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Patient Safety Monitor Journal

Patient Safety Monitor Journal answers your most important patient safety questions and offers field-tested compliance strategies to ensure your patient safety efforts measure up to The Joint Commission.

  • Q&A: IHI and NPSF merge to push patient safety initiatives

    Editor’s note: In March, the Institute for Healthcare Improvement (IHI) and the National Patient Safety Foundation (NPSF) announced that they would merge starting May 1. The two organizations have been leaders in the patient safety field for years, and there is much hope stemming from their collaboration. The following is a lightly edited Q&A with Tejal K. Gandhi, MD, MPH, CPPS, NPSF president and CEO, about what the merger will mean for the combined organization, now called the Institute for Healthcare Improvement. As of May 1, she is the Institute’s new chief clinical and safety officer.

    PSMJ: How did this merger come to be, and how long have you been planning it?
    Gandhi: The rationale behind our merger is straightforward: We want to ensure that safety is a central part of every organization’s improvement strategy today, and that the safety of patients and the healthcare workforce becomes a core value of healthcare systems around the world.
    IHI and NPSF have actually worked together intermittently for many years. More recently, however, we’ve shared a concern that while progress is being made in patient safety, there are also many other competing priorities in healthcare. With that in mind, we started talking about working more closely together to further raise the profile and urgency of patient safety.
    Over time, we came to the conclusion that the way to offer health professionals and patient safety advocates (including patients) the best resources, tools, and teaching to deliver the safest care would be to formally combine our strengths into a single organization.

    PSMJ: What do you hope the outcome of this merger will be for your combined organization and for healthcare in general?
    Gandhi: The governing boards and senior leaders of both organizations strongly believe that together, IHI and NPSF can advance their missions more effectively than they could by continuing to work apart. Together, we believe our combined knowledge, skills, and resources will be more effective in helping leaders and frontline clinicians meet all of today’s challenges, and together, we intend to develop some fresh approaches to focus and energize the patient safety agenda.
    Both organizations have put a strong emphasis on the importance of organizational culture and systems of safety rather than approaching patient safety as a series of projects. We also want to see greater emphasis on the continuum of care, because while most patient safety research and improvements have focused on hospitals, most care is delivered in the outpatient setting.
    IHI recently released A Framework for Safe, Reliable, and Effective Care (www.ihi.org/resources/Pages/IHIWhitePapers/Framework-Safe-Reliable-Effective-Care.aspx), [which] really describes a system of safety and how it can be achieved in healthcare.

  • Keeping fungi at bay

    In March, The Washington Post ran an alarming story about a new strain of Candida auris (C. auris) fungus in U.S. hospitals. At presstime, there were more than 50 C. auris cases in the U.S., mostly clustered in the Northeast.
    This particular fungus raises several concerns. First, some of its strains are resistant to all three classes of antifungal drugs. Its spores are extremely durable and can survive on skin and surfaces (such as doorknobs and bedrails) for weeks. Finally, unlike other yeast infections, C. auris can cause severe bloodstream infections. About 60% of patients who contract this fungus have died, though researchers note the sample size for this observation is small, and several of the patients already had serious medical issues.

    While fungal infections like C. auris may attract headlines, there are also plenty of other fungi that can pose risks to patients. In fact, there are about 1.5 million species of fungi in the world, though only 300 of them are known to be health risks. Fungal infection can cause a gamut of effects, from mild (runny nose) to severe (death). So what do you need to know about infection control (IC) for fungi?

    Rachel Marrs, MSN, RN, CIC, DNP, infection prevention and control program manager at University of Chicago Medicine (UCM), says fungal IC relies on many of the best practices used to combat bacteria and viruses: proper PPE, environmental cleaning, and hand hygiene. However, the main difference lies in how a particular fungus is transmitted—through touch or through the air.

    “If you’re focusing on a fungus like C. auris—which spreads through touch—you’re going to focus more on the handwashing and contact precautions like wearing gowns and gloves, and also environmental disinfection,” she says. “Whereas if it’s something like Aspergillus, [it’s airborne].  People commonly breathe in Aspergillus spores as they can be in the environment routinely. You’re going to focus more on air quality, having a HEPA filter in the building, and having construction barriers in place.”

    Overall, healthcare organizations do a pretty good job preventing fungi from propagating in their facilities, Marrs says. However, every year there’s at least one news story about a hospital fungal outbreak.

    “A lot of them [outbreaks] are around projects or in hospitals where they’re doing construction or renovation and they weren’t able to control the dust from that project and it got into the rest of the healthcare facility,” she says. “There’s also outbreaks linked to carpets, linens, and things like that. But I would say that construction is the biggest one.”

  • You've got harm

    The prevention of avoidable harms has been a goal of healthcare since day one, but it was given fresh life in 2010 when the Office of Inspector General (OIG) urged that healthcare facilities report all types of harms: medical complications, preventable harms, and system failures and errors. However, harms data has been chronically under-reported for years. Even the adverse events compiled in The Joint Commission’s Sentinel Event database only represent a small fraction of safety events.

    Then in April 2017, Christine Sammer, DrPH, RN, director of corporate patient safety at Adventist Health System (AHS), and co-authors published a new study that provided some encouragement.

    For 11 months, two AHS hospitals tried out an automated system called the Automated All-Cause Harm Trigger System (ACHTS). The system’s software uses 41 algorithms to monitor electronic medical records (EMR) for signs that harm has befallen a patient, with flagged charts sent to a reviewer to examine. By the end of the study, the ACHTS caught 2,696 cases of patient harm, compared to the 132 harms caught using the old sampling method. The system also saved reviewers time and gave physicians actionable information for helping patients. AHS published its results in The Joint Commission Journal on Quality and Patient Safety.

    “Electronic safety event detection systems hold much promise to remove the bottlenecks of more traditional, more analog, and more manual methods,” wrote Eric Kirkendall, MD, MBI, associate chief medical information officer at Cincinnati Children’s Hospital Medical Center, in the study’s accompanying editorial.  “Sammer et al. have demonstrated this nicely with their work. Now it's time to take the next steps of validating tools such as the Risk Trigger Monitoring system and determine how to widely implement them, with the goal of helping all healthcare providers ‘do no harm.’ ”

    Old vs. new
    The Institute for Healthcare Improvement (IHI) defines a harm as an “unintended physical injury resulting from or contributed to by medical care that requires additional monitoring, treatment or hospitalization, or that results in death.”

    Prior to this study, AHS had used the IHI’s Global Trigger Tool (GTT) to track the number of harms at its facilities. The GTT method required a clinician or nurse reviewer to sample 20 charts each month and manually search for signs (triggers) of harms.

    Five years ago, AHS approached Pascal Metrics about developing the ACHTS as a way to collect comprehensive data on all patients. The system automates the search for triggers, so reviewers’ only job is to check flagged charts and determine their cause. Then they categorize events based on severity and whether the harm was hospital- or outside-acquired.

    Using GTT, it took AHS 6.5 hours to analyze 20 charts. Using the ACHTS, it only takes 1.5 hours per 20 records, a considerable time reduction along with an increase in data points.

  • Right dose, right drug: WHO challenges hospitals to cut med errors in half

    At the end of March, the World Health Organization (WHO) announced its third global safety initiative, the Global Patient Safety Challenge on Medication Safety, which calls on facilities to cut the rate of medication-related errors in half by 2022. The organization hopes to do this by:
    •    Addressing weaknesses and flaws in how drugs are prescribed, distributed, and consumed
    •    Providing education on safer and more effective prescribing habits and methods
    •    Increasing patient and provider awareness on the dangers of medication errors

    Worldwide, medication errors cause at least one death per day and cost an estimated $43 billion annually (1% of global health expenditures). In the U.S. alone, 1.3 million people are injured annually due to medication errors. All these errors are potentially avoidable, says the WHO, so long as the right systems and procedures are put into action.

    “We all expect to be helped, not harmed, when we take medication,” wrote Dr. Margaret Chan, WHO director-general, in the press release (https://goo.gl/4pRbYB). “Apart from the human cost, medication errors place an enormous and unnecessary strain on health budgets. Preventing errors saves money and saves lives.”

    Can it be done?
    Joe Kiani, founder of the Patient Safety Movement Foundation (PSMF) and chair and CEO of the Masimo Corporation, has high hopes the WHO will achieve its goal of 50% harm reduction; as proof, he points to the success of the organization’s first global patient safety challenge on hand hygiene (www.who.int/gpsc/en). 

    “I think over 50 countries and nearly 20,000 hospitals have joined [the Clean Care Is Safe Care challenge],” he says. “They’ve reported that they are saving 7–8 million lives a year from it. So yes, I believe they can do it [with medication errors].”

    He says the people behind the project are very serious, dedicated, and caring, and he’s excited at the initiative’s potential.

    “This is one of the areas we’ve been pushing for at [PSMF],” he says. “Safe medications, dosage, and prescription. We’re delighted to get this reinforcement from WHO.”

    Megan Maddox, PharmD, BCPS, CDE, medication safety officer at Sanford Medical Center in Sioux Falls, South Dakota, says she’s thrilled that the WHO is shining a spotlight on medication safety.

    “This [medicine] is what we send people home on from the hospital,” she says. “They don’t go home and do procedures on themselves or surgery. That’s done at the hospital, and what we do to keep them well and out of the hospital is treat them with medication. Making medication safety a priority and having people really emphasizing patient understanding in what they’re taking and what for—I think it’ll have a very positive impact on keeping our patients safe and really keeping sure medications effectively work for our patients.”

  • Innovation in pursuit of high-reliability culture

    The Institute of Medicine sent waves racing across the surface of American healthcare when it published To Err Is Human in 1999. The unsettling report suggested medical errors were killing at least 44,000 and as many as 98,000 patients nationwide each year. Even the lower end of that spectrum would rank such mistakes eighth among leading causes of death—ahead of breast cancer, AIDS, and motor vehicle accidents.

    The report challenged the self-perception of modern healthcare personnel and inspired reforms designed to prevent errors or at least catch them before they impacted patients. Ambitious goals were set. But the path forward proved complex, and the fallout from that disturbing report continues to ripple from coast to coast as innovators pursue what has become known as “high-reliability culture.”

    Almost every hospital in the country has in recent years pursued initiatives to improve quality and safety in one or more key areas, says Brent Ibata, PhD, JD, MPH, FACHE, research compliance officer for Sentara Healthcare based in Norfolk, Virginia.

    “But they’re doing it in what I call a ‘whack-a-mole’ approach,” Ibata says. “There’s very few hospitals that are stepping back and taking it from a cultural perspective.”

    Although patient safety advocates have made strides in the past two decades, getting an entire medical staff to embrace high-reliability culture—also known as becoming a high-reliability organization (HRO)—requires a drastic shift in thinking, Ibata says.

    “The big picture is we’re making fantastic progress in avoiding the big avoidable things,” Ibata says. “We’re making incremental progress in avoiding the higher-hanging fruit.”

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