patient safety quality healthcare

NPSF Announces DAISY Award 2016 Honorees

The National Patient Safety Foundation along with The Daisy Foundation have announced the winners of the 2016 National Patient Safety Foundation DAISY Awards for Extraordinary Nurses. The award, a derivative of The DAISY Award for Extraordinary Nurses, places special emphasis on patient and workforce safety.

Now in its second year, this award is a derivative of The DAISY Foundations’ signature program, The DAISY Award for Extraordinary Nurses which is given to nurses in more than 2,200 healthcare facilities throughout the U.S. as well as 14 other countries. Nurses who received the DAISY award from their organizations between January 2014 and June 2015 were eligible for this 2016 international award.

“The National Patient Safety Foundation DAISY Award for Extraordinary Nurses is a way to formally recognize and celebrate exceptional contributions to patient safety by nurses,” said Tejal K. Gandhi, MD, MPH, CPPS, president and CEO, NPSF.

Rachel Whittaker, BSN, RN, CPN, of Children’s Hospital Colorado in Aurora, the recipient of the individual award, was chosen for her leadership, compassion, and practice of patient-and family-centered care, particularly during end-of-life decisions.

The Clinical Informatics Council of the University of New Mexico Hospitals in Albuquerque, will receive the team award for their efforts to address safety issues including an alert designed to prevent complications from ventilator use, a Pediatric Early Warning Score to predict a deteriorating patient, and a streamlined method for documenting wounds. Sheena Ferguson, MSN, RN, CNS, CCRN, chief nursing officer, noted this as a “huge improvement” in patient safety, because it allows multiple disciplines to document wounds in the same place and with consistent terminology.

“Choosing the final honorees for this international award was difficult because we had so many inspiring stories of truly compassionate nurses making a difference in patient and workplace safety,” said Bonnie Barnes, FAAN, co-founder and president of The Daisy Foundation.

The awards will be presented during the 18th Annual NPSF Patient Safety Congress in Scottsdale, Arizona at the end of May.

For more information about The DAISY Foundation, visit For updates about the award and the NPSF Patient Safety Congress, visit

Joint Commission Finalizes New Requirements for CAUTI NPSG

Proposed Joint Commission NPSG focuses on risks of pediatric CT scans

Radiology experts are split on whether the focus on head and chest scan is a valuable use of resources

A proposed National Patient Safety Goal (NPSG) released by The Joint Commission in February takes aim at judicious use of computed tomography (CT) imaging among pediatric patients, requiring hospitals to follow evidence-based guidelines when considering CTs for minor head trauma.

The proposed standard, released as NPSG.17.01.01, would apply to hospitals, ambulatory care facilities, and critical access hospitals. The Joint Commission accepted comments on the proposed requirement through the end of March.

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Taking a Patient Safety Cue from Denmark

Denmark's patient compensation program has helped transform the approach to patient safety in the country, allowing patients a full picture of a potential medical error and prompting physicians to openly confront mistakes, according to an article by ProPublica.

Denmark's approach to medical errors is drastically different from that of the United States. Instead of relying on malpractice claims to ferret out patient concerns, Denmark allows patients to file claims through a government-run system where a panel of medical experts reviews the patient's case file and awards monetary damages if an error occurred.

Patients have full access to their medical records and researchers can use the data on medical errors to hone in on national trends and concerns.

Perhaps more importantly, the system allows physicians to speak openly and honestly about patient safety failures.

For more, read the ProPublica article.

Weighing the Pros and Cons of Patient Safety Technology

Although some emerging technology promises a patient safety cure-all, hospitals need to evaluate clinician workflow before implementing new gadgets

In the 21st century, technology offers a solution to just about any everyday problem. Don't know that actor that just came onto your screen? Log onto the IMDB app. Need directions? Just type the address into your phone.

Healthcare is no different. Emerging technologies promise to solve the industry's biggest patient safety concerns, and sometimes they actually do, but not always. In some cases, healthcare technology can simplify complicated processes and improve care. In other situations, it can have negative consequences, particularly if hospitals fail to consider the technology's impact on workflow.

Just like the technology we encounter in everyday life, healthcare technology can be beneficial, but only when it is appropriately integrated into the system in which it is used. Unfortunately, in their rush to purchase cutting-edge gadgets, hospitals often neglect this step.

"Workflow needs to be assessed and made more efficient, and if possible, standardized so that when you introduce the new technology, you're not introducing something new into a bad process," says Mary Logan, president and CEO of the Association for the Advancement of Medical Instrumentation (AAMI) in Arlington, Virginia. "You're really looking at your process and making sure technology fits in with that, so it's an opportunity to improve. Hospitals historically haven't done that, but they need to."

This is an excerpt from the May issue of Patient Safety Monitor. Subscribers can read the rest of the article here. Non-subscribers can find out more about the journal, its benefits, and how to subscribe by clicking here.

Move to Refine Quality Measures Gaining Momentum

By Tinker Ready, HealthLeaders

Complaints about quality measures are as abundant as the measures themselves. But some doctors are doing something about it. They're working to identify metrics that are "realistic and actually will have an impact on patient care."

Call it pushback, validation, or measurement science. The revolt against the volume and usefulness of outcomes measures continues.  

The AHRQ alone lists 1,280 quality measures on its site.

Efforts are underway to both challenge and refine existing guidelines and requirements. And, wonks take note, providers and patients are on the job, too.

One example: The emergency department at Beth Israel Deaconess Medical Center in Boston's Longwood cluster of hospitals sees more than 50,000 patients a year. Every time a patient undergoes procedural sedation in the ED, doctors there follow up with a formal quality assurance review.

Their analyses are designed to meet a Joint Commission standard that requires monitoring and evaluation of such cases, which carry the risk that comes with sedation.

Now team, including BIDMC emergency physician Jonathan Edlow, MD, has decided to examine the utility of the review. "We are trying to find out what metrics make sense and what don't," he told me. 

In a March paper in The Journal of Emergency Medicine, Edlow and his team reported that the review "offers little advantage over existing quality assurance markers." They concluded that review of high risk cases "may be useful."

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Immersion Program for Emerging Leaders in Patient Safety

The Academy for Emerging Leaders in Patient Safety (AELPS) (aka Telluride Patient Safety Summer Camp) now offers a three-day immersion program in patient safety and quality education for risk managers, healthcare administrators, and health education faculty. This comprehensive workshop will be held July 27–30 in Napa Valley, California.

For 11 years, the AELPS faculty has convened thought leaders from around the world and nationally recognized patient advocates to develop a comprehensive patient safety curriculum for health science students and resident physicians. In response to numerous requests, the AELPS faculty has now designed a curriculum for healthcare leaders and educators who desire to broaden their knowledge in patient safety and risk reduction.

AELPS faculty members include David Mayer, MD, vice president of quality and safety, MedStar Health; Tim McDonald, MD, JD, chief quality and safety officer, Sidra Medical Center; Anne Gunderson, EdD, GNP, assistant vice president for education, safety, and quality, MedStar Health, and professor of medicine/associate dean for innovation in clinical education at Georgetown University Medical Center; Kim Oates, MD, emeritus professor of pediatrics, University of Sydney, and director of undergraduate education at the Clinical Excellence Commission.

The workshop is limited to a small number of attendees. The meeting curriculum uses case-based learning, stories and narratives, and simulation and gaming in an intimate, small group learning environment, allowing attendees to interact and work closely with faculty and peers. Attendees will leave with the knowledge, tools, and techniques necessary to lead change at their home institutions. Some key topics covered during the workshop include high reliability; disclosure and rapid remediation models; patient and family partnerships to drive safety & quality; human factors engineering; transparent and honest communication skills; and fair and just culture.

More information, including the full faculty list, is available at

Challenge Issued to Promote Precision Medicine for the Underserved

To support President Obama’s Precision Medicine Initiative, the National Health IT Collaborative for the Underserved (NHIT Collaborative) offers a challenge to advance health equity through the development of digital health tools. Proposals are invited for tools that:

  • Address the precision medicine needs of people in underserved and medically underserved communities
  • Facilitate participation of people from underserved and medically underserved communities to the precision medicine cohort
  • Promote the use of open health platforms to expand the breadth, depth, and interoperability of digital health tools and associated data to support the national Precision Medicine Initiative


Challenge partners, including HIMSS, Mass. General Hospital/Partners HealthCare’s Medical Device Plug and Play Lab, Intel Corporation, Howard University College of Medicine, TracFone, Global City Teams Challenge, and ICE Alliance, will provide experts to mentor, collaborate, and provide technical assistance for entrepreneurs selected through the challenge as they envision, deploy, and potentially commercialize their solutions.

Announcing the challenge, NHIT Collaborative CEO Luis Belen said, “Ensuring that everyone, especially those in underserved communities, benefits from advances in precision medicine will accelerate progress toward health equity.” Julian Goldman, MD, medical director of biomedical engineering at Partners HealthCare and director of the MGH Medical Device Interoperability Program, also supported the challenge, saying, “Our team has been working to revolutionize improvements in healthcare safety and quality through integration of devices into systems. We look forward to working with challenge participants to share this insight and host them in our lab.”

More information and submission guidelines are available at 

‘Citizen Jury’ Recommends Ways to Improve Diagnosis

The Society to Improve Diagnosis in Medicine (SIDM), the Jefferson Center, and the Maxwell School of Citizenship and Public Affairs at Syracuse University are working with healthcare consumers to develop a list of the ways patients can reduce diagnostic error. The project is using a process developed by the Jefferson Center’s founder, Ned Crosby, PhD, to provide informed deliberation and recommendations for action on specific social issues. The centerpiece of the process is its “citizen juries.”

Citizen juries are groups of between 20 and 100 people recruited randomly and selected to reflect local population demographics. A daily stipend and support for child care and other expenses help remove financial hardship as a barrier to participation. Jury members meet in person for a few days to learn and deliberate about a specific topic. At the end of the meeting, they issue recommendations.

The project on diagnostic error is part of a two-year study funded by the Agency for Healthcare Research and Quality and has two research interests: 1) assessing the quality of the deliberative process and 2) discovering practical methods for reducing diagnostic error through patient engagement.

To develop a citizen jury for diagnostic error, the Jefferson Center’s executive director, Kyle Bozentko, and associate director, Larry Pennings, worked with Tina Nabatchi, associate professor at the Maxwell School, and mailed recruitment materials to nearly 15,000 households in central New York state’s Onondaga County. With additional digital outreach and advertising, they were able to select enough individuals for citizen jury meetings held over two three-day periods.

The first panel, numbering approximately 50 people, met at Syracuse University in August 2015. The initial session included a half-day of presentations by SIDM representatives Paul Epner and Kathy McDonald. Half of the panel had been enlisted for this education-only part of the program and were finished after completing pre- and post-surveys. The remaining participants—the citizen jury—stayed for two-and-a-half days of further presentations, which included Helen Haskell and Peggy Zuckerman, members of SIDM’s Patient Engagement Committee.

Following facilitated discussion, the jury made preliminary identification of improvement actions. In November, the same 25 people came together again for a similar three-day program. At the end of that session, they issued recommendations for actions patients can take to reduce diagnostic error, as well as barriers patients may encounter in the current healthcare system.

In early February 2016, a new group of 100 citizens met in Syracuse for a one-day event. They received some background information about diagnostic error and the earlier deliberations and assessed the citizen jury’s recommendations for relevance and usability. In the coming months, SIDM, the Jefferson Center, and the Maxwell School will issue a final report on the project and the patient recommendations.

More information is available at

Winners of the Eisenberg Patient Safety and Quality Award Announced

The National Quality Forum (NQF) and The Joint Commission announced the 2015 winners of the John M. Eisenberg Patient Safety and Quality Award, last Friday. The award, named after the former head of the Agency for Healthcare Research and Quality, recognizes those who have made great achievements in the arena of patient safety and quality.

Individual Achievement Award—Pascale Carayon, PhD, Procter & Gamble Bascom Professor in Total Quality, Department of Industrial and Systems Engineering, University of Wisconsin-Madison
Pascale Carayon was honored for her work advancing both human factors engineering concepts and methods, and the Systems Engineering Initiative for Patient Safety model. She was also recognized for mentoring new leaders in this arena at the national and international level.

Local Level Award—Mayo Clinic Hospital-Rochester, Minnesota
By engaging its staff, using a multidisciplinary team approach, identifying possible interventions, and developing an effective toolkit, the Mayo Clinic Hospital-Rochester was able to cut catheter-associated urinary tract infections rates by 70% in its facility.

National Level Award—Premier, Inc., Charlotte, North Carolina
In 2008, Premier developed the national quality improvement initiative QUEST® (Quality, Efficiency, Safety and Transparency) to help health systems reliably deliver an efficient, effective, and caring experience for every patient. In the eight years since its inception, the QUEST program has enabled easy data sharing between 350 volunteer health systems and saved 176,000 lives and more than $15 billion in healthcare costs.

“We are pleased to honor Pascale Carayon for devoting her entire career to improving health care safety, as well as the contributions of all those who were a part of Mayo Clinic’s efforts to reduce CAUTI, and the Premier collaborative. All of them have made a great impact on the care of patients and should be commended,” said Mark R. Chassin, MD, FACP, MPP, MPH, president and CEO, The Joint Commission. “They have all worked to find solutions to some tough issues in health care that have defied easy fixes. Through their use of innovative quality improvement approaches, they are making a difference in the lives of patients.”

Read more about the 2015 John M. Eisenberg Awards here.

I-PASS and SBAR Handoff Tools Have Proven Benefits

Communication failures continue to plague patient care. Experts weigh in on why nearly one-third of malpractice claims involve a communication failure, leading to significant patient harm

For nearly two decades, communication failures have been frequently attributed to harmful events in healthcare. Judging by a new report looking at malpractice claims, those problems aren't getting any better.

The report, published in January by CRICO Strategies, a division of The Risk Management Foundation of the Harvard Medical Institutions Inc., analyzed 23,000 medical malpractice claims filed between 2009 and 2013 in which patients suffered some degree of harm. Researchers found that more than 7,000 cases featured at least one kind of communication breakdown and 44% of those cases resulted in high severity patient injuries or death. Nearly 60% of communication failures involved two or more healthcare providers, and 55% involved a miscommunication with the patient.

Although communication errors are not solely to blame for patient harm, they often serve as the catalyst to subsequent missteps, says Dana Siegal, director of patient safety for CRICO Strategies in Boston.

"To be quite honest, an error is very rarely a single missed step or missed event, it's a matter of multiple missteps lining up," she says. "There is a miscommunication and someone doesn't recognize it and that leads to a decision not to do a test which leads to a misdiagnosis."

For many healthcare experts, these statistics merely add to the overwhelming evidence that miscommunication continues to plague healthcare. A recent Institute of Medicine (IOM) report entitled Improving Diagnosis in Healthcare highlighted communication as a key focus area for providers (see "IOM report highlights long-standing concerns surrounding diagnosis," in the December 2015 issue of Patient Safety Monitor Journal). More than 15 years ago, IOM's landmark To Err Is Human report identified communication failures as a contributing factor to patient harm.

"I'm disappointed that we continue to have the same problems," says Frank Federico, RPh, vice president of the Institute for Healthcare Improvement (IHI). "We've been working on trying to improve communication for some time. Communication is the currency of healthcare; that's how we exchange information. We have to be able to know we have good systems in place and that we have good mechanisms in place."

By digging deeper into why and how communication failures occur, healthcare organizations can refine their approach to information exchange. Patient Safety Monitor Journal spoke with four patient safety experts about why communication failures occur so often in healthcare and what hospitals can do to reduce miscommunication.

This is an excerpt from the April issue of Patient Safety Monitor. Subscribers can read the rest of the article here. Non-subscribers can find out more about the journal, its benefits, and how to subscribe by clicking here.

Department of Homeland Security Issues Ransomware Warning to Hospitals

In response to a series of ransomware attacks that crippled healthcare systems across the country, the Department of Homeland Security (DHS), the U.S. Computer Emergency Readiness Team (US-CERT), and the Canadian Cyber Incident Response Centre (CCIRC) released a warning on specific types of ransomware used in recent attacks. The warning is directed at all organizations that use networked computer systems, but specifically mentions healthcare facilities and hospitals.

Locky and Samas are the two types of ransomware named as being behind the recent spate of attacks.

Ransomware, a type of malware that encrypts files with a key that’s withheld for ransom, emerged as a significant threat to healthcare systems this year. Hollywood Presbyterian in Los Angeles was among the first to report a ransomware attack, followed soon after by incidents at other facilities in California, Kentucky, and Canada. MedStar in Baltimore is the most recent organization to weather a ransomware attack. Ransomware typically takes a hospital’s entire network offline and locks providers out of electronic health records and email. Ransomware can be difficult for an organization to recover from and some files may be permanently lost.

Networks infected by ransomware are also likely infected by other types of malware, the warning says. Malware linked to ransomware infections may copy and transmit financial information including bank account numbers or credit card numbers.

Healthcare organizations are advised to take steps to prevent ransomware attacks. US-CERT recommends that users:

  • Back up data on separate servers
  • Have a recovery plan for restoring data from backup servers
  • Ensure all software and devices are operating on the latest version
  • Disable macros from email attachments
  • Use application whitelisting to create a restricted list of applications and software that are permitted to run and update

Organizations are discouraged from paying the ransom. Payment of ransom does not obligate a hacker to release the encryption key and does not guarantee that any files will be released. Organizations are advised to contact the FBI’s Internet Crime Complaint Center if they discover ransomware or other evidence of hacking on their network.

Mercy Selects Datix Patient Safety and Risk Managment Solution

Mercy, the seventh largest Catholic health care system, has selected patient safety and risk management software from Datix to give a comprehensive view of incidents, complaints and claims across the organization. After a thorough evaluation, Datix was selected as a result of its ability to aggregate patient safety data in real time. Datix’s powerful dashboards and report writer will provide the Mercy leadership team and managers with the ability to access and drill down into data to allow faster decision making, further progressing the culture of patient safety throughout the organization.

Dr. Keith Starke, Mercy’s chief quality officer, said, “Mercy is passionate about patient safety and technology. We were named as a ‘Most Wired’ health care organization last year by the American Hospital Association and were one of the first organizations in the US to have a comprehensive, integrated electronic health record to provide real-time, paperless access to patient information. The introduction of Datix will further enhance our ability to promote a culture of patient safety across the organization.”

Mercy includes 45 acute care and specialty (heart, children’s orthopedic and rehab) hospitals, more than 700 physician practices and outpatient facilities, 40,000 co-workers and more than 2,000 Mercy Clinic physicians in Arkansas, Kansas, Missouri and Oklahoma. The health care system receives around 10,000,000 inpatient and outpatient visits annually.

Dr. Peter Brawer, Mercy’s vice president of quality, added, “Datix will make it much easier to record adverse and near miss events and incidents and enable analysis and meaningful reporting at all levels of the organization, including the leadership team. We will be able to look at trends, identify issues and risks, and rapidly address them to increase safety and prevent repetition. The highly configurable nature of Datix software gives Mercy a tool to accurately reflect its current and future patient safety culture and processes.”

Datix brings transparency to patient safety data and its position as a leading global player includes large scale deployments in the US and Canada, 80% of the National Health Service in the United Kingdom and installations in other European countries, Australia and the Middle East.

John Scott, SVP Sales, Datix concluded, “We recognize the importance of data and analytics to Mercy as an organization. Datix is a proven patient safety and risk management solution with a long track record of helping healthcare managers make fast and effective decisions based on data and shared learning to help keep patients safe from harm.”


AORN Guideline Updates Focus on Counting, Communication to Prevent RSIs

Using a new evidence review model, AORN highlights key safety concerns, while one expert calls for more emphasis on human error.

Using a new evidence review model, updated guidelines released by one of the nation's leading surgical associations underscore the importance of clear communication and strong counting procedures to prevent the occurrence of retained surgical items (RSI).

The Association of periOperative Registered Nurses (AORN) released updates to its Guideline for Prevention of Retained Surgical Items effective January 15, 2016. The updated guidelines take the place of previous recommendations released in 2012.

Hospitals continue to struggle with RSIs. In January, The Joint Commission released a "Quick Safety" report building on its 2013 Sentinel Event Alert on unintended retained foreign objects (URFO). The Joint Commission reported that URFOs accounted for 115 of the sentinel events reported in 2015 and 112 in 2014, up from 102 in 2013.

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Safety Issues Dominate Joint Commission List of Most-Cited Standards of 2015

The Joint Commission’s latest list of most-cited standards was dominated by safety issues. Following a multi-year trend, eight of the top 10 cited standards came from the Environment of Care, Life Safety or Infection Control chapters, with most of them merely swapping places within the top 10.

The standards are those most frequently found not compliant by surveyors. Percentages indicate the number of organizations that were given Requirements for Improvement for the standards.

The top 10 most-cited standards of 2015 are as follows, based on 1,447 hospital surveys:

  • EC.02.06.01 (maintenance of a safe environment), 62%
  • IC.02.02.01 (reduction of infection risk from equipment, devices, and supplies), 59%
  • EC.02.05.01 (management of utility system risks), 58%
  • LS.02.01.20 (maintenance of egress integrity), 51%
  • LS.02.01.30 (building features provided and maintained to protect from fire and smoke hazards), 50%
  • RC.01.01.01 (maintenance of accurate, complete medical records for all patients), 47%
  • LS.02.01.35 (fire extinguishment features provided and maintained), 46%
  • LS.02.01.10 (minimization of fire, smoke, and heat damage via building and fire protection features), 45%
  • PC.02.01.03 (lawful provision of care, services, and treatment), 40%
  • EC.02.02.01 (management of hazardous materials and waste risks), 39%

For more information, visit here or see the April issues of Joint Commission Perspectives

Readmissions Dip 47% When Some Patients Self-Administer IV Antibiotics



By: Alexandra Wilson Pecci, HealthLeaders Media

Uninsured patients requiring prolonged courses of treatment with intravenous antibiotics can be trained to treat themselves at home and achieve outcomes comparable to patients who receive treatment in traditional settings, data shows.

Teaching uninsured patients how to self-administer IV antibiotics for outpatient parenteral antimicrobial therapy (OPAT) has paid off for Parkland Hospital, a safety-net hospital serving Dallas County, Texas.

The program has resulted in similar or better clinical outcomes than healthcare provider-administered OPAT and 47% lower 30-day readmission rates over a four-year period, according to a recent study published by PLOS.

Lead study author Kavita Bhavan, MD, medical director of the Infectious Diseases OPAT Clinic at Parkland, and assistant professor of internal medicine at the University of Texas Southwestern Medical Center, explains the program, in an interview with HealthLeaders. This is the first of two parts. The transcript of her remarks has been lightly edited.

About the program:
The program is for uninsured patients to self-administer antibiotics at home as an alternative to remaining in the hospital or a traditional healthcare setting to complete their therapy. Patients who receive OPAT services are typically those who have been diagnosed in the hospital with an infection that requires a prolonged course of antibiotics.

This is done for more invasive infections, whether it’s osteomyelitis (an infection of the bone) or endocarditis, a heart valve infection, for example.

OPAT has been around since the late 1970s, was initially shown to work in pediatric populations, and then in adult populations. We started this program in 2009. I’m proud to say that Parkland is the first to publish outcomes of doing this kind of model. We don’t know who else is doing something similar to this.

On why Parkland started the program:

We started the OPAT program because we recognized that patients with infections who require long-term antibiotics typically receive concentrated diagnostics and therapeutic services.

The first couple of days is when we’re really busy trying to figure out what’s wrong with the [patients], trying to figure out a diagnosis, getting a treatment plan going—there’s a lot of stuff happening. But once they’re stable—simply because they have no other place to go—safety-net hospitals would simply just absorb that and have them stay in the hospital or discharge them to another setting to receive care, but not home, necessarily.

We talk about healthcare disparities in this country, and see that the patients who are insured have the option to be discharged early to home or to a lower-cost nursing facility to complete their therapy. But unfunded patients don’t typically receive these options and they usually remain in the hospital.

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ABQAURP American Society for Quality American Society for Quality Healthcare Division Consumers Advancing Patient Safety
EMPSF Institute for Safe Medical Practices
Medically Induced Trauma Support Services (MITSS) Medication Safety Officers Society NPSF Partnership for Patient Safety Society to Improve Diagnosis in Medicine