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		<title>Joint Commission Perspectives on Patient Safety</title>
		<link>http://www.jcrinc.com</link>
		<description>Blog</description>
		<language>en-us     </language>
		
		
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					<title>December Issue now available in print and online!</title> 
					<link>http://www.jcrinc.com/Blog/2011/12/9/December-Issue-now-available-in-print-and-online/</link> 
					<description><![CDATA[
		
		The December 2011 issue of Perspectives on Patient Safety is now available, containing the following articles:
• Up to the Minute: Ensuring Timely Reporting of Critical Test Results
• Sound the Alarm: Managing Physiologic Monitoring Systems
• Effective Relationships: Key to Safety in a Complex Environment
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					<pubDate>Fri, 09 Dec 2011 20:14:23 GMT</pubDate>
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					<title>A New “Source” for Patient Safety Information from Joint Commission Resources</title> 
					<link>http://www.jcrinc.com/Blog/2011/10/12/A-New-“Source”-for-Patient-Safety-Information-from-Joint-Commission-Resources/</link> 
					<description><![CDATA[
		
				You, the readers, have told us that you’d like all the information you need on Joint Commission accreditation requirements, the accreditation process, performance measurement, and patient safety conveniently delivered, affordably priced, and in one place. To better meet your needs, JCR will introduce an improved, expanded version of The Source newsletter in January 2012.   The new Source will be enhanced with coverage of the National Patient Safety Goals and other emerging patient safety issues, as well as coverage of Joint Commission accountability measures and performance measurement, and Joint Commission certification programs. This includes content currently covered in JCR’s newsletters Benchmark and Perspectives on Patient Safety. These newsletters will cease publication at the end of 2011.The Source will be the most comprehensive, authoritative monthly resource on accreditation, performance measurement, and patient safety. Three newsletters, now all rolled into one comprehensive Source.   If you are a current subscriber to Perspectives on Patient Safety, you will automatically receive a subscription to the new Source. Patient Safety will discontinue publication at the end of 2011 (the December 2011 issue is the last), and its content will be rolled into the new and expanded Source starting with the January 2012 issue. Instead of the monthly Patient Safety newsletter, you will now get a monthly Source newsletter featuring the patient safety information you need, and more! 
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					<pubDate>Thu, 13 Oct 2011 00:44:23 GMT</pubDate>
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					<title>Come to the Home Care Executive Briefing </title> 
					<link>http://www.jcrinc.com/Blog/2011/8/1/Come-to-the-Home-Care-Executive-Briefing/</link> 
					<description><![CDATA[
		
		Every year Joint Commission Resources invites home care organization administrators, directors, and managers to this critical update on the home care accreditation.  This year, this one-day event will take place October 13 at The Joint Commission headquarters, located just outside of Chicago in Oakbrook Terrace, IL.

The event will focus on recent and forthcoming changes to the accreditation process, the most challenging standards for Home Care in 2011, the National Patient Safety Goals, and other emerging issues that affect home care organizations. 

Don’t miss this opportunity to meet with experts from The Joint Commission and Joint Commission Resources, hear the latest information, and ask your questions face-to-face.

Additional information about the briefing is available here.

Register now to take advantage of early bird pricing!

For questions related to registration fees and early bird discounts, please contact JCR Customer Service at 877-223-6866. For questions related to specific content or faculty discussions, please contact Alma Harrell, Program Manager at 630-792-5409.]]></description> 
					<pubDate>Mon, 01 Aug 2011 20:13:51 GMT</pubDate>
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					<title>Come to the Hospital Executive Briefings</title> 
					<link>http://www.jcrinc.com/Blog/2011/6/22/Come-to-the-Hospital-Executive-Briefings/</link> 
					<description><![CDATA[
		
				Hospital Executive Briefings Health care professionals who are interested and involved in improving patient safety at their organizations should attend one of JCR’s Hospital Executive Briefings The briefings are especially helpful for hospital executives, chief nursing officers, risk managers, quality improvement managers, accreditation managers, patient safety officers, chief medical officers, board members, and medical staff members involved with accreditation, quality improvement, and risk management processes in their hospital. A good portion of this year’s agenda will focus on identifying the most challenging National Patient Safety Goals and discussing solutions for improving compliance and performance. Discussion will also cover the new National Patient Safety Goal requirements that will become effective in 2012, including the goal related to catheter-associated urinary tract infections. 
		
		The schedule for this year’s lineup of briefings includes the following dates and locations: 
		
		
		
				
						 
				
				
						Hospital Executive Briefings 
				
				
						New York, NY 
				
				
						September 9, 2011 
				
				
						Product Code: EDU1136
				
				
						 
				
		
		
				
						Hospital Executive Briefings 
				
				
						Grapevine, TX (near Dallas) 
				
				
						September 15, 2011 
				
				
						Product Code: EDU1137 
				
				
						 
				
		
		
				
						Hospital Executive Briefings 
				
				
						Costa Mesa, CA 
				
				
						September 21, 2011 
				
				
						Product Code: 
				
				
						EDU1138 
				
				
						 
				
				
						Hospital Executive Briefings 
				
				
						Rosemont, IL 
				
				
						September 26, 2011 
				
				
						Product Code: EDU1139 
				
		
		
		
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					<pubDate>Wed, 22 Jun 2011 21:28:37 GMT</pubDate>
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					<title>Check Out These Upcoming Webinars!</title> 
					<link>http://www.jcrinc.com/Blog/2011/6/17/Check-Out-These-Upcoming-Webinars/</link> 
					<description><![CDATA[
		
				
						
						
						
				
		
		
				
						
								
										Patient safety is at the heart of Joint Commission accreditation. The ultimate purpose of every standard is protecting patients, preventing harm, and improving quality. 
						
				
		
		
				
						
								
										
										
								
						
				
		
		
				
						
								Joint Commission Resources is offering two new series of Webinars/Audio conferences that will take participants step-by-step through the entire accreditation manual for two of The Joint Commission’s largest accreditation programs: Ambulatory Care and Hospitals. Not only are these events online and accessible at your convenience, but they feature instruction from Joint Commission subject-matter experts and an opportunity for you to ask your questions––and get real-time answers.
								
								
								
						
				
		
		
				
						
								
								
						
				
		
		
				
						
								Details are below:
						
				
		
		
				
						
								
										
										
								
						
				
		
		
				
						
								
										2011 Ambulatory Breakfast Briefings Webinar/Audio Conference Series
								
						
				
				
						
								The nine-week 2011 Ambulatory Breakfast Briefings Webinar/Audio Conference Series begins September 7, 2011. Each week, Joint Commission experts will cover the Comprehensive Accreditation Manual for Ambulatory Care one chapter at a time, providing both a formal presentation and a moderated Q&A session. Choose a live connection or access the recorded web conferences, depending on your schedule and needs. 
						
				
		
		
				
						
								
										
												Find out more about the 2011 Ambulatory Breakfast Briefings Webinar/Audio Conference Series
										
								
						
				
				
				
				
				
				
		
		
				
						
								
										
										
								
						
				
		
		
				
						
								
										2011 Hospital Breakfast Briefings Webinar/Audio Conference Series
								
						
				
				
						
								The nine-week 2011 Hospital Breakfast Briefings Webinar/Audio Conference Series begins September 8, 2011. Each week, Joint Commission experts will cover the Comprehensive Accreditation Manual for Hospitals one chapter at a time, providing both a formal presentation and a moderated Q&A session. Choose a live connection or access the recorded web conferences, depending on your schedule and needs. 
						
				
		
		
				
						
								
										
												Find out more about the 2011 Hospital Breakfast Briefings Webinar/Audio Conference Series
										
								
						
				
				
						
						
				
		
		
				
				 
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					<pubDate>Fri, 17 Jun 2011 21:26:30 GMT</pubDate>
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					<title>Reminder: Annual Conference Coming Up!</title> 
					<link>http://www.jcrinc.com/Blog/2011/5/20/Reminder-Annual-Conference-Coming-Up/</link> 
					<description><![CDATA[
		The Joint Commission and Joint Commission Resources Annual Conference on Quality and Patient Safety, June 8–10, in Chicago is right around the corner.  Have you registered yet?   

This year’s conference includes the following expected keynote presenters: 
• James Reason, PhD, Professor Emeritus of Psychology University of Manchester, United Kingdom will speak present a retrospective and prospective analysis of human factors in patient safety 
•  Mark R. Chassin, MD, MPP, MPH, President, The Joint Commission, will provide a presidential overview of The Joint Commission and its accreditation process improvements to help health care organizations achieve high reliability and accountable care
• Fred Lee, Author of If Disney Ran Your Hospital: 9½ Things You Would Do Differently (which was awarded the 2005 Book of the Year from the American College of Healthcare Executives) will present on that topic  
• Jane L. Holl, MD, MPH, Associate Professor of Pediatrics and Preventive Medicine and Director, Institute for Healthcare Studies, Medical Director for Patient Safety Children's Memorial Hospital Feinberg School of Medicine, Northwestern University will talk about assessing and improving pediatric patient safety and quality of care through in-situ simulation 

Click here for more information or to sign up! 

I look forward to meeting you and getting your ideas on how to maximize content in Perspectives on Patient Safety. You’ll find me at our on-site book store.

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					<pubDate>Fri, 20 May 2011 17:32:34 GMT</pubDate>
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					<title>New Global Data on HAIs</title> 
					<link>http://www.jcrinc.com/Blog/2011/5/12/New-Global-Data-on-HAIs/</link> 
					<description><![CDATA[
		
				
				The World Health Organization (WHO) last week released a report, titled "World Health Organization Report on the Burden of Endemic Health Care–Associated Infection Worldwide." This report is a must-read for anyone interested in patient safety or infection prevention and control. 
		
		
				According to the report, health care–associated infections (HAIs) are the most prevalent type of adverse event worldwide. But the problem remains difficult to quantify in precise terms because of the difficulty of collecting reliable data. Data from the developing world in particular is scarce, with limited or unreliable data available from some regions and no data whatsoever available in others. The data provided in the report are based on a literature review of information published between 1995 and 2010 in high-, middle-, and low-income countries.
		
		
				Among the report’s key findings were the following:
		
		
				
				
		
		
				
				
		
		
				
						
								• Pooled HAI prevalence in mixed patient populations was 7.6% in high-income countries. 
						
				
				
						
								
								 
				
				
						
								• The European Centre for Disease Prevention and Control (ECDC) estimated that more than 4.1 million patients are affected by approximately 4.5 million HAIs every year in Europe. 
						
				
				
						
								
								 
				
				
						
								• The estimated HAI incidence rate in the U.S.A. was 4.5% in 2002, affecting 1.7 million affected patients and corresponding to 9.3 infections per 1000 patient-days. 
						
				
				
						
								
								 
				
				
						
								• Hospital-wide prevalence of HAI in the developing world varied from 5.7% to 19.1% with an overall prevalence of 10.1%. 
						
				
				
						
								
								 
				
				
						
								• Surgical site infection (SSI) is the most surveyed and most frequent type of infection in low- and middle-income countries with incidence rates ranging from 1.2 to 23.6 per 100 surgical procedures and an overall incidence of 11.8%. By contrast, SSI rates vary between 1.2% and 5.2% in developed countries. 
						
				
				
						 
				
				
						
								• The risk of acquiring HCAI is significantly higher in intensive care units, with approximately 30% of patients affected by at least one episode of HAI with substantial associated morbidity and mortality. 
						
				
		
		
				Click 
				
						here 
				
				to access the full WHO report. 
		
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					<pubDate>Thu, 12 May 2011 19:54:02 GMT</pubDate>
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					<title>Reminding Staff About Hand Hygiene</title> 
					<link>http://www.jcrinc.com/Blog/2011/4/21/Reminding-Staff-About-Hand-Hygiene/</link> 
					<description><![CDATA[
		
				Hand hygiene is a major patient safety priority in the United States and around the world. Many health care organizations continue to struggle with ensuring that staff comply with World Health Organization and Centers for Disease Control and Prevention guidelines, as well as Joint Commission National Patient Safety Goal Requirement NPSG.07.01.01. Recently I came across some amusing and interesting videos that organizations are using to help educate staff and promote hand hygiene compliance.  I want to share these with you:
		The University of Geneva Medical Center went so far as to hire a professional troupe to perform an interpretive dance depicting the proper application of antimicrobial hand gels for this video:
		Other organizations have taken a more home grown approach, creating videos that feature their very own staff, along with original music! For example, Gerber Hospital in Fremont, Michigan created this video, “I Wash My Hands for You.”
		Thomas Jefferson University Hospitals in Philadelphia promoted hand hygiene in this entertaining take on a certain late pop star’s “Beat It,” video.
		These are just a few great of examples of how organizations have developed creative reminders to help staff remember to follow hand hygiene guidelines. I hope they will inspire you to think of a similar project to help keep hand hygiene in the forefront of health care providers’ minds.  What about an essay contest for employees’ children on the importance of hand washing? Or a poster-design contest? There are endless possibilities.  Perhaps your organization has already done a video or other creative project to promote hand hygiene. If so, why not share the story or a link with the Patient Safety blog? 
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					<pubDate>Thu, 21 Apr 2011 18:23:28 GMT</pubDate>
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					<title>See you at the Annual Conference!</title> 
					<link>http://www.jcrinc.com/Blog/2011/4/7/See-you-at-the-Annual-Conference/</link> 
					<description><![CDATA[
		
				
				I hope to meet some of you in person at the upcoming Joint Commission and Joint Commission Resources Annual Conference on Quality and Patient Safety, June 8–10, in Chicago. I plan to attend the conference and would relish the opportunity to meet and talk with you, the readers. You’ll likely find me at our on-site book store. This year’s conference has an intriguing line up, with the following expected keynote presentations: · Human Factors in Patient Safety – Retrospect and Prospect,  James Reason, PhD, Professor Emeritus of Psychology University of Manchester, United Kingdom · Presidential Overview - The Joint Commission, Mark R. Chassin, MD, MPP, MPH, President, The Joint Commission · If Disney Ran Your Hospital,  Fred Lee, Author, If Disney Ran Your Hospital: 9½ Things You Would Do Differently, awarded the 2005 Book of the Year from the American College of Healthcare Executives · Assessing and Improving Pediatric Patient Safety and Quality of Care Through In-Situ Simulation, Jane L. Holl, MD, MPH, Associate Professor of Pediatrics and Preventive Medicine and Director, Institute for Healthcare Studies, Medical Director for Patient Safety Children's Memorial Hospital Feinberg School of Medicine, Northwestern University Sessions focus on decisions and actions for health care executives seeking to improve quality and reduce errors, contain costs, increase productivity, enhance execution, achieve organizational greatness, and build leaders throughout their organization. In addition, participants can attend breakout sessions organized into three tracks on leadership, patient care, and implementation of the National Patient Safety Goals. Click here for registration information. 
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					<pubDate>Thu, 07 Apr 2011 16:49:46 GMT</pubDate>
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					<title>Incident Underscores Importance of Patient Identification</title> 
					<link>http://www.jcrinc.com/Blog/2011/2/15/Incident-Underscores-Importance-of-Patient-Identification/</link> 
					<description><![CDATA[
		
				What are the odds, really, that a clinician might perform surgery on the wrong patient, or give the wrong blood product in a transfusion, or perhaps dispense the wrong medication? And really, how bad can it be? Perhaps we might ask a pregnant patient in Colorado whose retail pharmacist mistakenly gave her the drug methotrexate instead of the antibiotic she was prescribed, according to media reports. Methotrexate is a medication used in chemotherapy for cancer patients. It is also used to terminate early-stage pregnancies. This medication error put both the patient and her unborn child at serious risk. The error reportedly occurred because the patient had a name very similar to another patient, who was supposed to receive the methotrexate. 
		The Joint Commission’s National Patient Safety Goal NPSG.01.01.01 is intended to prevent incidents such as this. NPSG.01.01.01 requires organizations to use at least two patient identifiers when providing care, treatment, and services. Another requirement, NPSG.01.03.01 addresses patient identification when performing transfusions. 
		This process is essential to patient safety, but it does not have to be complicated. Typically, when I go to pick up a prescription, the pharmacist or technician asks me for my address, and sometimes my date of birth. It’s quick and simple. Another helpful practice is to remind patients to double check medication labels themselves before using the medication. Organizations can do this through posters or with printed material distributed with their medications. This is not required in the National Patient Safety Goal, but it is a helpful extra step that can prevent patient harm. 
		It’s true that in some situations, such as when a hospital inpatient is nonresponsive, for example, organizations may pursue more complex methods such as color-coding or bar-coded wrist bands and other methods of distinguishing patients from one another. Subscribers to the online version of Perspectives on Patient Safety have free access to articles in back issues that outline strategies for improving patient identification. Nonsubscribers can also purchase downloadable PDFs of the articles for a nominal fee. Some of the more recent articles on this topic include:• Patient Identification in the Laboratory: Complying with NPSG.01.01.01   January 2011• Protecting Patients from Medical Identity Theft   July 2010• Avoiding Blood Incompatibility Transfusion Errors   May 2009 • Eliminating Transfusion Errors Related to Patient Misidentification: Complying with NPSG.01.03.01   September 2008 • Identifying Patients Using Bar-Code Technology: Montefiore Medical Center reduces patient identity errors   October 2006
		
				To subscribe to 
				
						
								
										
												
														Perspectives on Patient Safety
												
										
								
						
				
				, please click here. 
		
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					<pubDate>Tue, 15 Feb 2011 17:12:03 GMT</pubDate>
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					<title>New CMS Rules Address Patient Safety/Rights Issues</title> 
					<link>http://www.jcrinc.com/Blog/2011/2/1/New-CMS-Rules-Address-Patient-Safety/Rights-Issues/</link> 
					<description><![CDATA[
		
				
						
								
										 
								
								
										
												
												Now is a good time for hospitals to evaluate their policies on who is allowed to visit patients. On Tuesday, January 18, 2011, new Centers for Medicare & Medicaid Services (CMS) regulations go into effect pertaining to patients’ rights to have visitors during hospital stays following a presidential memorandum  from last year.  The regulations impact all hospitals that participate in Medicaid and Medicare programs and are designed to guarantee the patients’ right to designate visitors of their choosing and to end discrimination in visitation based on a number of factors, including sexual orientation and gender identity. The issue of who can and cannot visit patients and participate in medical decisions is not only a matter of civil rights, it’s a serious patient safety issue. Take for example, a patient who may be estranged from his or her parents.  The patient’s partner or even friends will likely have more accurate knowledge about the patient’s lifestyle, habits, medications, chronic conditions, and other pertinent information than the parent to whom the patient has not spoken to in 10 years.  The key is that the word “family” is defined by the patient, not the organization.  For their patients’ sake, hospitals need to recognize that patients many not define their families strictly in terms of biological or marital relationships. The Joint Commission, in the glossaries of the manuals for all its accreditation programs, defines term family as “A person or persons who play a significant role in an individual’s life. A family is a group of two or more persons united by blood or adoptive, marital, domestic partnership, or other legal ties. The family may also be a person or persons not legally related to the individual (such as a significant other, friend, or caregiver) whom the individual considers to be family. A family member may be the surrogate decision-maker for the individual should he or she lose decision making capacity or choose to delegate decision making to another.” The new regulations, part of the Conditions of Participation for the Medicaid and Medicare programs, are part of the Code of Federal Regulations at 42 CFR 482.13(h) and 42 CFR 485(f). The regulations require hospitals to have written policies and procedures regarding patients’ visitation rights.  According to the regulations, hospitals must do the following: ·  Inform each patient of his or her right to receive visitors whom he or she designates, including a domestic partner. ·  Do not restrict or limit visitation rights based on sexual orientation and gender identity, among other factors. ·  Ensure that all visitors have full and equal visitation rights, consistent with a patient’s wishesThe regulations stem from a number of contentious incidents in which health care organizations prevented partners of lesbian-gay-bisexual-transgender (LGBT) patients from visiting. Some of these incidents—in one of which the patient died—were widely reported in the 
												
														media
												
												. In particular, the case of Janice Langbehn, Lisa Pond, and their family, received a great deal of attention and ultimately resulted in a law suit. It was in response to that incident that President Obama issued a 
												
														presidential memorandum
												
												last year directing the Department of Health and Human Services to develop the regulations. The hospital still maintains the ability to restrict visitation when medically appropriate, such as when there may be infection control issues, or when visitation may interfere with the care of other patient.
										
								
						
				
		
		
				To subscribe to 
				
						
								
										
												
														Perspectives on Patient Safety
												
										
								
						
				
				, please click here. 
		
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					<pubDate>Tue, 01 Feb 2011 17:12:41 GMT</pubDate>
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					<title>December Issue Links</title> 
					<link>http://www.jcrinc.com/Blog/2011/1/7/December-Issue-Links/</link> 
					<description><![CDATA[
		
				Happy New Year!  I hope all of you enjoyed a safe and restful holiday season. Shortly after December issue of Perspectives on Patient Safety went to press, The Joint Commission unveiled its new, upgraded Web site at http://www.jointcommission.org. As a result of this, a link to the Joint Commission’s report Improving America’s Hospitals:  The Joint Commission’s Report on Quality and Safety 2010 that appeared in the December issue was rendered obsolete. I apologize to readers who followed the link and received an error message.  To view the report, simply click here.  Also, the link has already been updated in the electronic version of the newsletter, so online subscribers should have no trouble.    To subscribe to Perspectives on Patient Safety, please click here. 
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					<pubDate>Fri, 07 Jan 2011 20:42:52 GMT</pubDate>
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					<title>2011 NPSGs Will Soon Become Effectve</title> 
					<link>http://www.jcrinc.com/Blog/2010/12/21/2011-NPSGs-Will-Soon-Become-Effectve/</link> 
					<description><![CDATA[
		
		The year 2010 is coming to a close and in a couple of weeks the 2011 National Patient Safety Goals will become effective!  Remember that if you have questions or concerns about how to interpret the goals, you can contact The Joint Commission’s Standards Interpretation Group (SIG) for help. Contact SIG at 630-792-5900, 8:30 a.m. - 5:00 p.m. (Central time).  You can also contact SIG by using this online request form. And of course, look for more strategies and solutions in 2010 for complying with the National Patient Safety Goals and other patient safety issues in Perspectives on Patient Safety. 

Thank you for another year of working together to improve patient safety in the nation’s health care organizations. I hope all of you enjoy the holiday season and wish you all the best for the new year. 
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					<pubDate>Tue, 21 Dec 2010 16:44:37 GMT</pubDate>
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					<title>Proposed NPSG Requirements in Field Review</title> 
					<link>http://www.jcrinc.com/Blog/2010/12/7/Proposed-NPSG-Requirements-in-Field-Review/</link> 
					<description><![CDATA[
		
				 The Joint Commission posted two proposed National Patient Safety Goal requirements designed to help hospitals, critical access hospitals, and long term care organizations prevent ventilator­-associated pneumonia (VAP) and catheter-associated urinary tract infections (CAUTI) on its Web site. These requirements may be integrated into existing Goal 7 to reduce the risk of health care–associated infections (HAIs).   The Joint Commission based the content for these requirements on strategies identified in the Compendium of Strategies to Prevent Healthcare–Associated Infections in Acute Care Hospitals developed by the HAI Allied Task Force, of which The Joint Commission is a member organization. VAP is one of the most common infections acquired by adults and children in ICUs, according to the compendium. While the compendium deals specifically with hospitals, The Joint Commission is also considering the proposed requirement for long term care settings because many residents require ventilation and face many of the same risks for VAP.   The compendium also identifies CAUTIs as the most common HAI overall. The common use of catheters in long term care organizations also makes this requirement a consideration for that program.   Be sure to submit your comments by January 27 on the requirements that, if approved, would become effective in 2012. Review the language and submit comments here. Please take advantage of this opportunity to have a voice in identifying some vital patient safety solutions that could have tremendous influence not only on accreditation, but also on health care quality. 
		
				To subscribe to Perspectives on Patient Safety, please click here.
		
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					<pubDate>Tue, 07 Dec 2010 18:05:37 GMT</pubDate>
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					<title>Tragic Incident Underscores Need to Prevent MDROs</title> 
					<link>http://www.jcrinc.com/Blog/2010/11/18/Tragic-Incident-Underscores-Need-to-Prevent-MDROs/</link> 
					<description><![CDATA[
		
				
				
				Earlier this week the tragic news broke that a newborn infant had died and 10 others were sickened during an 
				
						outbreak of methicillin-resistant Staphylococcus aureas (MRSA) 
				
				at a hospital in Richmond, Virginia. As a result of the outbreak, the hospital in question had to shut down its neonatal unit for five weeks. MRSA and other multidrug–resistant organisms (MDROs) continue to be a threat to patients in the United States and around the world. Among the ways The Joint Commission helps organizations prevent incidents like the outbreak in Richmond is through enforcement of National Patient Safety Goal NPSG.07.03.01: “Implement evidence-based practices to prevent health care–associated infections due to MDROs in acute care hospitals.” The first step in complying with this requirement is to conduct a periodic risk assessment for MDRO acquisition and transmission. This risk assessment informs the organization’s surveillance activities, infection prevention and control plan, outbreak alert systems, and MDRO-related education for patients and their families, staff, and licensed independent practitioners.  The cover story for the December issue of Perspectives on Patient Safety takes a look at how organizations can perform an MDRO risk assessment, including a sample SWOT analysis—which analyzes strengths, weakness, opportunities, and threats—and a discussion of whether or not it is beneficial for organizations to engage in active surveillance to detect and isolate cultures. (This is the practice of screening newly admitted or high-risk patients for MRSA and instituting contact precautions if necessary.)   Readers working in long term care organizations might also want to see the December issue of The Joint Commission: The Source newsletter. The December issue of The Source includes an article on how long term care organizations can use mock tracers as a risk assessment tool. For a more in-depth look at the art and science of assessing risk, readers may want to look at the recently published book, Risk Assessment for Infection Prevention and Control.   
		
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					<pubDate>Thu, 18 Nov 2010 19:38:31 GMT</pubDate>
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					<title>Tragic Event Reminds Us That Violence Is a Real Threat in Health Care</title> 
					<link>http://www.jcrinc.com/Blog/2010/10/7/Tragic-Event-Reminds-Us-That-Violence-Is-a-Real-Threat-in-Health-Care/</link> 
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				Health care professionals often encounter human beings at the most intense moments of their lives—moments of pain and grief as well as moments of intense joy—such as when a  child is delivered or a loved one recovers from a serious illness.    In these moments, people are charged with emotion, often anxiety and sometimes anger. Unfortunately, faced with these extreme situations, some turn violent. We saw this recently in Baltimore, when a man who was distraught over news of his mother’s condition lashed out. He shot and killed his mother, shot and wounded her doctor, and then turned the gun on himself, according to media reports. This dramatic incident illustrates a trend that has been building for years: Rape, assaults, and even homicides perpetrated by patients, family members, and sometimes staff, has been occurring with alarming frequency in health care organizations in the United States.   The Joint Commission recently addressed the issue in Sentinel Event Alert 45.  I encourage you to read the Alert, assess your organization’s current security, policies and procedures, and implement the suggested actions to prevent health care violence listed in the alert. 
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					<pubDate>Thu, 07 Oct 2010 06:12:00 GMT</pubDate>
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					<title>Is Your Organization Patient-Centered? </title> 
					<link>http://www.jcrinc.com/Blog/2010/9/11/Is-Your-Organization-Patient-Centered/</link> 
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				In an earlier post, I wrote about the importance of listening to patients and families during the course of providing care, treatment, and services. The theme of that earlier entry is summed up with this quote:  “The best practice is to consider the patient and family as full-fledged members of the care team. Family members (and the patients themselves) often have insights into a patient’s condition that would never occur to even the most compassionate health care provider—because he or she does not know the patient.” This type of communication is essential to patient safety.  It is also a central component of the emerging philosophy called “patient-centered care.” The Institute of Medicine (IOM) has identified patient-centered care as one of its six domains of quality (Safe. Effective. Timely. Patient-centered.  Efficient. Equitable.).  The IOM, in its 2001 report Crossing the Quality Chasm, defined patient-centered care as “providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions.” The Joint Commission has created a resource to help organizations make the care they provide more patient-centered. The free monograph, Advancing Effective Communication, Cultural Competence, and Patient-and Family-Centered Care: A Roadmap for Hospitals, was developed in collaboration with the The Commonwealth Fund. The monograph provides practice examples and recommendations designed to improve communication, cultural competence, and patient- and family-centered. A truly patient-centered organization must integrate these practices in its core activities. I hope readers will take advantage of this free resource. Also, please share your comments about experience and perceptions of patient-centered care. 
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					<pubDate>Sat, 11 Sep 2010 09:13:58 GMT</pubDate>
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					<title>Joint Commission Seeks Comment on 2010 Universal Protocol </title> 
					<link>http://www.jcrinc.com/Blog/2010/8/26/Joint-Commission-Seeks-Comment-on-2010-Universal-Protocol/</link> 
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				Accredited organizations now have the opportunity to tell The Joint Commission what they really think about the 2010 Universal Protocol. The Joint Commission is seeking public feedback on the 2010 Universal Protocol for Preventing Wrong-Site, Wrong-Procedure, and Wrong-Person Surgery™ for the Hospital, Critical Access Hospital, Ambulatory Care, and Office-based Surgery accreditation programs. Click here to view the Universal Protocol language. The Universal Protocol first became effective in July 2004; it is designed to address the continuing occurrence of wrong-site, wrong-procedure, and wrong-person surgery. The three principal components of the protocol include the following:  1.      Conducting a preprocedure verification process 2.      Marking the procedure site 3.      Performing a time-out before the procedure. The Universal Protocol in 2009 underwent extensive revisions based on feedback from a field review. Additional changes became effective January 1, 2010. The intent of the revisions is to address patient safety issues while allowing organizations flexibility in applying the requirements within existing work processes. Now, The Joint Commission would like additional feedback from organizations to ensure the revisions are meeting their needs.  To offer your feedback on the protocol, click here. 
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					<pubDate>Fri, 27 Aug 2010 05:01:15 GMT</pubDate>
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					<title>H1N1 Pandemic Officially Ends</title> 
					<link>http://www.jcrinc.com/Blog/2010/8/13/H1N1-Pandemic-Officially-Ends/</link> 
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				The H1N1 influenza pandemic that created great anxiety among health care organizations and the public for two years has ended, according to a statement released by Margaret Chan, M.D., director-general of the World Health Organization. Perspectives on Patient Safety covered the pandemic from its first stirrings to the moment of its greatest prevalence.  In February 2010, we published a special issue that focused on the pandemic and the importance of vaccination, not only for patients, but for health care workers as well. In the end, the H1N1 pandemic did not become the disaster everyone feared, a recurrence of the murderous 1918 Spanish Flu pandemic.  The virus did not develop resistance to antiviral drugs or evolve to become more fatal. Most people who acquired the virus were able to simply let their immune systems do their job.  As of fall 2010, seasonal flu vaccines now protect against that the H1N1 strain. For now, H1N1 slinks back into the ranks of ordinary seasonal flu that we deal with every year. However, it’s emergence allows us to test and evaluate our responses to emerging illnesses and future potentially deadly flu strains. It would be helpful for organizations to review the ways in which they responded to the pandemic and how it can be improved upon for later crises. 
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					<pubDate>Fri, 13 Aug 2010 10:09:27 GMT</pubDate>
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					<title>New Fall Prevention Resource</title> 
					<link>http://www.jcrinc.com/Blog/2010/8/6/New-Fall-Prevention-Resource/</link> 
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		A fall for an elderly or severely ill or weakened patient can be deadly. Health care organizations have a responsibility to take steps to reduce the likelihood of falls in their facilities. This is the impetus behind The Joint Commission’s National Patient Safety Goal 9, requirement NPSG.09.02.01, which guides organizations’ fall prevention efforts.   Falls remain a serious patient safety problem, especially for older patients. According to the Centers for Disease Control and Prevention, falls are the second leading cause of injury-related deaths for people ages 65 and older, and are the most common cause of injuries and hospital admissions among the elderly.   To empower patients and help organizations reduce falls, The Joint Commission has undertaken a national education campaign devoted to fall prevention, through its Speak Up™ program. Among the strategies the Speak Up materials present to the public are the following: • Taking care of your health—this includes exercise to improve strength and balance, staying hydrated, having an eye exam regularly and talking to your doctor about any side effects from medications that might cause drowsiness or confusion. • Taking extra precautions—simple actions such as turning on the lights when entering a room, keeping walkways clear, using handrails on stairs, and wearing proper shoes can make a difference. • Making small changes to your home—using motion sensors or timers for lights, placing nightlights in bedrooms and bathrooms, removing throw rugs, and applying non-slip decals on stairs and in bathtubs to reduce the risk of falls. Home care agencies, personal care and support agencies, or community programs may be available to help you accomplish these tasks if you are older or disabled.• Taking extra precautions in the hospital or nursing home, for example, people in health care facilities should use the call button to ask for help to get out of bed or go to the bathroom, wear non-slip socks, lower the height of the bed and bed rails, and tell the nurse or doctor if medicine is making you feel dizzy or sick.Organizations and patients can download the new brochure here.   
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					<pubDate>Fri, 06 Aug 2010 09:14:09 GMT</pubDate>
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					<title>Working Together to Improve Health Literacy</title> 
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				La mancata comunicazione sono molto frustrazinone.* 
				Aren’t they? For some patients, including some well-educated patients, health care information can seem like a foreign language. The total number of people in the United States who have limited health literacy exceeds 89 million.1 These patients have a difficult time obtaining, processing, and understanding basic health information and services and, therefore, are unable to make informed health decisions. This deficiency can have a great effect on health outcomes, so it falls to health care workers—from the support staff to the physician—to recognize the behaviors of patients who have low health literacy skills and help them understand information relevant to their own care. For example, when a patient says, “I left my reading glasses at home. Can you read this to me?” health care providers should dig deeper and assess the patient’s health literacy skills. Other behaviors might also indicate a literacy problem, including the following: • The patient’s registration forms are incomplete or inaccurately completed. • The patient frequently misses appointments. • The patient does not comply with medication regimens. • The patient does not follow through with laboratory tests, imaging tests, or referrals to consultants. • The patient says he or she is taking medication, but laboratory tests or physiological parameters do not change in the expected fashion. • The patient requests to bring a written document home to discuss it with a spouse or child. • The patient complains of a headache or other health problem too severe to allow reading. Education level is a poor indicator of a patient’s health literacy skills. Education level only measures the number of years an individual attended school—not how much the individual learned in school.2 The help health care organizations address this issue, the U.S. Department of Health and Human Services (HHS) has created a national action plan to improve health literacy. The plan is based on the “Universal Precautions” philosophy adopted by many health care providers in the area of infection prevention and control.  In a nutshell, universal precautions means that—because a provider cannot tell at first glance whether or not a patient has acquired an infectious illness—providers take precautions to prevent infection with every patient. HHS is advocating a similar strategy when it comes to health literacy. Do not assume that any patient completely understands the information you are giving him or her. Provide simple, clear, comprehensive communication to everyone. References:1. Kutner M., et al.: The Health Literacy of America’s Adults: Results from the 2003 National Assessment of Adult Literacy. U.S. Department of Education, Sep. 2006. 2. Weiss B.D.: Health literacy and patient safety: Help Patients Understand, 2nd ed., American Medical Association, May 2007.   * Translation: Communication failures are very frustrating.
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					<pubDate>Tue, 27 Jul 2010 04:55:13 GMT</pubDate>
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					<title>See you at the conference!</title> 
					<link>http://www.jcrinc.com/Blog/2010/6/18/See-you-at-the-conference-1/</link> 
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				I hope to see some of you at The Joint Commission/JCR Annual Conference for Quality and Patient Safety June 23–25 in Chicago.   The conference has an exciting line up of presenters this year, including plenary sessions led by: ·         Joint Commission President Mark Chassin, M.D. ·         Author John J. Nance, J.D. ·         John  Ovretveit, BSc(hons), M.Phil., Ph.D., C. Psychol., C.Sci., M.H.S.M., Director of Research for the          Karolinska Institutet of the Medical Management Centre in Stockholm, Sweden ·         JCR and JCI President and CEO Karen Timmons ·         David Whitson, D.D.S., Chairman of Joint Commission Board of Directors See the May 2010 issue of Perspectives on Patient Safety for an engaging interview with Dr. Nance,  a nationally renowned author and safety advocate in the aviation and health care industries. Click here for conference registration information.
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					<pubDate>Sat, 19 Jun 2010 04:41:28 GMT</pubDate>
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					<title>New Sentinel Event Alert on Violence in Health Care</title> 
					<link>http://www.jcrinc.com/Blog/2010/6/7/New-Sentinel-Event-Alert-on-Violence-in-Health-Care/</link> 
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				Here’s a head’s up: The Joint Commission has issued Sentinel Event Alert, issue 45, “Preventing Violence in the Health Care Setting.”Violence and crime represent a serious hazard to both patients and staff, and security can be a challenge because many organizations, such as hospitals, must be open to the public 24-hours-a-day, 365-days-a-year.   The problem can take many shapes, one patient attacking another, visitors attacking patients or staff, patients attacking staff, or staff attacking or abusing patients. The new alert discusses the roots of this problem and the ways in which organizations can present and address it. As is the case with many safety issues, leadership can have a powerful impact on violence and crime prevention.  Preventing violence and crime should be recognized by leadership as an essential part of your patient safety program, occupational safety and health program, and your organizational safety culture. Leadership should make this clear to staff and patients. Basic, every day precautions for preventing violence should come as second nature to health care workers, as much so as for hand hygiene or safe disposal of sharps. Has your organization experienced an act of violence? Share your story with other readers.  What happened? How did your organization respond?  
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					<pubDate>Tue, 08 Jun 2010 04:38:18 GMT</pubDate>
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					<title>JCR Selects 2010 Nurse Safety Scholar-in-Residence</title> 
					<link>http://www.jcrinc.com/Blog/2010/5/28/JCR-Selects-2010-Nurse-Safety-Scholar-in-Residence/</link> 
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				JCR and its partner Hill-Rom have selected a new Nurse Safety Scholar-in-Residence: certified wound, ostomy, and continence nurse Diane Whitworth, head of the Bon Secours St. Mary’s Hospital wound care team in Richmond, Virginia. Diane has more than three decades of clinical experience under her belt. She will taking over for the first Nurse Safety Scholar-in-residence, Nurse Practitioner Irene M. Jankowski, A.P.R.N., M.S.N, C.W.O.C.N., of Beth Israel Medical Center in New York. JCR and Hill-Rom launched the Nurse Safety Scholar-in-Residence program in 2009. This is a three-year project, the mission of which is to develop tools and best practices for maintaining skin integrity and prevent pressure ulcers. The program emphasizes the key role of nurses in bringing new research findings into actual patient care. The program’s goals include: • To foster the professional development of expert nurse clinicians and scholars to become translators of evidence into practice; • To disseminate best practice processes associated with providing safe care for specific clinical problems; and • To continue the work of a  hospital-based collaborative project focused on the implementation of pressure ulcer reduction strategies. Click here for more information about the program, and good luck Diane luck on this new endeavor. 
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					<pubDate>Sat, 29 May 2010 05:52:39 GMT</pubDate>
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					<title>Check Out JCR’s E-books </title> 
					<link>http://www.jcrinc.com/Blog/2010/5/18/Check-Out-JCR’s-E-books/</link> 
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				Perhaps you’re a fan of JCR’s books; chances are that you have a few in your library.  Did you know that many of JCR’s titles are also available as e-books? E-books are PDF files that are identical to the hard copy versions, but without all the shipping and the paper consumption. The e-books are specially priced and available for immediate download.  E-books are also searchable, making it easier to locate specific topics and key words that are important to you.  E-books cover a wide range of topics essential to all health care organizations, including: ·         Patient safety ·         Performance measurement ·         Performance improvement ·         Infection prevention and control ·         Medication safety ·         Staff competence ·         Environment of care ·         Accreditation Click here for more information.
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					<pubDate>Tue, 18 May 2010 11:23:24 GMT</pubDate>
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					<title>Happy National Nurses Week</title> 
					<link>http://www.jcrinc.com/Blog/2010/5/7/Happy-National-Nurses-Week/</link> 
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				This week is National Nurses Week! You are likely to see many signs, posters, and banners urging you to “Hug a Nurse Today.”  (While I certainly do not oppose this course of action, I would encourage readers to ask permission before pursuing it.) This is not only a good time to show gratitude for the incredible work nurses do, but a good time to consider their roles in the health care team and how those teams should operate.  Do not form a team in name only. The care team must be a truly collaborative effort, in which all members are treated as equals, including physicians, nurses, other providers, the patient, and the patient’s family (as defined by the patient, not the organization). Every person on the team should have an equal voice and should be regarded with equal respect. Of all the health care providers on the care team, the nurses have likely spent the most time with the patient and have developed a stronger rapport with patients and families. This makes their insights and perceptions crucial to the patient’s care. Their voices should not be drowned out by other staff who hold a traditionally “higher” organizational rank. JCR has created a page on its Web site for National Nurse’s Week. Feel free to check it out. Thank you nurses, for your commitment to caring for the nation’s sick and suffering, and for doing your part to improve patient safety!
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					<pubDate>Sat, 08 May 2010 05:24:55 GMT</pubDate>
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					<title>Organizations Still Struggle Against Health Care–Acquired Infections </title> 
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				Combating health care–acquired infections (HAIs) continues to be a serious challenge for health care organizations.  Despite intensified focus on HAIs by The Joint Commission, the public, patient safety advocates the media, the health care industry, and federal, state, and local government agencies, very little progress is being made on this hot button issue that first hit the spotlight in 2000, with the Institute of Medicine’s landmark report To Err is Human.   The nation’s health care providers have made “very little progress” on eliminating HAIs, this is what the U.S. Department of Health and Human Services said to Congress in the agency’s 2009 National Healthcare Quality Report.   Rates for some HAIs actually increased during 2009. Cases of adult surgery patients with postoperative catheter-associated urinary tract infections rose 3.6%. The incidence of postoperative sepsis rose 8%, and a category the agency called “selected infections due to medical care” increased 1.6%.   One area that did see significant improvement was postoperative pneumonia among surgery patients. The rate of these infections was reduced by 11.6%. Performance in some areas related to HAI prevention also improved. For example, the number of adult surgery patients who received prophylactic antibiotics within 1 hour prior to surgical incision increased by 26.4%.  Likewise, the number of adult surgery patients who had prophylactic antibiotics discontinued within 24 hours after their surgeries ended increased 32.9%.   On overall patient safety performance, of the 33 hospital measures related to safety that the agency tracks, only 12 saw improvements at a rate higher than 5%. By comparison, 19 hospital measures not related to safety, 16 improved at a rate greater than 5%.   The agency’s quality report said: “It is evident that more attention devoted to patient safety is needed to ensure that health care does not result in avoidable patient harm. Systems for identifying and learning from patient safety events need to be improved. Patient safety reporting systems are often laborious and cumbersome, and health care providers express fear that findings may be used against them in court or harm their professional reputations. Many factors, such as concerns about sharing confidential data across facilities or State lines, limit the ability to aggregate data in sufficient numbers to rapidly identify important risks and hazards in the delivery of patient care. More work is also needed to develop measures that capture the underlying processes and conditions that lead to adverse events and the practices that are most effective in mitigating them.”This echoes many patient safety advocates who have been calling for similar measures for years. However, I would like to hear from you, the front-line professionals. What do you see as the most daunting barriers to eliminating HAIs? What can we do about them?   The numbers would suggest that perhaps safety is not the organizations’ top priority. But is that necessarily the case? Is safety the most complex, most difficult and variable function of a hospital?  I look forward to hearing your insights.  
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					<pubDate>Wed, 28 Apr 2010 05:14:13 GMT</pubDate>
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					<title>The Joint Commission Annual Conference on Quality and Patient Safety</title> 
					<link>http://www.jcrinc.com/Blog/2010/4/20/The-Joint-Commission-Annual-Conference-on-Quality-and-Patient-Safety/</link> 
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				I hope to see some, if not all of you at The Joint Commission Annual Conference on Quality and Patient Safety, June 23-25 in Chicago. This is the 24th annual conference and this year brings an exciting line-up. The distinguished faculty for this event includes author, speaker, and veteran John J. Nance, J.D.; Joint Commission President Mark Chassin, M.D., M.P.P, M.P.H.; John  Ovretveit, BSc(hons), M.Phil., Ph.D., C. Psychol., C.Sci., M.H.S.M., director of research for the Karolinska Institute of the Medical Management Centre in Stockhom, Sweden, and professor of Health Management at Bergen University in Norway; Joint Commission Board of Commissioners Chairman David A. Whiston, D.D.S.; JCR CEO Karen Timmons; and Ann Rooney, vice president, Consulting and Education Services for Joint Commission Resources and Joint Commission International.   This will be my third time attending the conference, and I am looking forward to meeting and greeting readers as well as deepening my understanding of health care quality and patient safety. I am excited about hearing experts and advocates from around the world share their ideas, stories, and innovations. Click here for registration information. 
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					<pubDate>Tue, 20 Apr 2010 11:25:40 GMT</pubDate>
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					<title>Joint Commission Seeks Your Input for a New Monograph</title> 
					<link>http://www.jcrinc.com/Blog/2010/4/8/Joint-Commission-Seeks-Your-Input-for-a-New-Monograph/</link> 
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				This blog (and the newsletter itself) has covered the importance of influenza vaccines for health care workers.  However, we have to remember that influenza is not the only communicable disease from which health care providers and their patients need protection. The Joint Commission is currently looking for health care organizations of all types that are willing to share their experiences implementing tetanus, diphtheria, and acellular pertussis (Tdap) vaccination programs for patients and employees. This information will help The Joint Commission and its partners develop a new monograph that will describe strategies that have improved vaccination rates for people between the ages of 11 and 64. To create this monograph, The Joint Commission is partnering with the Association for Professionals in Infection Control and Epidemiology, Inc. (APIC), the Centers for Disease Control and Prevention (CDC), the Society for Healthcare Epidemiology of America (SHEA) and the National Foundation for Infectious Diseases (NFID). The monograph is expected to become available for free download from The Joint Commission Web site later this year. If your organization has a Tdap vaccination program, please click here to submit a description of your program by April 26, 2010.
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					<pubDate>Fri, 09 Apr 2010 04:40:14 GMT</pubDate>
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					<title>Listen!</title> 
					<link>http://www.jcrinc.com/Blog/2010/3/20/Listen/</link> 
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		My nephew Joshua struggles with cerebral palsy. For the time being, he requires a wheelchair and other equipment just to get through a typical day. He is unable to perform many simple tasks that most of us take for granted. It is inspiring to observe the grace with which he meets these challenges.   Joshua needs a lot of health care. He is sick often, and even when he doesn’t have strep throat or the flu he still has multiple health care appointments per week. He has been hospitalized more than once this year, and it’s only March. Trips to the emergency department are becoming virtually habitual.   Many times I have listened to my sister and her partner recount the difficulties they have had communicating with some of the numerous health care providers that have been working with Josh. Most provide excellent care, treatment, and services, and are responsive to the needs of the patient and his family members. However, every now and again they meet a physician or nurse or other personnel who just won’t listen.     In many cases, the provider seems to have an attitude that says, “I’m the expert. I don’t need to listen. I have seen all this before.” However, many patients who have difficulty verbalizing their needs give signals that only family members can interpret. When it comes to knowing the patient, the family are the experts and providers must make the time to listen respectfully. The information a family member provides can have a significant impact on the patient’s care. The best practice is to consider the patient and family as full-fledged members of the care team. Family members often have insights into a patient’s condition that would never occur to even the most compassionate health care provider—because he or she does not know the patient.   I just sent my sister a copy of Joint Commission Resources newest consumer book, The Smart Parent’s Guide to Getting Your Kids Through Checkups, Illnesses, and Accidentby Jennifer Trachtenberg, M.D., The Joint Commission, and RealAge. After reading my copy of the book I felt it was definitely a valuable tool for parents who want to be more involved in their children’s health care and communicate more effectively with the professionals who provide that care. As a parent, I know that few moments are more alarming or uncertain than when your child is injured or sick. I am grateful to have a guide that explains how to choose a pediatrician, or which emergency department to go to, or what check-ups and preventive or wellness care is needed. This book is an excellent resource for families; it not only educates, but empowers us to speak up–which can make all the difference for a loved one. 
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					<pubDate>Sat, 20 Mar 2010 09:28:46 GMT</pubDate>
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					<title>Patient Safety Awareness Week </title> 
					<link>http://www.jcrinc.com/Blog/2010/3/10/Patient-Safety-Awareness-Week/</link> 
					<description><![CDATA[
		This is Patient Safety Awareness Week, an annual observance designed to raise awareness of patient safety issues in the United States. This year’s theme underscores the critical importance of communication in providing quality health care: “Let’s Talk: Healthy Conversations for Safer Health Care.” Without quality communication, even the most perfectly executed technical skills and most advanced medical knowledge can be undone. Clear, effective communication is essential between patients and providers, among providers themselves, and in some cases between different organizations.   In Patient Safety Awareness Week, the emphasis is often placed on those first two words, and with good reason: Patient safety is the heart of the matter. However, we cannot forget the important third word:  Awareness.  To be aware of patient safety means more than to have heard of patient safety. Rather, it means to be ever mindful of patient safety when performing any task—or having any conversation—related to patient care. Health care providers must be focused on their patients and must actively consider the safety implications of any action, treatment, service, policy, or procedure at all times. Patient safety can never be allowed to fade into the background in favor of other personal or professional concerns. Health care providers can never forget patient safety. They must be aware to the fullest extent possible of how their action or inaction may affect a patient. This is what it truly means to “raise awareness.”   In addition to its year-round dedication to patient safety, this year Joint Commission Resources is contributing an online Patient Safety Quiz, intended to help patients and families learn how they can be more involved in their own health care.    Individuals who take the quiz are entered into a drawing to win a copy of one of JCR’s two consumer books: You The Smart Patient: An Insider’s Handbook for Getting the Best Treatment by Michael F. Roizen, M.D., and Mehmet C. Oz, M.D., with The Joint Commission; and the brand new The Smart Parent’s Guide to Getting Your Kids Through Checkups, Illnesses, and Accidentsby Jennifer Trachtenberg, M.D., with The Joint Commission and RealAge.   Both of these books are excellent resources for helping patients understand and take charge of their own care and their families’ care, including tips on how to communicate with health care providers.   In closing, I would like to share with you this excellent interview from the New York Times with physician, researcher, and patient safety advocate Peter Provonost, M.D., of the Johns Hopkins University Center for Innovations in Quality Patient Care in Baltimore. Dr. Provonost’s research has been cited more than once in the pages of Perspectives on Patient Safety, and he is a member of the Editorial Advisory Board for The Joint Commission Journal on Quality and Patient Safety. Click here to read. 
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					<pubDate>Wed, 10 Mar 2010 09:29:37 GMT</pubDate>
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					<title>Nomination Season Begins for 2010 Eisenberg Awards</title> 
					<link>http://www.jcrinc.com/Blog/2010/3/3/Nomination-Season-Begins-for-2010-Eisenberg-Awards/</link> 
					<description><![CDATA[
		
				The Joint Commission is now accepting nominations for the 2010 John M. Eisenberg Patient Safety and Quality Awards. Award submissions will be due at The Joint Commission by close of business April 12, 2010.
				
				
		
		
				The Eisenberg Awards recognize major achievements of individuals and organizations in improving patient safety and health care quality. The Joint Commission and the National Quality Form (NQF) 
				select recipients annually in five categories:
		
		
				1. Individual achievement (domestic and international combined) 
		
		
				2. Domestic system innovation in patient safety and/or health care quality at the national level 
		
		
				3. Domestic system innovation in patient safety and/or health care quality at the local level 
		
		
				4. Domestic research 
		
		
				5. International research or system innovation in patient safety and/or health care quality
				
				
		
		
				The awards are named in honor of John M. Eisenberg, M.D., former director of the Agency for Healthcare Research and Quality,
				and member of the founding Board of Directors of the NQF. The work of award nominees and applicants should be clearly linked to the principles that Eisenberg promoted during his career, including improving the quality of health care and patient safety, leadership in advancing methods for measuring and reporting health care quality, expanding the public’s capacity to evaluate the quality and safety of health care, and promoting health care choices based upon information about safety and quality.  
		
		
				
				
						 
				
		
		
				And yes, one may nominate him- or herself!
		
		
				
						 
				
		
		
				Visit The Joint Commission Web site
				for more information and for nomination forms. 
		
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					<pubDate>Thu, 04 Mar 2010 05:25:41 GMT</pubDate>
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					<title>Educate Patients about Dangerous Drug Interactions</title> 
					<link>http://www.jcrinc.com/Blog/2010/2/11/Educate-Patients-about-Dangerous-Drug-Interactions/</link> 
					<description><![CDATA[
		
				In late January the Associated Press and other media outlets reported that 13 hospitals in California were fined for patient safety violations by that state’s Department of Public Health. Each fine was in excess of $25,000. The most frequently occurring violations, nearly 30% of the total, involved medication errors.   Although not every adverse event will receive the media coverage garnered by the above examples, medication errors harm more than 1.5 million people in the United States every year according to a 2006 report by the Institute of Medicine. The report defined medication error as “all mistakes involving prescription drugs, over-the-counter products, vitamins, minerals, or herbal supplements.”   Medication safety is an important focus of Joint Commission standards and National Patient Safety Goals. National Patient Safety Goal 3 requires organizations to “Improve the safety of using medications.”  National Patient Safety Goal 8 requires organizations to “Accurately and completely reconcile medications across the continuum of care.”    This is especially important—and difficult—in this day and age, when many patients receive prescriptions from multiple health care providers and specialists. Many patients also ingest daily cocktails of vitamins and herbal supplements, as well as over-the-counter medications that may interact with each other or their prescribed medications.   When a patient gets sick, he or she just wants to feel better as quickly as possible. They may not consider the risks of dangerous drug interactions and may assume that if a product is on the shelf then it must be safe and effective.     Remember that a little communication can go a long way. It’s important for health care providers to specifically ask patients if they have been prescribed medications by other health care providers and for a complete list of medications they are taking. This should be done at every visit, in case something has changed. Health care providers should also specifically ask about vitamins, over-the-counter drugs, and other supplements. A patient may not consider these to be “medications” per se and may not mention them independently.   It never hurts to have a conversation with patients about the dangers of drug interactions. Patients may need a reminder that they should be certain that any new drug or supplement will not interact with anything they are currently taking. They should also be reminded to only use medications as prescribed or instructed in over-the-counter directions. Remind patients to stop by the pharmacist’s window before purchasing a medication or supplement and ask about potential interactions or side effects.  These simple precautions can go a long way.
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					<pubDate>Thu, 11 Feb 2010 19:57:22 GMT</pubDate>
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					<title>New Sentinel Event Alert</title> 
					<link>http://www.jcrinc.com/Blog/2010/1/29/New-Sentinel-Event-Alert/</link> 
					<description><![CDATA[
		
				Be sure to read the new Sentinel Event Alert on preventing death during or after pregnancy, released by The Joint Commission on January 26. Published for Joint Commission accredited organizations and interested health care professionals, Sentinel Event Alert identifies specific sentinel events, describes their common underlying causes, and suggests steps to prevent future occurrences. This new alert addresses the heartbreaking issue of maternal mortality (deaths that occur within 42 days of birth or termination of pregnancy).  Recent evidence indicates that maternal death rates in the United States may be on the rise. Since 1996, a total of 84 cases of maternal death have been reported to The Joint Commission’s sentinel event database, with the largest numbers of events reported in 2004, 2005 and 2006. The alert cites data from the National Center for Health Statistics that places national maternal mortality rate in 2006 at 13.3 deaths per 100,000 live births. (2006 is the most recent year for which data were available.)   While it is possible that these numbers are the result of increased reporting of maternal deaths rather than an increase in the actual incidence, experts who contributed to the alert point out that the number of maternal deaths has certainly not declined in recent years.   According to the Sentinel Event Alert, the leading causes of maternal death include hemorrhage, hypertensive disorder, pulmonary embolism, amniotic fluid embolism, infection, and pre-existing chronic conditions (such as cardiovascular disease).   Click here to read to full Sentinel Event Alert.    Perspectives on Patient Safety covered the issue of maternal death in the February 2009 issue, Subscribers can revisit that article ]." target="_blank" temp_href="http://docserver.ingentaconnect.com/deliver/connect/jcaho/15345181/v9n2/s3.pdf?expires=1264544417&id=54630129&titleid=11233&acc>].">here.
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					<pubDate>Fri, 29 Jan 2010 16:47:14 GMT</pubDate>
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					<title>Look for our Special Vaccination Issue! </title> 
					<link>http://www.jcrinc.com/Blog/2010/1/19/Look-for-our-Special-Vaccination-Issue/</link> 
					<description><![CDATA[
		
				
				The February issue of Perspectives on Patient Safety is our Special Vaccination Issue.   The issue includes an article about JCR’s successful Flu Vaccination Challenge, which promotes influenza vaccination among health care workers. (See my 
				
						previous blog
				
				 for more details.)   The issue also features a discussion with Kristin L. Nichol, M.D., M.P.H., M.B.A., about strategies for communicating with adult patients about vaccinations. Nichol is a professor of Medicine at the University of Minnesota and chief of Medicine at the V.A. Medical Center in Minneapolis, Nichol has more than 100 publications under her belt related to adult vaccines. She also is a member of the National Coalition for Adult Immunization Advisory Committee, and is an ex officio member of the U.S. Department of Veterans Affairs Advisory Committee on Immunization Practices. Be sure to check out the February issue to read Nichol’s insights on how to reach adult patients who may be reticent to receive vaccines or may not know they need them.   The timeliness of this issue hit home when, shortly after planning the February issue, I flipped through a recent issue of Discover magazine. Appropriately enough, I was sitting in a doctor’s office waiting room at the time.  The magazine was ranking what they considered the 10 most significant science stories of the decade. Their pick for the most significant science story was headlined “Vaccine Paranoia.”   Resistant to vaccination has been growing in the United States for a variety of reasons including fear of side effects, the growing popularity of “natural” or alternative remedies, and the mistaken belief among many adults that vaccines are just for children.   Ironically, part of the reason that some Americans do not realize the importance of vaccination may be the fact that vaccines have been so effective in preventing illnesses.  The United States is no longer plagued with deadly epidemics of polio, measles, and small pox. Consequently, Americans are no longer terrified of contracting these illnesses.   A few examples:  
		
		
				
						
								• According to the Centers for Disease Control and Prevention as recently as 1989-1991 more than 55,000 measles cases occurred in the United States, causing 120 deaths.  Thanks to vaccinations, measles no longer circulates in the United States or anywhere in the Western hemisphere. 
						
				
				
						
								
								 
				
		
		
				
						
								• As of 20 years ago, nearly 20,000 Americans contracted invasive bacterial meningitis every year. In 2010, a physician training to become a pediatrician will probably never see a case of that illness during the course of his or her career, thanks to vaccination. 
						
				
				
						
								
								 
				
		
		
				
						
								• A rubella virus epidemic in the 1960s resulted in more than 20,000 infants being born deaf, blind, afflicted with heart disease, developmental disabilities, or other birth defects. In 2010, rubella is no longer endemic to the United States. 
						
				
				
						
								
								An unfortunate side effect to this success: Without these epidemics, the vaccinations that make this safety possible no longer seem like such a priority. This kind of complacency has the potential to undo historic public health successes.   I’d like to hear from you. Do you talk to your adult patients about vaccines? How do you broach the subject? How do they respond?   Note: Also in February look to a piece authored by Seth Baker M.D., M.P.H., Michael Darin, M.D., and Omar Lateef, D.O., physicians from Rush University Medical Center in Chicago, about the importance of taking a multidisciplinary approach to morbidity and mortality conferences.
								 
				
		
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					<pubDate>Tue, 19 Jan 2010 17:23:19 GMT</pubDate>
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					<title>Happy New Year, readers!</title> 
					<link>http://www.jcrinc.com/Blog/2010/1/6/Happy-New-Year-readers/</link> 
					<description><![CDATA[
		
				This time of year is one of reflection and re-evaluation for many people. This reflection often culminates in a new year’s resolution.  Many of these resolutions deal with health: losing weight, eating healthier, quitting smoking, getting more exercise, getting regular medical and dental check-ups and so forth.     Health care providers also make resolutions, and being who you are, you are concerned not only with your own health but your patients’ health as well. Now, everyone knows most new year’s resolutions fizzle out by March. Indeed, the very concept of these resolutions has become almost a punch line, or a mere marketing tool by which empty health clubs entice wayward members to send in their renewal checks. (“Because you WILL go this year… It’s 2010! Blah. Blah. Blah.”)   So let’s forget these cultural suits and trappings and boil the term down to its core:  resolve.  According to Webster’s, resolve means “to reach a firm decision about” and “fixity of purpose.”  The word resolve invokes a sense of commitment and determination.   I propose that we in the patient safety community collectively resolve to recommit ourselves to preserving and improving the safety and well being of all patients.   This commitment can manifest itself in as many ways as there are providers and patients. It could mean doing your part to ensure your organization complies with National Patient Safety Goals.  For leaders, it could involve a re-examination of your entire organization’s safety culture. For a frontline provider, it could mean cultivating and expressing renewed empathy for the human beings who are your patients.   For me, this resolution means finding ways to enhance the patient safety information we send to you every month. It means creating a communal space in this blog where you can express your views and participate in discussion of all things patient safety. It means meeting and talking with you when opportunities present themselves at JCR conferences and other events. It means inviting professionals in the field to submit articles and case studies and to share their experiences with their colleagues nationwide.   Who’s with me?  In what ways will you personally commit to improving patient safety this year? 
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					<pubDate>Wed, 06 Jan 2010 16:54:10 GMT</pubDate>
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					<title>Remember: National Patient Safety Goals Become Effective January 1!</title> 
					<link>http://www.jcrinc.com/Blog/2009/12/17/Remember-National-Patient-Safety-Goals-Become-Effective-January-1/</link> 
					<description><![CDATA[
		
				Year’s end is approaching and in a few short weeks the 2010 National Patient Safety Goals will become effective!  Remember that if you have questions or concerns about how to interpret the goals, you can contact The Joint Commission’s Standards Interpretation Group (SIG) for help. Contact SIG at 630-792-5900, 8:30 a.m. - 5:00 p.m. (Central time).    You can also contact SIG by using this online standards question form.   During 2009 The Joint Commission undertook a process of reviewing the goals for enhanced clarity and to better tailor them to the characteristics of specific types of accredited organizations.  The entire November 2009 issue of Perspectives on Patient Safety covered the 2010 goals and the review and revision process. Subscribers may access that back issue online by clicking here.   And of course, look for more strategies and solutions in 2010 for complying with the National Patient Safety Goals and other patient safety issues in Perspectives on Patient Safety.
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					<pubDate>Fri, 18 Dec 2009 02:24:55 GMT</pubDate>
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					<title>JCR’s 2009-2010 Flu Vaccination Challenge Gaining Momentum </title> 
					<link>http://www.jcrinc.com/Blog/2009/12/10/JCR’s-2009-2010-Flu-Vaccination-Challenge-Gaining-Momentum/</link> 
					<description><![CDATA[
		Flu season is now in full bloom and I hope all our readers are weathering the storm, both in their roles as health care providers and as potential patients!    Of course, the most effective way to ensure that you, your patients, and your families are safe from influenza is to be vaccinated. Joint Commission standards require accredited hospitals, critical access hospitals, and long term care organizations to offer the flu vaccine annually on site to staff and licensed independent practitioners. Joint Commission Resources has been encouraging health care workers to get vaccinated through its Flu Vaccination Challenge. This is the challenge’s second year. In the 2008/2009 flu season, the challenge helped vaccinate nearly 1.1 million health care workers in more than 1,700 participating organizations. More than 78 percent of the participating organizations met the challenge’s target, which was a vaccination rate of 43 percent or higher.   For the 2009/2010 season, the challenge is even more ambitious. Health care organizations are being asked to achieve vaccination rates of 65, 75, or 90 percent, based on the organization’s rate the previous year.  Be sure to visit the Flu Vaccination Challenge Web site for more details, including a document discussing myths and facts about influenza vaccination.   The Flu Vaccination Challenge is designed to improve vaccination rates for the seasonal influenza season. This year, matters have been complicated by the emergence of the H1N1 strain. Millions of people have been affected, with cases running the spectrum from very mild to fatal. Health care workers are on the list of high-risk groups that are a priority for H1N1 vaccination. Check with your local health department about the availability of the H1N1 vaccine in your area.   Another way JCR is helping organizations raise awareness about influenza vaccination is by offering new buttons that read, “I got my flu shot. Did you?”   Organizations could distribute these buttons to employees who become vaccinated, as a fun incentive to doing the right thing for themselves and virtually everyone with whom they come into contact during the course of the day. 
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					<pubDate>Thu, 10 Dec 2009 18:15:31 GMT</pubDate>
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					<title>Joint Commission Launches Center for Transforming Healthcare</title> 
					<link>http://www.jcrinc.com/Blog/2009/9/10/Joint-Commission-Launches-Center-for-Transforming-Healthcare/</link> 
					<description><![CDATA[
		
				Most health care organizations have come to recognize that medical errors are most often the result of a breakdown in a system.  In many cases, several system failures contribute to a single incident of patient harm. Along the way in those cases, multiple opportunities are missed for someone to notice the breakdown and prevent the error.   To address patient safety problems at their root, The Joint Commission has initiated a major collaborative effort with a number of hospitals and health systems throughout the United States. This effort, called The Center for Transforming Healthcare, is setting out to identify the system causes of medical errors and find workable solutions. Its ultimate mission is to transform the health care system into a high-reliability industry. As a first step, the center’s first task will address the issue of hand hygiene. This effort could help prevent many of the health care–associated infections that cause nearly 100,000 deaths annually in the United States. Future projects will address breakdowns in patient handoffs, other aspects of infection prevention and control, patient identification errors, and medication errors.   To date, eight leading hospitals and health systems have pledged to work to find systemic solutions to this complex problem, using Robust Process Improvement™ (RPI) tools. RPI is a set of strategies, tools, methods, and training programs adopted by The Joint Commission and Joint Commission Resources for improving business processes. The RPI tool kit includes methodologies that have been proven effective in many sectors, including health care, and have been used to achieve dramatic improvements in quality and in cost. These methodologies include Lean Six Sigma, Change Acceleration Process (CAP), and Work Out.   Click here for more information on the Center and its projects.   I look forward to sharing more information with you about the Center’s work as it becomes available. In the meantime, I would like to hear from you. What are your suggestions for improving hand hygiene? Why does this continue to be a problem in our health care system? 
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					<pubDate>Thu, 10 Sep 2009 21:04:41 GMT</pubDate>
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					<title>Get Your Flu Shot!</title> 
					<link>http://www.jcrinc.com/Blog/2009/8/25/Get-Your-Flu-Shot/</link> 
					<description><![CDATA[
		Autumn is approaching. While many in the United States are bracing themselves for chilly winds and leaf raking, some are bracing themselves for what many experts say will be a particularly nasty flu season.   Part of the concern over this year’s influenza season is related to 2008-2009 H1N1 virus. H1N1 wrecked havoc in some locales, leading to closings of schools and businesses. To date, more than 182,000 cases have been reported to the World Health Organization (WHO), resulting in 1,799 deaths. WHO on August 17 issued a call to action outlining its recommendations for addressing an outbreak.   We are currently preparing the October issue of Perspectives on Patient Safety to go to press. The issue includes an article about the special concerns for pregnant women who become infected with H1N1, and a feature based on interviews with a number of health care and public health experts analyzing what we learned from the nation’s response to the H1N1 outbreak earlier this year.   Marie-Paule Kieny, director of the WHO Initiative for Vaccine Research, reported in an August 6 “virtual press briefing” that development of a H1N1 vaccine is underway and on schedule. As of mid-August, clinical trials were underway. WHO and the Centers for Disease Control and Prevention recommend vaccinations for influenza for health care workers. Also, Joint Commission standards require hospitals and long term care organizations to offer influenza vaccinations to staff and licensed independent practitioners.   During the last flu season, The Joint Commission and Joint Commission Resources (JCR) offer key information to health care organizations about the H1N1 virus.  Recently, The Joint Commission released the downloadable monograph “Providing a Safer Environment for Health Care Personnel and Patients through Influenza Vaccination: Strategies from Research and Practice,” to help organizations ensure their personnel receive critical vaccinations.  Joint Commission Resources launched the 2009-2010 Vaccination Challenge, which offers recognition to organizations that achieve specific vaccination rate benchmarks. To date, more than 1.1 million health care workers were vaccinated in conjunction with the program.   As you gather information about the H1N1 virus, I recommended the blogs posted by two of my JCR colleagues, the editors of The Source and Benchmark newsletters. (View those blogs here and here.)   I would be very interested in hearing how your organizations and communities responded to the outbreak, and how are you preparing for a second round in the fight against H1N1. Please share your experience in a comment. 
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					<pubDate>Tue, 25 Aug 2009 19:49:47 GMT</pubDate>
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					<title>Speak Up!</title> 
					<link>http://www.jcrinc.com/Blog/2009/8/6/Speak-Up/</link> 
					<description><![CDATA[
		Greetings readers!
		  Let me suggest to you a new and interesting resource that The Joint Commission is offering to your patients through its Speak Up!™ program. The newest offering from the Speak Up! Campaign is designed to help parents made better decisions regarding their children’s health care.   The new brochure is available in both English and Spanish.   The new brochure offers parents critical information that can make a real difference in their child’s health care, such as a list of symptoms that mean the parent should seek immediate medical attention for the child, preparing for your child’s next doctor visit, important questions to ask your physician, and medication safety.   The Joint Commission launched the Speak Up campaign in 2002, in collaboration with the Centers for Medicare and Medicaid Services. The nationwide campaign is designed to help patients become actively involved in their own care, by being better informed and empowered to ask questions.  Topics of Speak Up campaign brochures include: 
• Help Prevent Errors in Your Care • Help Avoid Mistakes in Your Surgery 
• Information for Living Organ Donors 
• Five Things You Can Do to Prevent Infection 
• Help Avoid Mistakes With Your Medicines 
• What You Should Know About Research Studies  
• Planning Your Follow-up Care 
• Help Prevent Medical Test Mistakes 
• Know Your Rights 
• Understanding Your Doctors and Other Caregivers 
• What You Should Know About Pain Management  
All Speak Up materials are available here. I hope you are able to use these valuable resources. Let me ask you, is patient involvement a priority in your organization? How do you help your patients feel empowered and get involved?]]></description> 
					<pubDate>Thu, 06 Aug 2009 19:52:49 GMT</pubDate>
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					<title>New MDRO Resource</title> 
					<link>http://www.jcrinc.com/Blog/2009/7/8/New-MDRO-Resource/</link> 
					<description><![CDATA[Joint Commission Resources is offering a new free resource to help combat a serious patient safety threat: multidrug–resistant organisms (MDROs).   The new toolkit What Every Health Care Executive Should Know: The Cost of Antibiotic Resistance, is available for free download here.   The Joint Commission’s National Patient Safety Goal 07.03.01 requires accredited organizations to implement best practices to facilitate the prevention of multiple drug resistant organisms.  This toolkit can help organizations elucidate the problem of antibiotic resistance and identify the best practices that are suitable for their organization and patients.   Does anybody have any stories about how they’re combating MDROs in their organization? I’d love to hear from you and I’m sure other readers of this blog and Patient Safety would enjoy hearing from you as well.]]></description> 
					<pubDate>Wed, 08 Jul 2009 20:29:27 GMT</pubDate>
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					<title>Stop on by!</title> 
					<link>http://www.jcrinc.com/Blog/2009/6/18/Stop-on-by/</link> 
					<description><![CDATA[
		I am interested in knowing which of our readers will be attending The Joint Commission Annual Conference in September. I plan to be there all three days, September 14–16, at the JCR Publications booth and in the sessions, and I hope to meet some of you face to face. 
		The conference has an exciting line-up of speakers this year, including Joint Commission President Mark Chassin, M.D.; Robert Wachter, M.D., from the University of California-San Francisco; and Barbara A. Glanz, C.S.P.; as well as a host of other health care leaders and experts. Click here for more information about the conference. If you have any questions about the conference itself, my colleague Susan Murray (smurray@jcrinc.com) will be glad to answer them. 
		If you are coming, please make a point to stop by the booth and say, “hello,” and offer any feedback you have about the newsletter, its look, and its content.  And if you happen to see a book you like, well, we offer a 20% discount at the conference. (I’ll post a reminder shortly before the conference.) Hope to see you there!
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					<pubDate>Fri, 19 Jun 2009 00:16:01 GMT</pubDate>
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					<title>The Cost of Cutting Corners: A Pound of Flesh? </title> 
					<link>http://www.jcrinc.com/Blog/2009/6/17/The-Cost-of-Cutting-Corners-A-Pound-of-Flesh/</link> 
					<description><![CDATA[In a past life I did a great deal of reporting on occupational safety and transportation safety. During that time it became apparent to me that many people viewed safety measures as an expense, draining money away from their personal or organizational bottom lines.   What the data revealed, time after time, was that investing in safety was actually a cost saving measure. The cost of injuries and illness in the workplace and on the roadways clearly outstrips the cost of common sense measures to prevent them.   I suspect that the same is true of medical errors—that the cost of treating iatrogenic injuries and illnesses is greater than the cost of prevention measures. One indicator of this is the Centers for Medicare & Medicaid Services decision to not reimburse organizations for care resulting from “Never Events” (as the National Quality Forum’s serious reportable events are often called.)   In Perspectives on Patient Safety’s August cover story, health care leaders from across the country weigh in on how the recent economic downturn has affected patient safety in their organizations.  I think now more than ever the argument that safety is an investment that will save money as well as lives needs to be made. As far as I have seen however, hard data on this question is scarce.    If any readers have seen some data or studies on this, or have a story they would like to share about how financial hard times have affected patient safety, please comment or shoot me an email at patientsafety@jcrinc.com.]]></description> 
					<pubDate>Wed, 17 Jun 2009 17:23:00 GMT</pubDate>
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					<title>Organizations Share Their Stories</title> 
					<link>http://www.jcrinc.com/Blog/2009/6/3/Organizations-Share-Their-Stories/</link> 
					<description><![CDATA[We are wrapping up the July issue of Joint Commission Perspectives on Patient Safety in the next few days. I am excited about this issue because it includes two case studies of exemplary organizations that have made great strides in improving the safety of their patients.    •   Baptist Health Home Health Network is a multisite home health and hospice agency that serves 800 patients in the state of Arkansas.  The organization has undertaken a program to help patients who suffer from chronic illnesses to better self-manage their conditions. This program helped Baptist Health increase patient satisfaction, reduce rehospitalization, improve clinical outcomes, and decrease staff turnover.   •   Cancer Treatment Centers of America, a four-hospital system caring for patients with all types of cancer. The organization has learned that many problems common to health care organizations, such as cost control and maintaining patient volume, can be addressed through a patient-centered care focus. The organization has not experienced any staffing shortages, and in fact has a waiting list for new employees; it also does not suffer any patient lawsuits because patients do not feel a lack of control or options. Anecdotally, the organization’s experience suggests that a patient-centered care model may actually help improve a person’s physical health by reducing stress.   These organizations should be commended not only for their contributions to patient safety, but also for their willingness to share their stories with the health care community. This openness demonstrates a commitment to improving the safety of not only their patients, but all patients. If your organization has a story to share, or if you would like to recommend an organization to be featured in a case study, please let me know at patientsafety@jcrinc.com.]]></description> 
					<pubDate>Wed, 03 Jun 2009 22:41:14 GMT</pubDate>
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					<title>Celebrate National Nurses Week!</title> 
					<link>http://www.jcrinc.com/Blog/2009/5/12/Celebrate-National-Nurses-Week/</link> 
					<description><![CDATA[
		This week represents the nation’s annual “shout out” to the backbone of our health care system:  Nurses.    National Nurses Week is celebrated each year from May 6 (National Nurses Day) to May 12 (Florence Nightingale’s birthday). Sponsored by the American Nurses Association, the theme for this year’s observance is “Nurses: Building a Healthy America.” The theme focuses on the issues of national health care policy reform, improving access to health care, nursing staff shortages, and working conditions for nurses. National Nurses Week is also intended to educate the public about the multifaceted roles of America’s 2.9 million registered nurses, including bedside patient care, medical research, education, and public advocacy. The contribution of nurses to our collective well being is truly incalculable. So, gentle readers, keep this in mind as you move about your organizations this week, and all the year round.  Should you happen upon a nurse, take a moment and deliver a sincere, “Thank you.”]]></description> 
					<pubDate>Tue, 12 May 2009 17:35:24 GMT</pubDate>
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					<title>Perspectives on Patient Safety Gets a New Look!</title> 
					<link>http://www.jcrinc.com/Blog/2009/5/8/Patient-Safety-Gets-a-New-Look-1/</link> 
					<description><![CDATA[
		
				
						
						
						“And now for something completely different.”   Your friendly neighborhood Perspectives on Patient Safety staff are pleased to unveil the newsletter’s new look. Designed by our trusty project manager, Bridget Chambers, we think the new design not only looks smashing, but also enhances readability. Check out the new design in your June issue, which is heading your way soon.   Of course, we are not substituting style for content. To quote the Bard, we “have that within which passeth show.” The issue has a great line up of articles. The cover story deals with the troubling issue of wrong site, wrong side, wrong patient surgery, which continues to be one of the leading causes of sentinel events reported to The Joint Commission. The article walks you through the final verification process designed to prevent such grievous errors, as required by The Joint Commission’s Universal Protocol and NPSG.01.02.01.   Also in June, the “Patient Safety Pulse” department brings readers up-to-date on resources The Joint Commission and Joint Commission Resources are making available to help organizations address the emerging H1N1 influenza strain and other potential pandemic flu viruses. Even if this illness does not become a pandemic on the scale of 1918’s Spanish Flu, for example, health care organizations should keep the threat of pandemic on their radar and make sure they have plans in place to address that challenge.   Another article examines deep-vein thrombosis and pulmonary embolism during hip and knee replacement surgery. These adverse events are considered serious reportable events, or “never events,” by the National Quality Forum and the Centers for Medicare & Medicaid Services.   The final article elucidates key principles of communication for health care providers, offering tips and strategies providers can use to improve communication with patients, as well as their colleagues. The special guest authors for this piece Joan McGrath, Myrna Pedersen, and William Rutenberg, M.D. These communication consultants and their firm have worked with health care luminaries such as Michael F. Roizen, M.D., and Mehmet C. Oz, M.D., the bestselling authors who wrote 
				
						YOU The Smart Patient: An Insider’s Handbook for Getting the Best Treatment. [ 
				
						http://www.jcrinc.com/YOU-The-Smart-Patient/
				
				]
		
		 
		
				
						
				
		
		
		
				 
		
]]></description> 
					<pubDate>Fri, 08 May 2009 23:20:08 GMT</pubDate>
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					<title> So .. how can I help you?</title> 
					<link>http://www.jcrinc.com/Blog/2009/4/9/So-how-can-I-help-you/</link> 
					<description><![CDATA[
		Every morning … the same ritual.   I wake up, brush my teeth, don my wizard’s cap and stroll to the deepest dungeon where I gaze into my Pool of Immortal Mystery, which shows me all pressing patient safety issues of the day.   OK, so it’s more like seven cups of coffee, a stack of media reports, checking in with the editorial advisory board, some tea, reading medical journals and press releases, sentinel event statistics, safety goal non-compliance rates, and a bagel. But you see what I mean.   The articles that appear in Perspectives on Patient Safety originate in a number of ways. A lot of it is my own research, or tips from editorial advisory board members, JCR consultants, reporters pitching story ideas, or breaking news.   Starting now, I want to add to that list. I would like you, the readers, to tell me what you want to read about. What patient safety issues keep you up at night? What challenges are your organizations struggling with? How can Patient Safety help you meet those challenges? What types of articles do you find most helpful?   Please post a comment and let me know what you would like to see covered in future issues of Patient Safety.  ]]></description> 
					<pubDate>Thu, 09 Apr 2009 22:36:14 GMT</pubDate>
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					<title>The Score on Med Rec.</title> 
					<link>http://www.jcrinc.com/Blog/2009/3/25/The-Score-on-Med-Rec/</link> 
					<description><![CDATA[
		
				Greetings!
				
		  The word is on the street:  For the remainder of 2009, Joint Commission surveyors will not be scoring National Patient Safety Goal 8, which addresses medication reconciliation.   During 2009, The Joint Commission is reviewing the goal language with a fine-tooth comb to ensure maximum clarity; they are consulting health care organizations, physicians, pharmacists, nurses, surveyors, and other stakeholders to ensure that the revised Goal 8 is clear, effective, and in tune with what health care organizations and their patients need.   However, organizations still have one important reason to keep doing med rec—their patients. If an organization is not reconciling patient medications, then that organization is gambling with their patients’ lives and well being. Medication errors and adverse reactions can be fatal to patients, or cause other serious harm.   Even without scoring Goal 8, The Joint Commission will continue to help organizations refine their medication reconciliation practices through 2009. Surveyors will evaluate medication reconciliation during on-site surveys, discuss opportunities for improvement, and collect information about organizations’ medication reconciliation processes. The difference this year is that the surveyor’s findings will not be factored into organizations’ accreditation decisions, nor will Goal 8 generate Requirements for Improvement or appear in the accreditation report.   The Joint Commission will unveil a revised Goal 8 at a later date, and scoring is expected to resume when that revised language becomes effective.   Stay safe,   Jim Parker]]></description> 
					<pubDate>Wed, 25 Mar 2009 16:50:08 GMT</pubDate>
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					<title>The Potato Incident: Lessons Learned</title> 
					<link>http://www.jcrinc.com/Blog/2009/3/17/The-Potato-Incident-Lessons-Learned/</link> 
					<description><![CDATA[
		
				
						Greetings!
						  A recent experience I had with a health care organization got me thinking about infection control, leadership, patient empowerment, and the importance of a collaborative work environment.   It all began with a potato.   The humble tuber’s time had come.  My family and I were going to eat it.   But this potato would not go gently into that good night.  In the act of peeling this potato, a hearty portion of one of my fingertips was peeled off as well.  (We wound up not eating the potato.)   As the wound continued to bleed the following morning, I let my wife talk me into going to a local urgent care center to have it looked at.  After a lengthy wait, I went back to the exam room and got all bandaged up.  The physician put a piece of mesh over the wound to help stop the bleeding, but said I should return the next day to have the mesh removed because it could interfere with healing.    My experience the next day is what got me thinking. I was seen by a different physician that day, as is often the case in urgent care.  That wasn’t a problem. The problem was that I had a great deal of difficulty getting the staff in the office that day to understand what it was that the staff from the previous day had done.  The nurse checked the records from the previous day, but that shed no light on the matter. After I spoke to three staff members, including the physician, I was able to make clear that I needed the mesh removed from the wound.    The physician decided the best method would be to soak the affected area in warm water. This was fine by me. After about 20 minutes, a nurse came back and perceived that the mesh was breaking apart, and although some of it was coming off , some of it was sticking to the wound.  The physician returned and decided to remove the sticky bits with tweezers.    The physician picked up his tweezers, took my hand, and leaned in to start picking, when someone spoke:   “Doctor, shouldn’t you put on gloves?”    It was the nurse. She couldn’t have been older than her mid-twenties and had mentioned at one point that she was new to the organization. The physician, meanwhile, was advanced in years and was clearly the more experienced of the two health care providers in the room.   The physician paused and—without looking at the nurse—responded that he didn’t think he needed gloves. The nurse clammed up.      Luckily, the patient in this case (me) had some familiarity with Joint Commission standards and requirements, including the following:
				• National Patient Safety Goal 7: Reduce the risk of health care–associated infections. 

				• National Patient Safety Goal 13: Encourage the active involvement of patients and their families in the patient’s own care as a patient safety strategy. 
		
		I am also familiar with The Joint Commission’s Speak Up!™ program, which among other things encourages patients to ask questions or raise concerns as they arise in the course of their care. Click here for more information. So … I spoke up. I told the physician that I preferred that he wear gloves, especially because I did not see him wash his hands after he came in to the exam room.  I also asked him to wash up before proceeding.  As anyone familiar with World Health Organization (WHO) hand hygiene guidelines knows, gloves are not a substitute for hand hygiene.  (Patient Safety subscribers can read an article comparing the WHO guidelines to the Centers for Disease Control and Prevention Guidelines by clicking here:  NPSG.07.01.01 requires organizations to follow at least one of those two organizations’ guidelines.)   The physician washed his hands and put on gloves.   These are my thoughts on the whole affair: 1. Hand hygiene. Hand hygiene remains a problematic issue in health care organizations. Several accreditation programs continue to see double-digit noncompliance rates with NPSG.07.01.01.  Organizations need to take pains to ensure that staff wash their hands to protect themselves and patients from infection. Look for new articles Perspectives on Patient Safety in 2009 that address hand hygiene and other key infection prevention and control practices. 2. Leadership. Leadership. Leadership.  Leadership comes in many forms. When The Joint Commission uses the term in its standards, it is usually referring to organizational leadership, such as the CEO, the organization’s board, and so forth. However, there is what I will call “the leadership in the room” and “leadership in practice.”   In the above scenario, the leader in the room was the physician. The CEO and board members were not there, and the physician was the medical authority in the room. However, the leader in practice was the nurse. Why? Because she took the initiative to speak up when the proper procedures were not being followed. She, in essence, took the lead by trying to steer the process in the right direction. In recent years, a plethora of patient safety leaders and experts have advocated for clinicians to adopt a collaborative work environment, in which the team is focused on the patient and on adhering to best practices, in which the voice of every team member is respectfully heard without regard to organizational hierarchy or, to be frank, an individual’s ego. While this idea is starting to gain ground in health care, the concept is not new. The Chinese philosopher Lao Tzu in the 6th Century B.C. wrote:  "To lead people, walk beside them ... As for the best leaders, the people do not notice their existence … When the best leader's work is done the people say, 'We did it ourselves!'”3. Empower patients.  When experts talk about providing health care in a collaborative work environment, it’s important to note that this includes the patient. Patients have the right and responsibility to take an active role in their own care and to ask questions when they don’t understand or agree with the treatment they are receiving. Organizations must remember to not only be receptive to patients’ questions and comments, but to encourage patients to ask questions. There is no harm in saying to a new patient up front: “You have the right to ask questions and voice your concerns about your care.” Many patients are afraid to question their health care providers; others don’t even realize that have that power. It is incumbent upon health care providers to help change these false and dangerous perceptions.Be safe! Jim Parker ]]></description> 
					<pubDate>Tue, 17 Mar 2009 22:20:05 GMT</pubDate>
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					<title>Patient Safety Week Blogs: Day 5, Health Care Worker Fatigue</title> 
					<link>http://www.jcrinc.com/Blog/2009/3/9/Patient-Safety-Week-Blogs-Day-5-Health-Care-Worker-Fatigue/</link> 
					<description><![CDATA[
		
		
		
		
				
						Greetings!
						
				
				
		
		
				
						Happy National Patient Safety Awareness Week! I'll be writing a new blog every day of this week, discussing a different patient safety topic. The fifth topic in this series is "Health Care Worker Fatigue."
				
				
		
		
				
						Listen carefully, clinicians, because I am only going to say this once:  My job is much less stressful than yours. If I come to work tired, worn out, stressed out, or a bit under the weather, it’s unlikely that anyone will get hurt. Sure, I might make a mistake, but chances are I will have a chance to correct it before the public sees it. 
		
		
				
						For health care providers, matters are different. An “off day” can have a long-term impact on a patient’s life and health. Fatigue poses a serious threat to patient safety and impairs human performance. For example, according to the National Highway Traffic Safety Administration, driving a motor vehicle after going a day without sleep has virtually the same effect as driving with a blood alcohol content level of 0.1%, well above the legal limit. These effects include the following:
				
				
						• Slower reaction time• Reduced vigilance• Deficits in information processing • Short-term memory impairment
				
				
						It would be incredibly unethical for a health care provider to work while intoxicated, right? Why, then, should organizations not address worker fatigue, which brings similar impairments of perception and judgment?  
				
						Joint Commission standards require organizations to identify conditions and practices that may contribute to health care worker fatigue, implement processes to identify fatigue that poses a threat to patient safety, and take action to mitigate the risks.
				
				
		
		
				Some clinicians have expressed concern that addressing these risks could exacerbate other hazards. For example, they worry that limiting work hours could result in larger numbers of patient handoffs and create more interruptions in the continuity of care by the providers who are most familiar with a particular patient.  However, a number of studies have shown that work-hour limits have no ill effects on patient outcomes. (Patient Safety subscribers can click here to view a 2007 Patient Safety article on minimizing health care worker fatigue.)
				
		
		
				
						Consider the following steps organizations can take to mitigate the risk of worker fatigue:
				
		
		
				
						• Encouraging employees to come to work well rested, as much as possible• Educating employees about how to recognize their own fatigue and acknowledge the limits of human memory and performance• Encouraging employees to ask team members for help when they are experiencing the effects of fatigue• Ensuring that employees pay special attention to following policies and procedures for patient handoffs
				
		
		
				
						With that, I open the forum for discussion. How do your organizations address this issue? Have you been involved or witnessed a situation in which worker fatigue affected patient care? 
		
		
				Stay safe,Jim Parker
		
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					<pubDate>Mon, 09 Mar 2009 23:18:00 GMT</pubDate>
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					<title>Patient Safety Week Blogs: Day 4, Patient Involvement</title> 
					<link>http://www.jcrinc.com/Blog/2009/3/9/Patient-Safety-Week-Blogs-Day-4-Patient-Involvement/</link> 
					<description><![CDATA[
		
		
		Greetings!Happy National Patient Safety Awareness Week! I’ll be writing a new blog every day of this week, discussing a different patient safety topic. The fourth topic in this series is “Involving Patients in Their Own Care.”As I pondered how I should approach the subject of patients’ involvement in their own care, I had a visitor. A curly-headed friend of mine popped in and announced she was going to have her curls straightened.  However, she was having a frustrating time making an appointment with a hairdresser. She wanted to go to a place that would listen to her and respect what she wanted done, and she refused to go anywhere that would not meet with her in advance of the actual hair straightening. My sister had a similar experience when looking for someone to remodel her kitchen. “No one is touching my cabinets until I am sure they understand exactly what I want them to do,” she said.This is a pretty common phenomenon, a basic element of customer service that we consumers have come to expect.  If we’re paying someone to provide a service, we expect them to listen to us and to respect our wishes. This has become integral to our understanding of “quality.”  We want to be involved in the decisions that will affect the services we are paying for, as well as the end results. If we feel shut out or unheard, we don’t feel like we’re getting quality service. The two examples I gave above illustrate the wide range of services to which we apply that principle. It seems ironic, then, that when it comes to health care, many consumers are willing to just take their providers’ word for it. Many report feeling too intimidated to even ask questions about the care they are receiving, even though the stakes in health care are much higher than with other services, such as home repair or hair styles. This reality is something that many in the patient safety movement are working to change. The Joint Commission has made patient involvement a priority by including the issue in its National Patient Safety Goals.  NPSG.13.01.01 requires organizations to “encourage the active involvement of patients and their families in their own care.” The rationale for this goal states that “communication with patients and families about all aspects of their care, treatment, or services is an important characteristic of a culture of safety.”  Note: That communication has to be two-way; it’s not just a matter of providers giving information to patients. Providers must try to understand what the patient is experiencing; this is essential to providing quality care. When patients and families feel empowered—when they are treated like respected partners in the care team—they are more likely to comply with treatment and have better health outcomes. Some ways that organizations can empower patients include the following:•   Creating an supporting a culture that allows patients to feel comfortable asking questions and reporting concerns about their own care •   Letting patients know that it’s okay to ask caregivers if they have washed their hands (The Wall Street Journal recently published a column about empowering patients to ask questions, which quoted Joint Commission President Mark Chassin, M.D.) •   Taking the time to explain your organization’s safety procedures to patients•   Prompting patients with open-ended, specific questions about their health and medications•   Providing a way for patients to report errors anonymously and encouraging them to do soI’d be interested to know what you see at your organizations.  Do your patients ask questions? How does your organization empower patients? How can your organization improve is this area?Stay safe,Jim Parker]]></description> 
					<pubDate>Mon, 09 Mar 2009 22:11:16 GMT</pubDate>
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					<title>Patient Safety Week Blogs: Day 3, Handoff Communications</title> 
					<link>http://www.jcrinc.com/Blog/2009/3/9/Patient-Safety-Week-Blogs-Day-3-Handoff-Communications/</link> 
					<description><![CDATA[
		
		
		
				
		
		
				
						
								Greetings!
								
								
						
				
		
		
				
						
								Happy National Patient Safety Awareness Week! I'll be writing a new blog every day of this week, discussing a different patient safety topic. The third topic in this series is "Handoff Communications." 
				
		
		
				Sometimes the best way for health care providers to take care of a patient is simply to talk to them.
		
		
				Last year in addition to editing Perspectives on Patient Safety, I edited a book called Handoff Communications: Toolkit for Implementing the National Patient Safety Goal. This project involved 9 months of looking in depth at patient handoffs, which have been a part of the Joint Commission’s National Patient Safety Goals since 2006. (NPSG.02.05.01 requires organizations to implement a standardized approach to handoff communications, including an opportunity to ask and respond to questions.) 
		
		
				Patient handoffs are a serious issue. According to The Joint Commission’s Sentinel Event Database, communications breakdowns were the root cause of more than 65% of 3,811 sentinel events. Of those communications breakdowns, 75% resulted in the patient’s death.  More than half of these breakdowns were associated with patient handoffs. 
		
		
				The handoff’s objective is to provide accurate information about care, treatment, or services that a patient has received as well as the patient’s current condition and any recent or anticipated changes in the patient’s condition. Some examples of handoffs include:
		
		
				
				
		
		
				
						•   Nursing shift changes•   Physicians transferring complete responsibility for a patient•   Physicians transferring on-call responsibility•   Temporary responsibility for staff leaving the unit for a short time•   Anesthesiologist’s report to the postanesthesia recovery room nurse•   Nurse and physician handoff from the emergency department to inpatient units•   Different hospitals, nursing homes, home health care, and other types of organizations •   Laboratory and radiology results sent to physician offices
				
		
		
				
				
		
		
				Other examples can be unique to certain settings, such as transitioning patients between clinical staff and program staff in behavioral health care organizations. 
		
		
				In all of the above situations (and in any other scenario in which one provider is handing over responsibility for a patient to another), accuracy of information is paramount. The handoff process must also be interactive, meaning it should include an opportunity to ask and respond to questions.  This “question and answer session” should be a formal process that takes place during all handoffs. A provider should not simply pause a moment and assume a colleague knows that is the time for questions.
		
		
				Remember that the purpose of communication is mutual understanding. Avoid vague or potentially confusing terminology. Choose your words carefully to ensure clarity, and make sure you have correctly understood the information you have been given and your colleague understands information you have been given.  Interruptions should be kept to a minimum, and providers should focus their attention on the information being exchanged. If there is a time and a place for multitasking, it is not during a patient handoff. Also remember, there is no place for ego in health care. Do not be afraid to ask questions, not matter how simple they may appear. 
		
		
				The handoff communication should not end until both parties feel confident that the exchanged information has been understood correctly by everyone involved. Don’t take this for granted. Institute a “repeat” or “read-back” procedure in which the recipient of the information repeats the information to ensure accuracy.   Also helpful is the use of a written checklist, questionnaire, or tool to ensure you have covered all the bases.
		
		
				How does your organization ensure successful, safe handoffs? 
Stay safe, 
		
		
		
		
		
		
		
		
		
		
		
		
				Jim Parker
		
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					<pubDate>Mon, 09 Mar 2009 22:04:40 GMT</pubDate>
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					<title>Patient Safety Week Blogs: Day 2, Hand Hygiene</title> 
					<link>http://www.jcrinc.com/Blog/2009/3/9/Patient-Safety-Week-Blogs-Day-2-Hand-Hygiene/</link> 
					<description><![CDATA[
		
		
		
		
				
						Greetings!
						
				
				
				
						
								Happy National Patient Safety Awareness Week! I’ll be writing a new blog every day of this week, discussing a different patient safety topic. The second topic in this series is “Hand Hygiene.”
								
								
						
				
		
		
				
						
								Attack of the Helping Hand is a 1981 short film starring horror film director Sam Raimi. This movie is so hopelessly obscure that even Google can provide no synopsis. While I would be willing to bet that the film has nothing whatsoever to do with health care, the title is a great characterization of what happens when a health care worker does not exercise proper hand hygiene. The “helping hand” becomes a threat that attacks the patient’s immune system with otherworldly legions of insidious microbes.
						
				
		
		
				
						Hand hygiene is the foremost patient care measure for reducing infections. The Joint Commission has made hand hygiene a priority by including it in its National Patient Safety Goals. NPSG.07.01.01 requires organizations to comply with current World Health Organization or Centers for Disease Control and Prevention hand hygiene guidelines.
		
		
				Hand hygiene involves more than the traditional rub-a-dub-dubbing your digits with soap and water. For instance, alcohol-based hand rubs are effective at reducing the number of microorganisms on the skin. Better yet, they work quickly—when used correctly. When using such a product, health care workers should apply it to the palm of one hand and rub their hands together, ensuring coverage of the entire hand and fingers, until the hands are dry.  Be sure to check on how much of the product you need to use to kill a healthy amount of germs; the necessary amount varies depending on which hand rub your organization uses. 
		
		
				
				Hand rubs are an effective and convenient tool. But don’t let easy access to such products make you complacent about hand washing. Hand rubs do not kill all bacteria. For instance, Clostridium difficile, one of the most prevalent types of health care–associated infections in the United States, usually survives a hand-rub onslaught. Health care workers still have to wash their hands with soap and water after contact with patients, especially patients who suffer from infectious diseases like C. difficile or when you see visible soiling. 
		
		
				Subscribers to Perspectives on Patient Safety have access to our searchable online archive and can access the plethora of articles we have published on hand hygiene (
				
						http://www.ingentaconnect.com/content/jcaho/jcpps
				
				). These articles contain a wealth of tips and strategies that can help your organization address this critical patient safety issue. Nonsubscribers can access past articles on a pay-per-view basis.  
		
		
				For the standpoint of accreditation, hand hygiene has proved to be a sticky issue for many organizations. Some accreditation programs have double-digit noncompliance rates for NPSG.07.01.01. I would be very interested in hearing your thoughts on this question.  What does your organization do to ensure that your staff’s “helping hands” stay clean and do no harm? 
		
		
				Stay safe, 
		
		
				
				Jim Parker
		
]]></description> 
					<pubDate>Mon, 09 Mar 2009 21:51:00 GMT</pubDate>
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					<title>Patient Safety Week Blogs: Day 1, Safety Culture</title> 
					<link>http://www.jcrinc.com/Blog/2009/3/5/Patient-Safety-Week-Blogs-Day-1-Safety-Culture/</link> 
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										Greetings!
								
						
						
				
				
				
				
		
		
				Happy National Patient Safety Awareness Week! I’ll be writing a new blog every day of this week, discussing a different patient safety topic. The first topic in this series is “Building a Culture of Safety.” 
		
		
				
						Webster’s Dictionary defines “culture” as the set of shared attitudes, values, goals, and practices that characterizes a group of human beings. Likewise, an organization’s attitudes, values, goals, and practices regarding the safety of patients and staff make up its safety culture.
		
		
				If you think about some of the key words in this definition—attitudes, values, goals—it becomes apparent that we are not talking about mere policies and procedures, rules,  or job expectations.  We are talking about matters of identity.  When we talk about culture, we talk about who we are and who we aspire to become. 
		
		
				
						This is also true for health care organizations. The organizational culture defines to a large degree how employees understand their individual roles and how they fit into the larger picture of the organization’s work; culture defines the ways in which individuals go about fulfilling those roles and how they interact with each other and their patients. 
		
		
				The Joint Commission addresses matters of safety throughout its accreditation process, in its standards, and in the National Patient Safety Goals. However, the term “safety culture” is specifically invoked in the “Leadership” chapter of the accreditation standards. This is because defining the culture is first and foremost a function of leadership. 
		
		
				Every staff member has a part to play in the safety culture, but leaders set the tone and direction. Leaders must made clear that safety is not an afterthought or just one more item on a long “to do” list. Leaders must make clear, by their words and examples, that safety is the organization’s top priority and that safety is integral to everything the organization does.  
		
		
				Some ways leaders can institute this include encouraging a collaborative work environment in which every member of the care team has a voice, instilling a culture of blameless reporting for errors and near misses, and ensuring that patients and their families are treated with respect and are active participants in the care process. (Note that “family” should be defined by the patient, not the organization or its policies.) Leaders also must err on the side of prevention, and demonstrate a willingness to share lessons learned with staff and patients. 
		
		
				The above, along with education and communication, are all essential components of safety culture. But the true hallmarks of a safety culture are passion and compassion.  Leaders must be passionate about safety and compassionate toward patients and staff and make clear that they expect every member of the organization to share those values. 
		
		
				The French writer and aviator Antoine de Saint-Exupery gave some relevant advice: “If you want to build a ship, don't drum up people together to collect wood and don't assign them tasks and work, but rather teach them to long for the endless immensity of the sea.” This is precisely the attitude health care leaders should take when it comes instilling safety as a value in their staff. Staff must strive for safety for safety’s sake, because they understand that is the right thing to do—because they care.  And often this begins when they see that their leaders care. 
		
]]></description> 
					<pubDate>Fri, 06 Mar 2009 21:09:55 GMT</pubDate>
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					<title>The Blog is Back!</title> 
					<link>http://www.jcrinc.com/Blog/2009/3/5/The-Blog-is-Back/</link> 
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						Greetings!
				
				
				
		
		
				It’s been while since this blog was updated, and for that I apologize. The blog was on a brief hiatus while some technical issues were worked out. Those being resolved, I am pleased to tell you that the blog is returning to active duty.  
		
		
				Next week, March 8–14, is National Patient Safety Awareness Week. To celebrate, I will post a new blog each day that week on patient safety hot topics, including:
		
		
				
						•   Building a Safety Culture•   Hand Hygiene•   Handoff Communications•   Involving Patients in Their Own Care•   Health Care Worker Fatigue
				
		
		
				I hope you will visit the blog, read, and respond with your comments. Thanks!
		
		
				Stay safe,
		
		
				Jim Parker
		
]]></description> 
					<pubDate>Thu, 05 Mar 2009 20:52:03 GMT</pubDate>
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					<title>Greetings!</title> 
					<link>http://www.jcrinc.com/Blog/2008/12/11/Greetings/</link> 
					<description><![CDATA[
		
		My name is Jim Parker. Since March 2006, it’s been my privilege to participate in the sharing of critical patient safety information with the health care community through The Joint Commission’s Perspectives on Patient Safety newsletter.My professional background is in magazine journalism. Prior to joining Joint Commission Resources, I spent seven years covering pre-hospital emergency health care, homeland security, emergency response, and transportation safety. I look forward to another year of working with you to promote patient safety in health care.With the launch of this blog, you and I can communicate with each other more directly than ever. This is an opportunity for me to share with you supplemental information to the articles in the newsletter and other news. More importantly, it’s a chance for you—the health and safety professional—to share your comments with me and your colleagues nationwide. I hope to hear from you soon.With the new year nearly upon us, I want to remind you that most of The Joint Commission’s 2009 National Patient Safety Goals become effective January 1. The new requirements for Goal 7 have a one-year phase-in period, with full implementation expected by January 1, 2010. These include NPSG.07.03.01, NPSG.07.04.01, and NPSG.07.05.01. Throughout 2009, Perspectives on Patient Safety will be exploring strategies to help you meet with these and other National Patient Safety Goals and improve the safety and quality of patient care. Also, we will take a look ahead at what we can expect for the goals in 2010.Be safe, Jim Parker]]></description> 
					<pubDate>Thu, 11 Dec 2008 20:09:18 GMT</pubDate>
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