CHPSO February Patient Safety News

February 2013

In this issue:

  • PSO reporting and incident reporting system vendor contracts
  • Increasing safety through HIT surveillance
  • “Making better choices” keynote topic at Annual Meeting
  • Register for Annual Meeting by March 7 and save
  • Tackling the most common laboratory errors: specimen labeling mistakes
  • Practical tips for transforming peer review
  • Children’s Hospital Los Angeles institutes “Daily Influenza Debrief Call”
  • Feb. 11 member call: Crucial Conversations
  • CHPSO / ECRI Patient Safety Evaluation System Webinar Feb 13.
  • Upcoming patient safety events

PSO reporting and incident reporting system vendor contracts

With the upcoming Affordable Care Act mandate for PSO participation, incident report system vendors are receiving more requests to help providers link their system to a PSO. Some vendors are having challenges with this new workload.

In light of these challenges, CHPSO recommends that hospitals entering into new incident report system vendor contracts memorialize in those contracts any representations made regarding PSO reporting integration. Terms should include cost, implementation requirements, compatibility with specific PSOs (e.g., CHPSO) and implementation timeline. As with any other contract for future delivery of a service, appropriate language should be in place to address failure to perform as expected.

CHPSO is working with the incident report system vendors to ease this transition into electronic reporting.

Increasing safety through HIT surveillance

Health Information Technology (HIT) has great promise for improving patient safety but provides new risks as well. A recent IOM report, Health IT and Patient Safety: Building Safer Systems for Better Care, noted that the risks are poorly understood, stating: “To fully capitalize on the potential that health IT may have on patient safety, a more comprehensive understanding of how health IT impacts potential harms, workflow, and safety is needed.”

The Office of the National Coordinator for Health Information Technology (ONC) recently released a draft Health Information Technology Patient Safety Action & Surveillance Plan. This plan has two objectives: 1) promote the use of HIT to make care safer, and 2) improve the safety of HIT itself.

This plan uses Patient Safety Organizations as a nexus for gathering information from users and developers: making it easier for users to report patient safety events and risks through the electronic health record to PSOs, linking software developers to PSOs, and providing support to PSOs to identify, aggregate and analyze these reports.

CHPSO members interested in learning more about support for Health Information Technology event reporting are encouraged to contact Rory Jaffe at Further information about the surveillance plan is at

IOM (Institute of Medicine). 2012. Health IT and Patient Safety: Building Safer Systems for Better Care. Washington, DC: The National Academies Press.

“Making better choices” keynote topic at Annual Meeting

Chip Heath, professor at the Graduate School of Business at Stanford and co-author with his brother, Dan, of the bestsellers, Switch and Made to Stick, will kick-off CHPSO’s Annual Meeting April 8. He will introduce a four-step process to improve decision-making based on his forthcoming book, Decisive: How to Make Better Choices in Life and Work. Research reveals that our decisions are often made based on biases and irrationalities. Why? Often, we are overconfident. We seek out information that supports our biases, ignoring evidence to the contrary. And we are persuaded by short-term emotions. Attendees will hear fresh strategies and practical tools to begin making better choices immediately, plus take home a hot-of-the-press copy of the Heath brothers’ powerful new book.

Register for Annual Meeting by March 7 and save

Register online now for CHPSO's Second Annual Meeting—Getting to Zero: Innovate, Collaborate, Accelerate—April 8–9, 2013, at the Hyatt Regency Sacramento. The statewide meeting provides innovative strategies and practical tools to eliminate preventable harm and improve patient safety. Topics include groundbreaking patient safety work; culture change; device, medication and surgical safety; high-reliability organization case studies, meaningful quality measures, leadership lessons, and much more. The program is designed for hospital senior leaders and clinical leaders, including physicians, nurses, pharmacists, as well as quality, risk management and patient safety staff. Member cost is $295 and non-member cost is $395. Fees increase $105 after March 7. The Hyatt Regency Sacramento is the host hotel for the meeting. A block of rooms has been set aside at a special room rate of $179 for single/double occupancy. Please call the hotel directly at (888) 421-1442 and mention the “CHPSO conference” to make your reservation at the discounted rate or click here to reserve your room online. Don't delay; the discounted rate is first-come, first-served and expires March 18, 2013.

Tackling the most common laboratory errors: specimen labeling mistakes

A typical hospital laboratory receives and analyzes thousands of specimens every day. A review of PSO reported incidents indicates that while the vast majority of lab tests are performed without error, some errors do occur, many as a result of specimen labeling mistakes. At least one study calculates that about 5 to 10 percent of these errors result in patient harm. The overall incidence is likely higher since the estimate does not include testing in commercial and physician-office laboratories. Laboratory staff catch many of the labeling mistakes, but when errors are missed, the consequences can be far-ranging, some causing inconvenience and discomfort to the patient if a specimen must be re-collected, and others resulting in serious harm or death. To learn from evidenced-based best practices on how to avoid these errors, log into your member’s CHPSO/ECRI portal, scroll down to the PSO Navigator and read the article in the February 2013 issue, “Tackling the Most Common Laboratory Errors: Specimen Labeling Mistakes.”

From QA to QI

Practical tips for transforming peer review

Marc T. Edwards, MD, MBA
If you’ve paused to assess how well your hospital’s clinical peer review program conforms to the QI Model:, you’re probably thinking about how to initiate changes. The overall process of adopting the QI Model involves the following key tasks:

  1. Engage medical staff and hospital leadership
  2. Develop the new process including a plan for overall program governance
  3. Design review forms to support the desired process and data collection needs
  4. Get approvals
  5. Mobilize any needed program support from hospital administrative staff and information systems
  6. Select and train reviewers and support staff on the new process
  7. Follow through to assure full implementation

These seven steps to peer-review heaven might require a circuitous route. That’s OK. The best path ultimately depends on organizational culture, politics and personalities. The greatest challenges are typically found at the beginning and end.

So, start by using the QI Model score to communicate the improvement opportunity to others in your organization. Explain that your current dysfunctional peer review process is blocking the path to safety and quality by perpetuating a culture of blame and neglecting the role of systems factors in human error. If you meet with initial resistance, take it as a positive sign that people are being challenged to think it through. Still, after digesting your words, at least 10‑20 percent of those you talk to will get it. They are your allies for change. Enlist their support. Ask for their advice as to how to proceed. If you don’t find immediate support for wholesale program restructuring, you’ll still likely find one department that is either already out front with a better process or that is willing to experiment. If so, work with that.

For example, the first time I took an organization through a redesign of peer review, the work sprang out of an innocent effort to solve a problem verbalized by one department chair. We took a blank sheet of paper and together sketched out a new process. We tested it in that one department. It was an instant winner! It wasn’t long before the medical staff leadership absorbed the impact and decided that all departments would need to adopt the new model. With other hospitals, I found equal success in getting support for a one-shot redesign. The end result was the same.

There is yet another approach that may interest you. Many organizations have become accustomed to using a collaborative process with like-minded institutions to catalyze change. For an overview of how this would work for peer review, see: With process design, the devil is in the details. In future columns, we’ll explore some of the top issues.

Coming Next: Multispecialty Review Committees

Children’s Hospital Los Angeles institutes “Daily Influenza Debrief Call”

Communication key to safe health care delivery

Mary Virgallito, RN, MSN, CIC, Clinical Administrator of Infection Prevention and Control, Children’s Hospital Los Angeles

When the media began to highlight outbreaks of seasonal influenza and norovirus in the eastern states during January, leadership at Children’s Hospital Los Angeles had already begun to see high census, increased emergency department (ED) and ambulatory clinic volume due to high rates of other respiratory illnesses in the local community, such as Respiratory Syncytial Virus (RSV).

Leaders knew they must mobilize for safe and effective care delivery in anticipation of a potential surge of patients. They identified that clear and open communication would be key, so they instituted in mid-January what has become known as the “Daily Influenza Debrief Call.”

“The Daily Influenza Debrief call constitutes a well-spent eight to ten minutes for optimizing safe and effective care, and maintaining organization-wide preparedness,” says David Moromisato, MD, MHA, chief patient safety officer.

During the call, held Monday through Friday, hospital leaders from a variety of departments discuss key patient care issues such as inpatient bed availability, ED volumes,; resources, staffing levels, and updates from pharmacy on flu vaccine and treatment (such as Tamiflu) availability.

The group determines whether alternate actions (e.g. delaying non-emergent surgeries or admissions) are necessary. The participants also assess the need for activating the facility’s Surge Plan.

Already, leaders have indicated that they have benefited from having a single point of information, are staying well-informed and have been able to strategize methods for safely handling existing patient volumes and preparing for future increases, hence developing a culture that reduces errors.

Feb. 11 member call: Crucial Conversations

10–11 a.m., Pacific Time Zone

Hospitals are aggressively trying to address the challenges of new technologies, quality care delivery, and outcomes reimbursement. However, there is a culture of silence that threatens progress. During CHPSO’s Member Call, Feb. 11, 10–11 a.m., we will explore why it is difficult to speak up and how to overcome the obstacles to holding these “crucial conversations.” The Joint Commission suggests that lack of communication is a top contributor to sentinel events. A recent study found that 84 percent of physicians and 62 percent of nurses and other clinicians had witnessed coworkers taking shortcuts that could be dangerous to patients. Unfortunately, only about 10 percent of them felt comfortable in approaching their peers to discuss their concerns.

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

CHPSO / ECRI Patient Safety Evaluation System Webinar Feb. 13

10–11:30 a.m., Pacific Time Zone

CHPSO members will find out how to create, implement and manage a Patient Safety Evaluation System (PSES) in this CHPSO / ECRI webinar. Participants will learn about moving from concepts to action; determining what is patient safety work product; defining, implementing and managing a PSES; and using the PSES Pathway Toolkit. Members will receive an email a few days before the event with information on how to participate.

Until recently, PSO participation, while the right thing to do, has not been mandated. This webinar is part of a series of programs CHPSO is offering to help members get ready for new requirements under the Affordable Care Act. By Jan. 1, 2015, qualified health plans in insurance exchanges may not contract with a hospital of 50 beds or more unless that hospital has a PSES in place that collects, manages and analyzes information for reporting to a PSO. Hospitals that want to participate in this insurance market will need to comply with that requirement.


Upcoming patient safety events

CHPSO events

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 or call (916) 552-2600.
Feb. 1 Retained Surgical Items Webinar: Results from the Multi-State Collaborative, 8–9 a.m.
Feb. 11 Monthly Member Call: Crucial Conversations, 10–11 a.m.
Feb. 13 CHPSO / ECRI Patient Safety Evaluation System Webinar, 10–11:30 a.m.
March 11 Monthly Member Call: TBD, 10–11 a.m.
April 8-9 2013 Annual Meeting, Hyatt Regency Sacramento

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

Feb. 26 Perinatal Patient Safety Council, National University, 11 a.m.–2 p.m.
May 28 Perinatal Patient Safety Council, National University, 11 a.m.–2 p.m.

Hospital Council of Northern and Central California

Feb. 27 State of the Art Palliative Care – What, Why, How, 10 a.m. –3 p.m.

Copyright © 2013 CHPSO, all rights reserved.