CHPSO April newsletter.
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April 2013

In this issue:

Lessons Learned: The Impact of Distractions & Interruptions

In the State of California, drivers are prohibited from talking on a hand held device or texting while driving because it is well known that these distractions can and often lead to unsafe driving. Distractions and interruptions pull your attention away from the activity that you are involved in and may lead you to miss a step or make a mistake. In the 1980s, aviation introduced the concept of a “sterile cockpit,” which refers to a distraction-free cockpit; a time when the captain and crew engage only in flight related conversation. It had become apparent that a number of accidents and near misses were related to distracting conversation among the flight deck and cabin personnel.

Unfortunately, clinical staff are faced with constant distractions while trying to deliver care to their patients. Imagine a nurse who is preparing medications for his patient being interrupted by a visitor asking for directions to the cafeteria. Imagine a physician being interrupted for a phone call while she is placing an order for a radiology exam. Add to this the ongoing distractions from alarms by monitors and IV pumps. Distractions and interruptions are grouped into a category of human factors that have been identified as contributing or root causes in several of the adverse events that have been reviewed. In our CHPSO database, it was identified as a contributing factor in 81 percent of the events reviewed.

Since many of these distractions are unavoidable, hospitals need to establish a safe work environment that minimizes distractions and interruptions where it is possible and during the most crucial times.

During medication administration

The Agency for Health Care Quality (AHRQ) published a protocol (updated February 2013) that consists of seven relatively simple, inexpensive interventions that are based on safety measures used in the airline industry: (1) a focused protocol and checklist on how to properly administer medications, (2) a quiet zone to retrieve/prepare medications, (3) education of staff to not distract and to “field” interruptions for nurses who are administering medications, (4) the wearing of a special vest or sash designed to signal to others the need to avoid distracting the nurse during medication administration, and (5) use of quiet zone signs on medication room doors and above medication dispensing machines to remind others not to interrupt (6) nurse education about no conversation during medication administration unless it is about medications, and (7) patient education/orientation about the meaning of the vest and the process. A quasi-experimental evaluation showed that both the focused protocol/checklist and the checklist-vest combination significantly reduced the number of distractions experienced by nurses.

During hand-offs

The Joint Commission has identified qualities of effective hand-offs, including limited interruptions. However, units are sometimes the busiest during change-of-shift, when clinical staff are transitioning or handing-off care to another clinician. Unless an issue is urgent, the hand-off procedure for all clinicians, including physicians, should be completed without interruption.

Hospital policies should also address limiting or eliminating the use of personal cell phones and protocols for not answering workplace cell phones or other wireless communication systems (Polycom, handheld radio) while performing patient care. Developing a standard approach and communicating that approach and expectation to everyone, including families and visitors, is essential for success in decreasing interruptions and distractions.

ECRI Customized Research Section of Portal

Custom research requests are included in your PSO membership. These researches can be helpful when you are trying to identify and implement recommended best practices or develop a corrective action plan. The de-identified responses to some of our research requests have now been added to your CHPSO/ECRI portal so that everyone can share and learn from this information. When you log into your portal site and choose PSO under “Your Subscriptions,” you will see this section at the bottom of the page.

To request customized research, please contact Gail Horvath

See You in Sacramento April 8–9

The CHPSO Second Annual Meeting is just days away! We hope to see you in attendance, where we will start the conference with one great author (Chip Heath) and end the conference with another (Sorrel King). In between we will have testimonies and presentations from nurses, physicians, and executives, who are practicing patient safety right now in their hospitals and regulatory presentations from AHRQ and CalPERS.

The Annual Meeting focuses on content for hospital leaders including CEOs and hospital executives; quality, risk and patient safety leaders; and nursing, physician and pharmacist leaders. All are invited to attend; CHPSO members receive a discount. Additional information and registration can be found at

Beyond the intuitive knowledge being passed down in the presentations, attendees will also receive a copy of Decisive: How to Make Better Choices in Life and Work by Chip and Dan Heath and Josie’s Story: A Mother’s Inspiring Crusade to Make Medical Care Safe by Sorrel King. Mrs. King will be available at the end of the day for a book signing for anyone interested.

Presentations will be available on our Attendees-only website, where attendees can download or print the presentations before the conference. It is highly recommended you download/print before the conference as access could be delayed due to usage.

Haven’t registered yet? There’s still time!

We’d like to thank our sponsors, the California HealthCare Foundation, California Healthcare Insurance, and SurgiCount Medical.

Multi-Specialty Peer Review Committees

From QA to QI

by Marc T. Edwards

My research has shown that roughly 20 percent of hospitals make significant changes in their clinical peer review program’s structure, process or governance every year. Unfortunately, this high rate of change has not resulted in substantial improvement. Much of the recent change has concentrated on the replication of a multi-specialty review process, with neglect of factors central to the evidenced-based QI Model. You can refresh your understanding of the QI Model through a brief online program self-evaluation questionnaire at

In fact, multi-specialty review has become something of a fad. Although it has successfully challenged the claim that only like specialists can be considered peers, there is no published literature validating the concept. While there may be merit to this design, particularly in terms of reviewer participation, standardization and the ability to address clinician-to-clinician issues, multi-specialty review is not of itself sufficient to close the gap in program performance and eliminate the “Blame Game.”

Read more

CHPSO Learning Series: Improving Your Causal Analysis Process

Most hospitals are acquainted with the root cause analysis (RCA) process and have conducted numerous in the past 17 years since The Joint Commission first required its use to investigate sentinel events. RCA is a type of event investigation used to identify why adverse events occur and how to prevent them.

As with any tool, improper use can render the process not only useless, but also harmful, if the underlying issues are not correctly identified and addressed. Too often quality and safety professionals are given little guidance or training on conducting an effective causal analysis.

This five-part learning series provides you with information that can be implemented directly into your process and will be incorporated into the monthly CHPSO Member Calls. Many of the lessons learned and recommendations were developed through the evaluation of RCAs that were submitted by CHPSO members.

May 13, 2013

It Starts with Your Culture

June 10, 2013

Conducting a Thorough Investigation and Team Response

July 10, 2013

Identifying Contributing and Root Causes

Aug. 12, 2013

Developing and Implementing a Corrective Action Plan

Sept. 9, 2013

Monitoring for Effectiveness

PSO Deep Dive™ Call to Action

Report at least 10 Laboratory related events by May 24

CHPSO, ECRI Institute and partner PSOs are performing a “deep dive” into laboratory-related events.

As a member of CHPSO, you have the opportunity to participate in this collaborative that will help you and your colleagues learn from your laboratory-related adverse events and, more importantly, help prevent similar errors from reaching others. Thanks to the federal Patient Safety and Quality Improvement Act (PSQIA), CHPSO members may report near misses and incidents through a voluntary and confidential mechanism.

A laboratory-related event is a defect occurring at any part of the laboratory cycle, from ordering tests to reporting results and appropriately interpreting and reacting on these. These errors may lead to repeat testing and/or wrong or delayed care to a patient. Your participation in this deep dive will assist in the exploration of patient safety risks associated with laboratory events.

To that end we are asking members to submit at least ten laboratory events from April 15th through May 24th. The laboratory fields are available in the event type Laboratory/Radiology.

A kick off presentation demonstrating how to submit the events will be offered by web conference on April 4th at 10 a.m. PDT and repeated on April 11th 8 a.m. PDT. Call-in details will be provided. Please forward this call to action to others in your organization who may be interested.

Your data will be used by ECRI Institute PSO in combination with all other facilities in the collaborative to do a deep dive analysis of all laboratory events and related events submitted and provide the results. We will post all materials on the CHPSO / ECRI Portal for access to copies of reports, slides, research, tools, etc. We will also present the results at a webinar to all CHPSO members.

To get started log in to the CHPSO / ECRI Portal to enter events, or, if your institution is reporting electronically to CHPSO, identify and transmit laboratory events.

CHCF Health Care Leadership Program Applications Due May 15

The California HealthCare Foundation (CHCF) Health Care Leadership Program is a part-time, two-year fellowship that offers clinically trained health care professionals the experiences, competencies, and skills necessary for effective vision and leadership of our health care system.

Fellows attend seminars six times during the two-year program and they participate in ongoing learning activities throughout. Graduates of the program acquire broadened management and sharpened leadership skills, and they gain unique insight into the trends and challenges facing health care leaders in California.

Program Objectives

The goal of the CHCF Health Care Leadership Program is to prepare health professionals to assume significant roles in the improvement of California’s health care system. The program seeks to enhance the leadership and management skills of health professionals who have demonstrated leadership ability and to create a network of leaders who will provide mutual support for improving the health care system for all California citizens.


Curriculum of the six Seminars and Inter-session activity covers leadership, business, and health subjects including:

  • building and leading teams
  • giving and receiving feedback
  • managing change
  • managing human resources
  • applying new technologies and information systems
  • understanding and using financial management tools
  • applying economic principles to health care
  • developing organizational strategies and goals
  • balancing personal and professional life
  • communicating within and outside of an organization
  • understanding emerging trends, such as consumerism and changing demographics


The fellowship is available to clinically trained health care professionals who live and work in California and currently serve in management or leadership roles.

Cost and Fee Waivers

This program is sponsored by the California HealthCare Foundation, which covers most of its costs, including the cost of seminars and other learning experiences, education materials, electronic and print resources, lodging and most meals related to attending the seminars. A program fee of $2,500 per year or $5,000 over the course of fellowship will be paid by the fellow’s employer/organizational sponsor.

Full and partial fee waivers are available to qualifying representatives of safety-net and non-profit organizations, educational institutions and governmental agencies for which this fee would present a hardship. Requests for fee waivers are due at the time of application submission and will not influence the selection process.


All applications are due May 15, 2013.

You can find out more information about the program at and start the application process by following this link.

Upcoming Patient Safety Events

California Hospital Patient Safety Organization

Unless noted, all CHPSO events are for 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.
April 4
10–11 a.m.
PSO Deep Dive™ Call to Action Kick-off Presentation
April 8–9 2013 Annual Meeting, Hyatt Regency Sacramento (open to members and non-members)
April 11
8–9 a.m.
PSO Deep Dive™ Call to Action Kick-off Presentation (repeat of April 4 presentation)
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

April 19
12:30–2 p.m.
Patient Safety First Webinar on Reducing Healthcare Facility Associated Microorganisms with Drs. Cliff McDonald and Katherine Ellingson, Division of Healthcare Quality Promotion, CDC
May 28
11 a.m.–2 p.m.
Perinatal Patient Safety Council, National University

Hospital Council of Northern and Central California

April 23
11 a.m.–3:30 p.m.
Patient Safety First: Luncheon and Educational Program, South San Francisco Conference Center

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