center” on the CHPSO website.


Results of Member Survey

We want to thank everyone who took the time to complete the January 2013 member survey that asked where your hospital is in the development of your patient safety evaluation system (PSES) and what, if any, obstacles you may be experiencing for which we can assist you.

The results indicated that approximately 60% of the respondents have not established a PSES. A majority (57 %) indicated that they have not established a PSES because development is either in progress or not viewed as a priority and some indicated that they are not sure who in their institution is responsible to set up their PSES. Approximately 30% replied that they did not know what steps were needed to establish a PSES and 14% replied that they did not have the personnel or resources available to complete the work.

Of those who have established a PSES, 71% indicated that they are not currently submitting incident data to CHPSO. The main reason identified for not submitting data was because the respondent did not know the process for sending data to CHPSO/ECRI. Approximately 40% replied that they did not have the personnel or resources available to submit data to CHPSO/ECRI.

A webinar was hosted in January that covered PSO Basics: Getting Started and another one was hosted in February on Patient Safety Evaluation System. The slides from these presentations have been posted for members only on our website. These are great resources for those of you who are still having difficulty establishing your PSES. You can also contact us if you continue to have questions or need assistance.

We have communicated with several reporting system vendors your need to eliminate as many manual steps in the event submission process as possible. At this time, Midas is the only system that has successfully provided mapping services to its customers. RL Solutions, Quantros and Verge are working to develop the ability to provide automation to their customers. We encourage you to contact your vendor directly to discuss the services they can provide for easier PSO data submission, and to contact us if your vendor needs assistance in meeting your needs.


Children’s National Medical Center “Keeping Our Kids Safe: You Have Our Permission” Video

February’s Member Call, “Crucial Conversations,” was facilitated by Rhonda Filipp, RN, MPA, CHPSO’s Director of Quality and Patient Safety. The presentation included a short video produced by the Children’s National Medical Center that is an inspiring example of leadership commitment in supporting a culture in which everyone feels safe to “speak up”. We encourage everyone to take two minutes to view the video and share it with your facility.


Members-Only at CHPSO.org

Did you know that www.chpso.org has information set aside just for members? View slide presentations from member-only webinars, sample policies and procedures, and more as it comes along each month. If you have not done so, you will need to create a new account (separate from the CHPSO / ECRI portal account). As long as you are logged in, you will see options available only to members.


Upcoming Patient Safety Calendar

CHPSO

Unless noted, all events are for CHPSO members only. Members will receive an email a few days before each event with information on how to participate. All times are for the Pacific Time Zone. For more information, contact info@chpso.org or call (916) 552-2600.

March 11
10–11 a.m.
Monthly Member Call: Creating a Safe Journey for Patients — Maximizing Results from Your AHRQ Culture of Safety Survey
March 18
11:30 a.m.–12:30 p.m.
CHPSO / ECRI Webinar: PSO Deep Dive: HIT and Example of an HIT Tool
April 8-9 2013 Annual Meeting, Hyatt Regency Sacramento (open to members and non-members)
April 15
11:30 a.m.–12:30 p.m.
CHPSO/ ECRI Webinar: Creating your Patient Safety Evaluation System (PSES): A Health System’s Journey

Hospital Association of Southern California

March 12 Southern California Patient Safety First—Phase 2 Kickoff Event, Pacific Palms Conference Resort, Industry Hills, CA

Hospital Association of San Diego and Imperial Counties

March 8
11:30 a.m.–3 p.m.
SNF-Hospital Readmissions Forum, San Diego Medical Society
March 15
11:30 a.m.–1 p.m.
Hospital Quality Forum, Hospital Association of San Diego and Imperial Counties
March 20
11 a.m.–2 p.m.
San Diego Patient Safety Council, 3750 Torrey View Court, San Diego
March 26
7:30 a.m.–4:30 p.m.
Supporting Transitions in Patient Care across the Provider Continuum: Reducing Readmissions in San Diego and Imperial Counties, Scottish Rite Center, 1895 Camino Del Rio South, San Diego
May 28
11 a.m.–2 p.m.
Perinatal Patient Safety Council, National University

Hospital Council of Northern and Central California

March 19
11 a.m.–3:30 p.m.
Patient Safety First: Luncheon and Educational Program, Crowne Plaza Sacramento


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