Health IT Mistakes Can Hurt Patient Safety

breakdown of medical errors

Over on Health Data Management they recently published a report showing how some Health IT mistakes cause patient safety errors. As simulation touches so much technology and is driven to improve patient safety, I thought this important to consider for those in professional healthcare settings:

Despite the potential for health information technology to improve patient outcomes, adverse events associated with the use of health IT can cause extensive harm and are encountered across all healthcare settings.


Sponsored Advertisement:


That’s the finding of a new analysis of electronic health record-related harm in cases submitted to a large database of malpractice suits and claims maintained by CRICO, an evidence-based risk management group of companies owned by the Harvard medical community.

Researchers identified 248 malpractice cases showing serious unintended consequences from the use of EHRs, representing less than 1 percent of all cases in the database. Of cases with causes related to EHRs, 80 percent involved moderate or severe harm. EHR errors were found to occur more frequently in ambulatory settings than in inpatient settings. Although ambulatory care accounted for more than half of the cases, deaths were more likely to occur in inpatient settings.

Read the full article on Health Data Management’s website!


Sponsored Advertisement:


Professional Learning Series Webcasts from the National Patient Safety Foundation

 

In celebration of our attendance tomorrow at that National Patient Safety Summit today we are sharing about the Professional Learning Series Webcasts from the National Patient Safety Foundation.

The NPSF Professional Learning Series offers the convenience of continuing education and peer-to-peer collaboration in an online learning environment. Members of the American Society of Professionals in Patient Safety (ASPPS) may register for their individual participation in a webcast at the member rate of only $20. Stand Up for Patient Safety member organizations receive complimentary registration for webcasts for their teams. As of January 2016, the cost of attendance for nonmembers has been reduced to $99

_________________________________________________________

 

Free from Harm: Accelerating Patient Safety Improvement
Tuesday, January 26, 2016 | 2:00 – 3:00 pm Eastern Time
Complimentary webcast: open to all at no charge

During this webcast, the co-chairs of an expert panel convened by NPSF will discuss the panel’s recommendations for future work in patient safety, recently published in the report Free from Harm: Accelerating Patient Safety Fifteen Years after To Err Is Human.

Featured speakers
Donald M. Berwick, MD, MPP
President Emeritus and Senior Fellow, Institute for Healthcare Improvement
Lecturer, Department of Health Care Policy, Harvard Medical School

Kaveh G. Shojania, MD
Director, Centre for Quality Improvement and Patient Safety, University of Toronto
Editor-in-Chief, BMJ Quality & Safety

Moderator
Tejal K. Gandhi, MD, MPH, CPPS
President and CEO, National Patient Safety Foundation
President and CEO, NPSF Lucian Leape Institute

Registration will open soon. Please check back here.
_____________________________________________________________

Evaluation of Perioperative Medication Errors and Adverse Drug Events
Thursday, February 25, 2016 | 2:00 – 3:00 pm Eastern Time

Featured speaker
Karen C. Nanji, MD, MPH
Anesthesiologist, Massachusetts General Hospital

In this webcast, Dr. Nanji, lead investigator of a recent study on this topic, will discuss her team’s findings. Read the paper published in Anesthesiology.

Registration will open soon. Please check back here.
____________________________________________________________

 

Learn more at the NPSF website today!

Report of an Expert Panel Convened by the National Patient Safety Foundation

to-err-is-human-update

In order to continue the growth of healthcare simulation utilization, our community must further connect with resources from Patient Safety organizations, like the NPSF. This powerful organization just released a report by an expert panel discussion assessing the state of healthcare on the 15th anniversary of “To err is human” — a critical report that outlined the number of patient deaths attributed to medical error. The number has since grown to as many as 440,000 patients a year in the US alone! How can we better connect healthcare simulation learning opportunities to better patient outcomes?

About the report:

Fifteen years after the Institute of Medicine brought public attention to the issue of medical errors and adverse events, patient safety concerns remain a serious public health issue that must be tackled with a more pervasive response.

With a grant from AIG, the National Patient Safety Foundation (NPSF) convened an expert panel in February 2015 to assess the state of the patient safety field and set the stage for the next 15 years of work.

The resulting report calls for the establishment of a total systems approach and a culture of safety, and calls for action by government, regulators, health professionals, and others to place higher priority on patient safety science and implementation.

The report makes eight recommendations:

  1. Ensure that leaders establish and sustain a safety culture
  2. Create centralized and coordinated oversight of patient safety
  3. Create a common set of safety metrics that reflect meaningful outcomes
  4. Increase funding for research in patient safety and implementation science
  5. Address safety across the entire care continuum
  6. Support the health care workforce
  7. Partner with patients and families for the safest care
  8. Ensure that technology is safe and optimized to improve patient safety

Download the full report for free at NPSF.org!


Sponsored Advertisement:


When Something Goes Wrong At The Hospital, Who Pays? Costs of Medical Errors

medical errors

Shefali Luthra of Kaiser Health News recently shared the story of one patient’s unfortunate experience — which represents a global problem with the costs of medical errors: 

Despite the Institute of Medicine’s landmark 1999 report, “To Err Is Human,” and, more recently, provisions in the 2010 health law emphasizing quality of care, entering the hospital still brings risk. Whether because of mistakes, infections or plain bad luck, those who go in don’t always come out better.

More than 400,000 people die annually, in part thanks to avoidable medical errors, according to a 2013 estimate from the Journal of Patient Safety. In 2008, the most recent year studied, medical errors cost an extra $19.5 billion in national spending, most of which was spent on extra care and medication, according to another report.

If a problem such as Thompson’s stemmed from negligence, a malpractice lawsuit may be an option. But this can take time and money. And lawyers who collect only when there’s a settlement or victory may not want to take on a case unless it’s exceptionally clear that the doctor or hospital is at fault.

That creates a Catch-22 situation, said John Goldberg, a professor at Harvard Law School and an expert in tort law. “We’ll never know if something has happened because of malpractice,” he said, “because it’s not financially viable to bring a lawsuit.” That leaves the patient responsible for extra costs.

Ann and Charles Thompson maintain that he experienced an avoidable error. The hospital denied wrongdoing, Ann said, and the physician’s notes indicated the Thompsons had been advised of the risks of the procedure, including injury to the colon. She and her husband tried pursuing a lawsuit but couldn’t find a lawyer who would take the case. The hospital and the doctor who performed the test declined to comment, with the hospital citing patient privacy laws.

Read the full article on the Kaiser Health News Website!

17th Annual NPSF Patient Safety Congress Early Bird Ends March 17th!

patient safety congress

Early Bird Registration Ends March 17
17th Annual NPSF Patient Safety Congress
April 29-May 1, 2015 | Austin, TX

Save $200 if you register by March 17, 2015*

Join NPSF and their expert faculty at the only meeting with global reach and a singular focus on patient safety.

KEYNOTE SPEAKERS

  • Lucian L. Leape, MD, one of the founders of the National Patient Safety Foundation; chair of the NPSF Lucian Leape Institute
  • Gerald B. Hickson, MD, Senior Vice President for Quality, Safety and Risk Prevention, Joseph C. Ross Chair in Medical Education and Administration, and Assistant Vice Chancellor for Health Affairs Vanderbilt University Medical Center
  • Gary S. Kaplan, MD, FACMPE, Chairman and CEO, Virginia Mason Medical Center
  • Kaveh Shojania, MD, Director of the Centre for Quality Improvement and Patient Safety, University of Toronto, and editor-in-chief of BMJ Quality & Safety
  • Allan Frankel, MD, Chief Medical Officer, Safe and Reliable Healthcare,and an author of The Essential Guide for Patient Safety Officers
  • Kim Blanton, Patient and Family Advisor, Vidant Health
  • Chrissie Blackburn, Principal Advisor, Patient and Family Engagement at University Hospitals of Cleveland
  • Beth Daley Ullem, MBA, Patient Advocate and Governance Expert, Board of Directors, ThedaCare Hospital System and Solutions for Patient Safety

PRE-CONGRESS DAY, April 29

Full-day intensive sessions:
• Certified Professional in Patient Safety (CPPS) Review Course
• Leadership Day: Safer Health Care Through Transparency
• Keeping Kidz Safe During Kare: Advancements and Lessons from Pediatrics *NEW THIS YEAR*
• Sharing and Caring: Practical Initiatives for Advancing Patient and Family Engagement
• Patient Safety Science: Successful Practices to Optimize Root Cause Analysis (RCA)

EDUCATIONAL BREAKOUT SESSIONS in six theme tracks:

• Optimizing the Benefits and Minimizing Harms of Health Technology
• Creating and Sustaining Joy, Meaning, and Safety in the Workplace
• Patient Safety in the Ambulatory Setting
• Accelerating the Cost Case for $afety
• Partnering with Patients and Families for the Safest Care
• Advancing Safety Science Implementation

We’ll also have posters, live health care simulations, networking, award presentations, and more.

———————————–
What past attendees say:
“From a participant’s perspective, this year’s NPSF Congress was one of the strongest patient safety meetings I have attended in years.”

“It was an excellent event and really highlights the shift and progress made in the wider patient safety discussion, especially over the past few years.”

“Thank you, NPSF — you crafted a thought-inspiring, provocative, robust Congress — we leave with ideas, plans, and a sense of purpose!!!”
——————————
*Members of the American Society of Professionals in Patient Safety atNPSF or the NPSF Stand Up for Patient Safety program save even more with member discounts. Log in to npsf.org and check the member pages for the discount codes.

Register online or learn more: http://bit.ly/NPSF_17


Sponsored Advertisement:


Collaborative Caring: Stories & Reflections on Teamwork in Healthcare

collaborative caring suzanne gordon

A newly released book from our friend Suzanne Gordon and coauthors David Feldman, MD and Michael Leonard, MD. Suzanne is the coauthor of “Beyond the Checklist: What Else Health Care Can Learn from Aviation Teamwork and Safety” (click the link to read my book review), and coeditor of “First, Do Less Harm”, both from Cornell. She is coeditor of the Culture and Politics of Health Care Work Series and was program leader of the Robert Wood Johnson– funded Nurse Manager in Action Program.

About Collaborative Caring:

Teamwork is essential to improving the quality of patient care and reducing medical errors and injuries. But how does teamwork really function? And what are the barriers that sometimes prevent smart, well-intentioned people from building and sustaining effective teams? Collaborative Caring takes an unusual approach to the topic of teamwork. Editors Suzanne Gordon, Dr. David L. Feldman, and Dr. Michael Leonard have gathered fifty engaging first-person narratives provided by people from various health care professions.

Each story vividly portrays a different dimension of teamwork, capturing the complexity—and sometimes messiness—of moving from theory to practice when it comes to creating genuine teams in health care. The stories help us understand what it means to be a team leader and an assertive team member. They vividly depict how patients are left out of or included on the team and what it means to bring teamwork training into a particular workplace. Exploring issues like psychological safety, patient advocacy, barriers to teamwork, and the kinds of institutional and organizational efforts that remove such barriers, the health care professionals who speak in this book ultimately have one consistent message: teamwork makes patient care safer and health care careers more satisfying. These stories are an invaluable tool for those moving toward genuine interprofessional and intraprofessional teamwork.

Praise for the New Book:

“Collaborative Caring makes a unique contribution in the scope and breadth of teamwork it considers. It is an important book.”—Audrey Lyndon, PHD, RNC, FAAN, University of California San Francisco.

“Teamwork is the neglected part of medical training and the new frontier for reliable delivery of quality care. It’s not enough to know what to do. Providers need to be able to deliver that care reliably—and that takes teamwork. This book emphasizes the essential elements of real teamwork: actions coordinated by a shared goal, shared mental model of the situation, cross-monitoring, a flat hierarchy, mutual respect, and trust. If your operating room team or patient care team does not have these characteristics, then this book is for you.”— John. R. Clarke, MD, Professor of Surgery, Drexel University; Clinical Director of Patient Safety and Quality Initiatives, ECRI Institute; Clinical Director, Pennsylvania Patient Safety Authority.

Get your copy of Collaborative Caring from Amazon today!

Omnicell and Pocket Nurse Announce Agreement to Provide State-of-the-Art Medication Automation to Nurse Education Organizations

omnicell pocketnurse

Hot off the wire this morning is this fantastic announcement about a collaborative partnership between Pocket Nurse and Omnicell to provide better educational training solutions through simulation!

Lees-McRae College First Institution to Benefit from New Partnership

Mountain View, Calif. January 14, 2015. Omnicell Inc., (NASDAQ:OMCL), today announced that Pocket Nurse, a leading provider for nursing healthcare education and medical simulation initiatives, has entered into an agreement to bring state-of-the-art medication automation solutions to the nursing education market. Pocket Nurse will develop real-world simulated education curriculums using Omnicell automated medication dispensing systems for nursing students in healthcare education and medical simulation education programs in the USA & Canada.

Together, Omnicell and Pocket Nurse will bridge the academic preparation of nursing students with real-world experience by providing medication management technology used by nurses in the majority of hospitals across the country.

Simulation labs are today’s adjunctive method for nurse education1. Just as pilots refine and hone their skills on the ground in simulators, nurses need to be able to practice their craft in a dynamic and realistic environment. The rapid advance of technology in simulation education allows students unlimited opportunities to practice clinical events in a safe and controlled environment. As simulated education programs continue to evolve, educators are tasked with improving and fine-tuning the skills of today’s nurses as current staffing shortages increase and the demand for nurses heightens. Validating this new initiative, Lees-McRae College will be deploying Omnicell technology into their updated state-of-the-art simulation labs, scheduled to be open in fall 2015.

Pocket Nurse is well known within the nurse education and simulation center communities. Key purchasers of the Company’s solutions include nursing educators, simulation center supervisors, and programs for continuing nursing education. Pocket Nurse will provide a wide range of Omnicell’s catalog of products, particularly those designed for nursing, including:

  • OmniRx automated medication dispensing cabinets (medication cabinets) including the integrated Medication Label Printer that allows nurses to print patient-specific labels right from the medication cabinet during medication issue. The Omnicell medication cabinets also include the Touch & Go advanced biometric ID system, designed with state-of-the-art biometric technology to improve efficiency and security.
  • Savvy™ mobile medication workstation, which streamlines the medication administration process and provides safe and secure transportation of medications from the medication cabinet to the patient’s bedside.
  • Anywhere RN™ remote medication management software, a unique web-based application that allows nurses to remotely access the Omnicell dispensing cabinets at their convenience from virtually any hospital workstation, to streamline workflow and minimize interruptions that can lead to medication administration errors.

“Omnicell has a long-standing history of supporting the vital role nurses play in caring for patients with innovative solutions that improve their workflow and support improved patient outcomes,” states J. Christopher Drew, executive vice present, Field Operations at Omnicell. “We are proud to work with Pocket Nurse. This agreement further supports nurses in the academic environment prior to the start of their professional careers.”

“Continuous innovation and realistic, dynamic environments are central to nursing education and offer the hands-­‐on experience necessary to properly refine clinical skills,” says Anthony Battaglia, president at Pocket Nurse. “As a company founded and operated by nurses, we take pride in understanding the daily demands nurses face and our goal is to lessen the transition of students out of the classroom and into clinical settings. Partnering with Omnicell expands the technology we’re able to offer simulation centers and increases the quality of education nursing students receive.”

“It’s impossible to teach student nurses a correct and comprehensive way to practice their skills without all the properly integrated technology in place,” offers Justin Allen, BSN, RN, instructor of Nursing and Health Sciences at Less-­‐McRae College. “With the number of pre-­‐licensure nursing students outpacing the amount of clinical experience available, it’s important that in the simulation environment these students have the most exposure we can give them to real world experiences.”

Omnicell representatives were present in the Pocket Nurse booth at the International Meeting for Simulation in Healthcare (IMSH) conference January 10-13 where they had an opportunity to discuss the new agreement with attendees.

About Pocket Nurse

Pocket Nurse, a leading simulation laboratory and healthcare education solutions company, was founded more than twenty years ago to conveniently and cost-­‐ effectively provide essential clinical learning supplies to colleges and universities. Today, Pocket Nurse sells more than 7,500 products throughout the U.S. and in 180 countries worldwide to a diverse population of public and private institutions across the academic, governmental and healthcare enterprise. A Nurse Owned and Operated company, Pocket Nurse is the market share leader for products such as Student Health Totes for clinical education and Demo Dose simulated medications. Headquartered in a new 128,000+ square foot green-­‐certified corporate complex and state-­‐of-­‐the-­‐art distribution center in Monaca, Pa., Pocket Nurse is committed to providing best-­‐in-­‐class instructional solutions—from essential standards to the latest in technological innovation—to meet and exceed the supply needs of the simulation laboratory and healthcare education industry.

About Omnicell

Since 1992, Omnicell (NASDAQ: OMCL) has been creating new efficiencies to improve patient care, anywhere it is delivered. Omnicell is a leading supplier of comprehensive automation and business analytics software for patient-­‐centric medication and supply management across the entire health care continuum—from the acute care hospital setting to post-­‐acute skilled nursing and long-­‐term care facilities to the home. More than 3,000 customers worldwide have utilized Omnicell Automation and Analytics solutions to increase operational efficiency, reduce errors, deliver actionable intelligence and improve patient safety. Omnicell Medication Adherence solutions, including its MTS Medication Technologies brand, provide innovative medication adherence packaging solutions to help reduce costly hospital readmissions. In addition, these solutions enable approximately 6,000 institutional and retail pharmacies worldwide to maintain high accuracy and quality standards in medication dispensing and administration while optimizing productivity and controlling costs.

For more information, visit www.pocketnurse.com & www.omnicell.com!


Supported Organization:


Dr. John James, Author of Shocking 2014 Patient Safety Article on Medical Errors, Calls for National Patient Safety Board

patient safety regulations

To mark the anniversary of the Institute of Medicine’s watershed report “To Err Is Human: Building a Safer Health System,” West Health is running a series of interviews between their Chief Medical and Science officer Dr. Joe Smith and IOM committee members who helped produce the report (which estimates 440,000 lethal errors each year including hospital acquired infections), as well as other national health experts to examine what progress has been made in reducing medical errors in the US. Do you agree that we need a National Patient Safety Board to better regulate healthcare? Leave a comment and let us know!

This week’s Q&A features John T. James, PhD, former chief toxicologist for a federal agency, who has dedicated his life to patient safety after the loss of his teenage son to medical errors in 2002. He is the author of “A Sea of Broken Hearts: Patient Rights in a Dangerous, Profit-Driven Health Care System” and founder of Patient Safety America, a website that provides information for patients on the quality of healthcare in the U.S.

Excerpt from the West Health Article:

Joe Smith: Your recent publication on medical errors in the Journal of Patient Safety has achieved widespread notice, leading to medical errors being identified as the third leading cause of death in the United States, though your background is different than many involved in patient safety efforts. Could you please describe your background and what drove your interest in this important area?

John James: I recently retired from a federal agency where I was the chief toxicologist for 25 years. I am board certified in toxicology and earned a PhD in pathology in 1981 from the University of Maryland while working at a Baltimore hospital and doing research at the National Cancer Institute. In 2002, my 19-year-old son died while running. Three weeks earlier he had been evaluated by cardiologists for five days, primarily as an in-patient after experiencing a non-fatal collapse while running. After obtaining a complete set of his medical records, I realized that multiple, catastrophic medical errors had been made by his doctors. These included failure to follow a widely published guideline for potassium replacement in patients with heart arrhythmias, failure to make an obvious diagnosis of acquired long-QT syndrome and failure to communicate to him that he should not be running. He was also denied informed consent because he was deceived about the outcome of his cardiac MRI, which had not been properly performed. I did not find this information out until long after he died.

While reading medical literature and looked for root causes, I realized that lethal medical errors are not all that uncommon. In 2000, the late Barbara Starfield, MD, estimated far more lethal medical errors than in the 1999 IOM report. I also discovered that cardiologists board certified before 1990, such as my son’s lead cardiologist, are certified for life with no requirement to demonstrate continuing competency. Furthermore, the Texas Medical Board verifies Continuing Medical Education in only one percent of doctors each year. I also learned that getting doctors, especially cardiologists, to follow evidence-based clinical guidelines is a challenge and that diagnostic errors are common, but often go unrecognized. Doctor-to-doctor and doctor-to-patient communication errors are also common and occurred in my son’s case.

JS: What role do you think government plays in combating medical errors? What agency should have oversight and be charged with reducing medical error deaths?

JJ: Overall government agencies, including Congress, have not been assertive in addressing the problem of medical errors. In some ways, the Affordable Care Act has addressed some patient safety concerns without changing the fundamental culture that permits errors to continue. Government officials can be heavily influenced by money originating from medical industry special interests. Harmed patients or their survivors contribute little to political campaigns or PACs. A new agency controlled by leaders in the patient safety movement is needed. It could be called the National Patient Safety Board, modelled to some extent after the National Transportation Safety Board or Consumer Product Safety Commission. The goal of such an agency would be to discover, track and analyze medical errors, and where appropriate, enforce changes – all in a completely transparent way. The well-known limitations and secret-keeping of state medical boards and hospital accreditation organizations would become history. In addition, the agency would enforce a national bill of rights for patients. Violations of those rights would be as serious as civil rights violations or violations of OSHA standards that put workers in harm’s way.

Other West Health Series Articles on “To Err is Human”:

  • A Look Back, Behind the Scenes of the IOM’s Report on Errors: By William Richardson, PhD, Former Chair, IOM Committee
  • A Mother’s Perspective: Q&A with Sorrel King, Founder, The Josie King Foundation
  • 15 Years Later: Q&A with Molly Coye, MD, MPH, UCLA Health
  • Uniting for Patient Safety: Q&A with Tejal Gandhi, MD, MPH, CPPS, National Patient Safety Foundation

Read the full interview and other Patient Safety Articles on WestHealth.org!

Some Physicians Continue to Ignore Learning Opportunity From Aviation Simulation

airway chart

Suzanne Gordon, author of Beyond the Checklist: What Else Can Healthcare Learn from Aviation Teamwork and Safety, recently wrote up an article entitled “…just two guys in a box” – Really?” which focuses on her frustration when healthcare physicians criticize the training take-aways from aviation without true understanding.

“As we have gone around the country discussing our book Beyond the Checklist: What Else Health Care Can Learn from Aviation Teamwork and Safety, we have been struck by the number of people who insist that healthcare has little to learn from aviation because the two enterprises are entirely different. Critics suggest that healthcare is far more complex than aviation. One physician in charge of simulation at a large medical school blithely opined that really “in aviation, it’s just two guys in a box.” Another physician insisted that “…flying a 747 is really no different than flying a Cessna.” On further inquiry, we learned that he had done neither. Even many who are somewhat sympathetic to our message believe that healthcare and aviation have little in common.

This idea has likely taken root because people do not understand the complexity of the global system of aviation safety in which each individual flight is embedded. People think of an airplane flight as an individual, discrete entity: Plane takes off, plane lands. Just two guys in the box get it off the ground and back on the ground, and with remarkably few glitches – this happens day in and day out. This idea is reinforced each time we look up at the sky and see this vast expanse of blue (or gray if you live in Seattle as Patrick does) with maybe the odd airplane skimming the horizon. What the individual standing on the ground does not see are the many, many airplanes that are up in the sky at 28,000 to 60,000 feet, all of which function in the same kind of interconnected system that patients in a hospital or other complex facility depend on.”


Organizing the World’s Flights Everyday

Suzanne provides multiple examples of the difficulty of flying, before continuing that the differences in the content of learning is not what should be in question regarding such a conversation — but rather the structure of culture and training.

How can the responsible parties in any industry or organization best function to protect those who depend on their skills and professional judgment for survival? We can learn from best practices and relevant models wherever and whenever they are developed and then adapt them to different settings in which they may be useful. What is paramount is how an institution—or, in the case of CRM, an entire global industry—learned to change for the better and for the safer and how it has sustained change over time. What did the airline industry do concretely to transform workplace relationships and create a different model of workplace hierarchy and teamwork? How did it confront power and status differentials and learn to help people speak up about safety without fear of reprisal? What strategies and tactics did it utilize, what obstacles did it confront and overcome, and what values and practices did it change—and how? We also believe that, in spite of the differences between healthcare and aviation, the principles of CRM—learning to communicate more effectively, learning to lead a team and work effectively on a team, as well as learning to manage stressful workloads and anticipate a variety of threats to safety, as well as to prevent, manage or contain error—are crucial in healthcare and can and should be taught to and learned by all who care for the sick and vulnerable.

We think you’ll appreciate this argument even more if you consider the complexity of what happens up there while you are down here. Or what happens up there to get you back down here safely. Aviation, with all its system complexity managed to transform a toxic and dysfunctional culture over thirty years ago. We believe, as healthcare acknowledges its own similarities to where aviation was, those lessons can be similarly and very effectively applied. “

Read Suzanne’s full article and many more at her website http://suzannecgordon.com/

NPSF President Interviewed by AHRQ & Prepares for May Patient Safety Congress

patient safety foundation

The AHRQ, aka the Agency for Healthcare Research and Quality, had Web M&M editor Dr. Robert Wachter sit down with Dr. Tejal K. Gandhi to discuss the National Patient Safety Foundation and the organization’s evolving role in enhancing healthcare safety at a national level.

What is the NPSF? The National Patient Safety Foundation’s vision is to create a world where patients and those who care for them are free from harm. A central voice for patient safety since 1997, NPSF partners with patients and families, the health care community, and key stakeholders to advance patient safety and health care workforce safety and disseminate strategies to prevent harm. NPSF is an independent, not-for-profit 501(c)(3) organization.

Before we get to the interview snippet, remember that NPSF is holding its 16th annual Patient Safety Congress this May 14th-16th at the Renaissance Orlando at Seaworld. Simulation continues to increase its presence at this event, and here is a full day pre-conference workshop I found on the topic taking place May 14th:

Pre-Congress Session
Wednesday, May 14, 2014 | 8:00 AM–4:00 pm

Continuing Education for this Program
6.5 contact hours for physicians, pharmacists, nurses, health care risk managers, health care quality professionals, and health care executives

This interactive, multidisciplinary session will push the boundaries of traditional health care simulation programs. During the first part of the program, participants will look closely at the spectrum of simulation, experience live demonstrations, help write patient safety simulation scenarios, and participate in hands-on opportunities with simulation equipment. During the second part of the program, participants in the patients and families session will join the group for a joint learning opportunity. Simulation experts and patient and family representatives will work together to provide attendees opportunities to examine ways in which patients and families, who are integral parts of the health care team, can provide perspective and knowledge not always gained through the use of traditional health care simulation programs. This session will incorporate the patient and family perspective, and participants will have opportunities to identify and apply ways to improve the patient experience and improve the safety of their organization. Take-home tools will be provided.

nps congress


I have excerpted some of the interview text for you below, but you can read the full interview on the AHRQ website linked at the bottom of this post. (You can also listen to a portion of the interview here).

RW: Much of what NPSF does is education and convening. Is the new technological world that we find ourselves in—the world of MOOCs and videos—changing the nature of how you think about getting people together and working collaboratively across time and space?

TG: This is an area that we’re just starting to explore. We, and I think other organizations, have found that it’s harder to get people to travel to meetings. Even though the one-on-one networking at meetings is really valuable, given financial and time constraints, this is a challenge for many organizations. I think we are going to be much more engaged in other forms of convening technology and best practice sharing technologies. We’ve done webinars, but in the next year or two we will be exploring other ways to try to convene folks that doesn’t involve face-to-face interaction.

RW: You’ve been one of the leading experts in the role of information technology (IT) in patient safety. We’ve gone from 10% IT in American hospitals and clinics to probably 60% to 70% in a few years because of Meaningful Use incentives. How has that changed the environment for safety generally and then NPSF specifically?

TG: I’m a firm believer that health information technology can improve the safety of the care we deliver. This rapid transition is a good thing. We’re getting over that adoption hump and getting into these new systems, which have great potential to improve care. The challenge is that often the systems are not necessarily implemented to optimize safety and quality for a variety of reasons, whether it’s workflow or poor design. But there are many reasons why I don’t think we’re maximizing the benefits of health IT. Another big issue—it often feels like every implementation is standalone, where every hospital or clinic is trying to decide which way is the best way to do things. Best practices around how to implement are starting to come out but are still quite rudimentary.

Many decisions are made in implementation that have big impacts on quality and safety, but they are decided in one-off situations instead of having a standard for how we should be implementing to optimize quality and safety. A concrete example is around drug interactions. Which ones should we show or not show to optimize the benefits while minimizing over-alerting? It’s a decision that every place makes on its own. It strikes me that there should be a standard for something like that, but also there’s all this work happening at each site that could be avoided if there was a best practice around this. Another example is around medication lists: who can touch them, how should they be kept accurate, what should a specialist do versus a primary care doctor? I know places are spending days, weeks, months, and years trying to figure this out. Is there a way to get some best practice standards out there to help people optimize these things? Because having an accurate medication list is such a fundamental component to delivering safe care, yet we really struggle with it. I feel like the role of the National Patient Safety Foundation is to use our convening function to create some of these best practices around health IT implementation, for example.


Learn more about the AHRQ and their TEAMSTEPPS Communication tools for healthcare educators.

Learn more about the NPSF, and their May Patient Safety Congress!