CHPSO October Newsletter

October 2013
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In this issue:

Assertion: Making Sure Your Concern is Heard to Avoid Errors

Part 2 of the Working as a Healthcare Team series

The following scenario is drawn from an incident reported to CHPSO:

During patient rounds a pharmacist asked if the patient should be on GI prophylaxis because he had an NG tube and recent abdominal surgery. The physician’s response was to draw up his fingers like a gun and “shoot” the pharmacist for asking the question. The pharmacist was embarrassed and intimidated by the physician’s actions and kept quiet for the remainder of rounds. He also commented to a co-worker that this was the last time he was going to speak up during rounds when Dr. X was around.

Inhibition of communication between health care professionals is clearly linked with reported errors. This type of response would make most people feel intimidated and avoid future confrontations that may result in a similar situation. The authority gradients that are prevalent in health care are a leading cause of inhibited communication. [1] This problem can occur not only between health care providers, but between patients and their health care providers. This is the premise behind the “Speak Up” campaign that was launched by The Joint Commission and CMS, which urges patients to take an active role in preventing health care errors by becoming involved and informed participants on their health care team.[2]

The solution to reduce these errors is to change the culture of the hospital to one of collaboration through advocacy and assertion. Advocacy and assertion are actions that advocate for the patient regardless of the situation. It is generally caused when team members’ viewpoints don’t coincide with that of a decision maker. When a team member disagrees with a decision, or has knowledge that could potentially change the situation, the member must assert a corrective action in a firm and respectful manner.

This is done with the use of an assertive statement: a non-threatening statement that ensures that critical information is addressed.

The AHRQ provides the following framework for an assertive statement:[3]

*Note that this format is similar to SBAR: situation, background, assessment, recommendation

Two Challenge Rule

What do you do if your concern is ignored or dismissed? It is your responsibility to assertively voice your concern at least two times to ensure that it has been heard. The member being challenged must acknowledge the concern. If the outcome is still not acceptable, take a stronger course of action, utilizing a supervisor or chain of command.

If the issue is critical, empower any member of the team to “stop the line” if he or she senses potential harm to a patient. This is an action not to be taken lightly, because it requires immediate cessation of the process and resolution of the safety issue. However, staff need to know that they are supported by their management and administration should they decide that this is a necessary step in advocating for the patient.

It is important to do all this with respect – the goal is to ensure that all members of the healthcare team are aware of the same issues and concerns without finger pointing or blame.

Cultivate your Culture for Advocacy and Assertion

The assertive statement and the Two Challenge Rule will be more effective if the organization prepares its physicians, nurse leaders, and other professionals to receive them.  One surgeon at a recent patient safety seminar make a remark about his reaction to receiving such a statement. A nurse responded with a compelling “I’m acting as the patient’s advocate!”; “What do you think I am?” he blustered in reply. 

We must help our medical staff and other clinical leaders to understand the value of strengthening the practice of sharing patient care information and viewpoints: the opportunity to prevent medical errors. We must prepare them to recognize and patiently receive that assertive statement so that an air of altercation does not immediately come into play. 

Start with one unit, help physicians and nurses talk about strengthening advocacy and assertion, and have them “role play’ a few scenarios. Encourage physicians who discover the practice to be beneficial – perhaps even preventing an error for one of their patients- to tell their peers about the value of advocacy and assertion in a culture for patient safety.


1. Agency for Healthcare Research and Quality (AHRQ). TeamSTEPPS: Strategies & Tools to Enhance Performance and Patient Safety Training Materials. Available at: Accessed September 17, 2013
2. The Joint Commission. Facts about Speak Up Initiatives. Available at: Accessed September 17, 2013.
3. Agency for Healthcare Reasearch and Quality (AHRQ). Appropriate Assertion Call (Transcript). December 14, 2010. Available at: Accessed September 17, 2013.


The “Ask CHPSO” column is intended to provide answers to common inquiries.  If you have a question, please contact us at (916) 552-2600 or

What does CHPSO do with the reports it receives from members?

The data we receive is fundamentally different from that collected by measurement initiatives, such as the Hospital Engagement Network, in a multitude of ways, including:

  1. Lack of standardization: Incident reports (the majority of the data we receive) are completed differently by different providers, and, until there is widespread adoption of the Common Formats and standardization of incident reporting processes, the majority of the useful information is in free text, not structured fields or numbers.
  2. Meaning in content, not numbers: We collect information not to count, but rather to understand. Our goal is to help providers identify fundamental causes of preventable patient harm and the corresponding mitigating actions.
  3. Individual value: A single report may contain valuable information for improving safety; conversely, other reports may be related to well-understood issues and not provide any new information.

To address these challenges and maximize the benefit, we have the following process that allows us to identify and analyze particularly valuable incident reports. Additionally, soon we will be asking our members to nominate exceptional personnel within their organizations to be members of a multidisciplinary Safety Council. This Council will advise on report analyses, provide insight into the current state of patient safety across California, and provide feedback and direction for future CHPSO initiatives.

  1. High-harm reports review: These events are known to pose a significant risk to patients, unlike low-harm events, which may or may not pose significant risk. All high-harm events are reviewed and, when appropriate, feedback provided to the reporting institution.
  2. Focus topics: CHPSO identifies focused areas of concern through environmental scans; checking with other PSOs, monitoring government agencies such as the FDA, and examining the nature of the reports it is receiving. Reports in the focus area, regardless of harm, are individually reviewed. A current focus area is Health Information Technology, which has contributed to very serious events in nationwide and is a focus of the Office of the National Coordinator (ONC). As with many of our initiatives, we are carrying this out in coordination with our partner PSOs in the group we lead, the Nationwide Alliance of PSOs (NAPSO). NAPSO represents roughly 40% of all the PSOs in the USA.
  3. High-value events: When CHPSO receives one or a few events that illustrate significant issues, it acts on those to provide feedback to all hospitals. Members can assist CHPSO in this by contacting us when submitting a low-severity high value event to call it to our attention. When CHPSO received two troubling HIT events, one with significant harm, one a worrisome close call, it developed an HIT focus topic (described above) and is working with the ONC to provide useful tools for hospitals and will be working with HIT vendors to facilitate the design of safer systems.
  4. Data mining: CHPSO currently has about 100,000 events in its database and anticipates having many more soon, as more members bring their automated CHPSO reporting online. Managing this volume of textual information requires data mining approaches, rather than individual review of each report. We review subsets selected by looking for clusters of related issues and events related to known vulnerabilities in health care delivery. We are hiring another clinician whose primary responsibility will be report review.

In brief, the analyses we carry out can be compared to an epidemiologic outbreak investigation. We are looking to:

  1. Locate a problem
  2. Define the issue
  3. Identify and review reports meeting the issue definition and other information sources to characterize it in a generalizable way
  4. Identify the causes
  5. Help providers implement control measures with the broadest impact

Members can help CHPSO and help each other by:

  1. Ensuring that CHPSO is informed when a high-value event is submitted.
  2. Submitting as many events as possible, particularly those related to focus topics (currently HIT).
  3. Identifying nominees for the CHPSO Safety Council.

Have questions for CHPSO?  Submit them to with the subject line "Ask CHPSO". All inquirers will remain anonymous.

Causal Analysis Learning Series: Monitoring for Effectiveness

CHPSO Monthly Member Call

Monday, October 14, 2013, 10 a.m.–11 a.m., Pacific Time

Register for this event

Are you tracking and/or measuring the success of your corrective action plan? Many facilities do not and risk recurrence of the identified problems. During this webinar, we will review tools and processes that can be used to determine if your changes were fully adopted into practice and whether or not they were effective at addressing the problems.

For more information on this learning series, visit analysis.

This call is for members only.  Registration is required and can be found at Please note that a website member account is a requirement to sign up for member-only webinars. Registrants will receive an email by noon on Friday, October 11. Members registering on or after Friday, October 11 should contact CHPSO for participation information at (916) 552-2600.

Continuing Education:
-Provider approved by the California Board of Registered Nursing, Provider #CEP 16084, for 1.0 contact hour. Full attendance, completion of online survey, and attestation of attendance is required to receive CE for this webinar. CE is complimentary for registrants.

NAPSO Health IT Safety Webinar

Thursday, October 10, 2013, 11 a.m.–1:30 p.m., Pacific Time

Members Only

Best practices for capturing the benefits of health information technology (IT), while also reducing risk of patient harm, is on everyone’s mind, including the Office of the National Coordinator for Health IT (ONC).
Join us for this presentation by ONC Senior Policy Analyst, Kathy Kenyon, and Dr. Karen Zimmer from ECRI Institute about what they have learned from their “deep dive” into Health IT related events and the important role of PSOs will play in promoting HIT safety.

ONC — Coordinating with Providers, PSOs, and EHR Developers on Health IT Safety


  1. Describe ONC’s view of the roles of providers, PSOs, and electronic health record (EHR) developers, working together, on health IT safety, based on the Health IT Patient Safety Plan.
  2. Identify tools that will assist providers, PSOs, and developers integrate health IT into patient safety programs.
  3. Describe contracts ONC has in place to keep moving head on health IT patient safety objectives.   
ONC’s Health IT Safety Plan relies on the private sector, especially healthcare providers, PSOs, and EHR developers, to integrate health IT into effective patient safety programs. This presentation will acknowledge some of these efforts and ONC’s plans to support them over the next couple of years. We have something approaching consensus that health IT has the potential to reduce hazards found in paper-based delivery systems, while recognizing that health IT can create new hazards if not well designed, implemented, maintained, monitored, and used properly. This presentation will describe ONC-sponsored work that is designed to assist health IT safety efforts in the private sector, including newly designed tools.

A PSO Deep DiveTM into Health IT Related Events


  1. Identify the types of patient safety events that are associated with the use of health IT.
  2. Describe the strategies needed to safely adopt and implement health IT to ensure the technology is used to improve care delivery.
As healthcare organizations adopt health IT systems, such as electronic health records, risk managers and patient safety must identify strategies to address the “unintended consequences” of the technology that can cause patient harm. While health IT has the potential to provide multiple benefits to healthcare, it can also contribute to errors if, for example, data is entered incorrectly or the system malfunctions. This session will briefly discuss where we are with EHR adoption and review health IT errors and events that have been reported to one Patient Safety Organization with a national presence.

Research Assistance Available

Looking for strategies for responding to patient violence? Have questions about the best practice for retained surgical needles? Other CHPSO/ECRI members are interested in these topics, too, and have requested customized research assistance. You can access the de-identified reports of such research by logging into your CHPSO/ECRI portal site. Choose PSO under “Your Subscriptions,” and you will see “Custom Research Responses” at the bottom of the page.

Not only are these research results available to you, but you can request research for topics of interest at your own facility. This can be helpful when you are considering best practices for a corrective action plan or creating a new protocol or policy.

Members can request an unlimited number of simple searches. In-depth research can also be conducted with approval. If you have a topic in need of research, please contact ECRI Patient Safety Analyst, Gail Horvath, at

National Healthcare Quality Week (HQW), October 20-26, 2013

Celebrate by sharing your quality improvement and patient safety work throughout your organization and community.
  • Let your key physicians & other staff know how much you appreciate their support by recognizing those who have made a significant contribution to your quality management program.
  • Share the healthcare quality message with all hospital employees.
  • Generate conversation about the meaning of quality.
  • Hang posters in prominent locations within the hospital.
  • Include all departments and patients in the events.
Go to the National Association for Healthcare Quality (NAHQ) website,, for more information.

Preventing Opioid-Induced Respiratory Depression: Clinical vs. Electronic Monitoring

CHPSO / ECRI Webinar

Monday, October 21, 2013, 11:30 a.m.–12:30 p.m., Pacific Time

Register for this event

Opioids are necessary for effective pain management. However, individual patient response to opioid therapy varies widely and overdose can cause respiratory depression, a harmful adverse drug event.
Does your hospital have effective monitoring techniques to identify patients at increased risk of respiratory depression?

This webinar will focus on the use of opioids for pain management during a patient’s acute care stay. During the call, we will review case studies based on events reported by PSO members. No identifying information will be included. We encourage you to participate in the dialogue so that we can learn from each other.
Note the webinar will not address medications used during anesthesia or procedural sedation and analgesia.

This call is for members only.  Registration is available at the top and right of this web page. Registrants will receive an email on October 18 with participation information.  Members registering on or after October 18 should contact CHPSO for participation information at (916) 552-2600.

Notice to CHPSO Members: BAA Changes

Pursuant to the changes in HIPAA from the 2013 omnibus privacy rule, CHPSO has revised its Business Associate Addendum (BAA). Copies are available at
The new BAA is derived from the California Hospital Association model agreement with several changes:
  1. CHPSO does not hold a portion of the designated record set so provisions related to access and amendment of PHI are unnecessary and omitted.
  2. Information exchanged under this agreement is also governed by an additional privacy law, the Patient Safety and Quality Improvement Act of 2005, and language is in place to express that.
  3. Information flow will be bilateral, and on rare occasions a provider may be considered a business associate of CHPSO. To manage that, the BAA is bilateral.
All organizations that signed the old version of the BAA will need to sign the new version. Over the next few months CHPSO will contact those members still using the old BAA to ensure all are updated. Due to the evergreen nature of the CHPSO-provider contract, those contracts signed prior to January 25, 2013, have until September 22, 2014 to be compliant. CHPSO has already contacted those organizations that joined January 25 or later, since for those contracts the new HIPAA rules mandate compliance now.

Please contact CHPSO with any questions. Return signed contracts to CHPSO at:

1215 K St Ste 705
Sacramento, CA 95814

Upcoming Patient Safety Events

California Hospital Patient Safety Organization

Unless noted, all CHPSO events are for members only, are free and require registration. The registration link will be located on each webinar’s webpage. All times are for the Pacific Time Zone. For more information, contact or call (916) 552-2600.
October 10
10–11 a.m.
NAPSO Health IT Safety Webinar
For CHPSO members and other NAPSO-affiliated hospitals
October 14
10–11 a.m.
Causal Analysis Learning Series: Monitoring for Effectiveness
CHPSO monthly member call
October 21
11:30 a.m.–12:30 p.m.
Preventing Opioid-Induced Respiratory Depression: Clinical vs. Electronic Monitoring
CHPSO / ECRI webinar
November 11
10–11 a.m.
Engaging Staff & Leadership in Patient Safety
CHPSO monthly member call

Hospital Council of Northern and Central California

October 17
10 a.m.–3:30 p.m.
Enhancing Caregiver Resilience: Burnout and Quality Improvement
Saint Agnes Medical Center, Fresno, CA
November 14 BEACON Patient Safety Exchange In-Person Meeting
South SF Conference Center, South San Francisco

Hospital Association of Southern California

October 2
9–10 a.m.
Patient Safety First/Southern California Patient Safety Collaborative – Sepsis
October 16
9–10 a.m.
Patient Safety First/Southern California Patient Safety Collaborative – HAI C. Difficile
October 17
8:30 a.m.–12:30 p.m.
Sherlock Holmes or Inspector Clouseau: How to Conduct Effective Internal Investigations
Good Samaritan Hospital, Los Angeles, CA
November 5 Southern California Patient Safety First Collaborative
Montebello, CA

Hospital Association of San Diego and Imperial Counties

For more information visit or contact Alicia Muñoz.
November 19
7:30 a.m.–3 p.m.
San Diego and Imperial Counties Learning and Action Network
Scottish Rite Center

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