Provider Resources
The following resources can help healthcare professionals improve the safety and quality of services to patients.
Infection Prevention
Monograph: Preventing Central Line-Associated Infections: A Global Challenge, A Global Perspective
The Joint Commission, May 2012
Quality Indicators
AHRQ Quality Indicators Toolkit for Hospitals: Improving Performance on the AHRQ Quality Indicators
Agency for Healthcare Research and Quality, November 2011
A toolkit to help hospitals understand AHRQ’s quality indicators and use them to improve quality and patient safety.
Communication
Words to Watch (National Patient Safety Foundation)
Many patients have trouble understanding words used by doctors and in healthcare institutions. This fact sheet provides a quick reference of words that patients struggle to understand and possible alternatives.
Taking Care of Myself: A Guide for When I Leave the Hospital (Agency for Healthcare Research & Quality)
An easy-to-read guide that can be used by both hospital staff and patients during the discharge process; provides a way for patients to track their medication schedules, upcoming medical appointments, and important phone numbers.
Inpatient Facilities
Rapid Response Teams
Rapid response teams play an important role in advancing patient safety by increasing the early detection of patients in trouble and identifying opportunities to prevent adverse events. The Institute for Healthcare Improvement describes the importance of establishing a rapid response team and provides a practical approach for getting started.
Pharmacy
Advancing Pharmacy Health Literacy Practices Through Quality Improvement: Curricular Modules for Faculty
Agency for Healthcare Research and Quality, December 2011
A set of modules to help pharmacy faculty integrate health literacy and health literacy quality improvement into courses, experiential education, and projects for PharmD students and pharmacy residents.
List of Confused Drug Names (Institute for Safe Medicine Practices)
A resource to help pharmacists determine when special precautions are needed to avoid medication mix-ups.
Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation (Agency for Healthcare Research & Quality)
This toolkit provides a step-by-step guide to improving the medication reconciliation process. The MATCH toolkit aides evaluation of the effectiveness of an existing medication reconciliation process and the identification and response to any gaps; emphasizes standardization of the process for doctors, nurses, and pharmacists within the facility to document and confirm a patient’s home medication list upon admission; and also emphasizes the need to clearly define roles and responsibilities of clinical staff.
Surgery
Preventing Wrong-Site Surgery (Pennsylvania Patient Safety Authority)
Analysis of wrong-site surgery events in Pennsylvania suggests opportunities for prevention. Many steps of preparing the patient for an operation and performing an operation can lead down the path of wrong-site surgery. Preventing wrong-site surgery may require attention at every step of the process.
Putting Adverse Event Reporting Data to Work
When a report is submitted to the Oregon Patient Safety Commission, it becomes part of a secure database of all adverse events submitted since the program’s inception in 2006. The Commission uses information from adverse event reports and other patient safety initiatives to provide the following support to Oregon’s healthcare facilities:
Healthcare Facilities Benefit from Adverse Event Reporting
What if it were possible to prevent an adverse event before it happens? It is possible—we can prevent the events that we know about. Facilities need reports of adverse events, including near misses, to learn about and prevent adverse events. The Commission strongly believes that sharing the lessons from reports of adverse events, especially those high-risk/low-frequency events, will help to prevent similar events in other facilities across Oregon.
What Makes a Successful Reporting Program?
In the article Reporting of Adverse Events, Lucian Leape (2002) identifies seven characteristics of successful reporting systems: nonpunitive, confidential, independent, expert analysis, timely, systems-oriented, and responsive. The Oregon Patient Safety Commission’s Patient Safety Reporting Program embodies each of these characteristics and has identified one additional characteristic that is particularly important to the success of Oregon’s voluntary program: volume of reporting.
Adverse Event Reporting Systems: How Does Oregon Compare?
Oregon, along with 26 other states and the District of Columbia, operates a patient safety reporting system used to collect reports about adverse events. In 2007, the National Academy for State Health Policy (NASHP) studied the differences and similarities of adverse event reporting systems throughout the country (Rosenthal and Takack, 2007). The study found wide variation and inconsistency in how programs are funded, the type of healthcare entities that report, and the nature of adverse events that must be reported. The following list summarizes some of the variations between the country’s 27 adverse event programs:
Learning from Experience to Improve Patient Safety
In seeking to improve safety, one of the most frustrating aspects for patients and professionals alike is the apparent failure of health-care systems to learn from their mistakes. Too often neither health-care providers nor health-care organizations advise others when a mishap occurs, nor do they share what they have learned when an investigation has been carried out. As a consequence, the same mistakes occur repeatedly in many settings and patients continue to be harmed by preventable errors.
-World Health Organization, 2005
In complex healthcare systems, a majority of problems are caused by breakdowns in system and processes, not by poor practices or incompetent practitioners. The World Health Organization (WHO) has recognized that “We know that most problems are not just a series of random, unconnected one-off events. We know that health-care errors are provoked by weak systems and often have common root causes which can be generalized and corrected. Although each event is unique, there are likely to be similarities and patterns in sources of risk which may otherwise go unnoticed if incidents are not reported and analyzed” (World Alliance for Patient Safety, 2005). One of the Oregon Patient Safety Commission’s primary goals is to identify these events and learn from them in order to improve the healthcare system.
Oregon Ambulatory Surgery Center Infection Prevention & Control Toolkit
The Oregon Ambulatory Surgery Center Infection Prevention & Control Toolkit is specifically designed to provide guidance on the development and implementation of infection prevention programs that meet infection control standards outlined in Medicare’s Conditions of Coverage and State of Oregon administrative rules. The toolkit was developed by the Oregon Patient Safety Commission to help Oregon’s ambulatory surgery centers (ASCs) implement infection prevention quality improvement projects, reduce infection risks, and better protect patients.
Oregon Adverse Event Disclosure Guide
A RESOURCE FOR PHYSICIANS AND HEALTHCARE ORGANIZATIONS
The Oregon Adverse Event Disclosure Guide is intended to help Oregon’s physicians and healthcare organizations better understand the purpose of disclosure and provide resources to help develop and improve disclosure programs in Oregon healthcare organizations. The guide is organized in a question-and-answer format to help readers navigate to useful information.
Click here to view the Oregon Adverse Event Disclosure Guide »
Project JOINTS
Project JOINTS (Joining Organizations IN Tackling SSIs) is an initiative funded by the federal government aimed at helping hospitals implement the latest Institute for Healthcare Improvement (IHI) surgical site infection (SSI) prevention techniques for hip and knee arthroplasty surgeries. Oregon is one of only ten states selected to participate in the project – five states began in May 2011 and Oregon, along with four other states, began in April 2012. Oregon’s participation in Project JOINTS is scheduled to last through September 2012.
Overview: Oregon Adverse Event Disclosure Guide
A Resource for Physicians and Healthcare Organizations
The Oregon Adverse Event Disclosure Guide is intended to help Oregon’s physicians and healthcare organizations better understand the purpose of disclosure and provide resources to help develop and improve disclosure programs in Oregon healthcare organizations. The guide is organized in a question-and-answer format to help readers navigate to useful information.
Download a printable copy of the Oregon Adverse Event Disclosure Guide (pdf)
Why Should Events be Disclosed?
Contents: Reasons why providers and healthcare organizations should disclose adverse events, common disclosure concerns, legal protection for disclosures made in Oregon, and additional resources
How Should an Event be Disclosed?
Contents: Common elements of disclosure, the importance of supporting disclosure through an organizational culture of safety, examples of successful disclosure policies and programs, and additional resources
Why Should Oral Disclosure & Written Notification be Used Together?
Contents: The value of combining oral disclosure and written notification and the specific role that written notification can play in adverse event disclosure
What Information Should be Disclosed?
Contents: The components that should be included in any oral disclosure or written notification, downloadable sample written notification letters, and additional resources
When Should an Event be Disclosed?
Contents: Perspectives and work plan for ensuring disclosure is provided in a timely manner
To Whom Should Disclosure be Made?
Contents: Brief statement on who should receive a disclosure
By Whom Should Disclosure be Made?
Contents: Perspectives, tools, and additional resources for individual and team approaches to disclosure
Are There Reasons Not to Disclose an Event?
Contents: Discussion of the limited circumstances in which a disclosure may not be made, suggestions for when to modify disclosures to fit the specific circumstances of the event, and additional resources
Additional Resources
Two entities have compiled extensive bibliographies on the subject of disclosure that provide a range of research and perspectives:
- Communicating After an Adverse Event: Selected Bibliography and Resources. Institute for Healthcare Improvement, 2009.
- Disclosure of Adverse Events to Patients: Annotated Bibliography. Washington University in St. Louis, School of Medicine.
Oregon Surgery Center Creates Operating Room “Quiet Zone”
Technology such as smartphones, computers, and other devices has benefited healthcare workers by providing rapid access to drug information, patient data, scientific references, and two-way communication between colleagues. Though not well studied, electronic devices may have a beneficial impact on patient safety by reducing communication delays, medical errors, or injury; however, the potential impact on care as a result of distraction, electromagnetic interference, and infection control is not well understood.
The American College of Surgeons (ACS) has approved a statement on use of cell phones in the operating room (Bulletin of the American College of Surgeons, 93(9), September 2008). In the statement, the ACS discouraged the “undisciplined” use of cellular devices in the operating room. The ACS stressed the need to:
- Avoid interfering with the technology required for patient care
- Only engage in urgent or emergent outside communication during surgery
- Not compromise the integrity of the sterile field with cellular devices or accessories
By following the ACS guidelines and establishing a “Quiet Zone” policy, all members of the operating room team can focus on the patient, which can increase the safety of the patient and promote a sense of teamwork.
To address patient safety concerns, the Oregon Outpatient Surgery Center in Tigard sought governing board approval and implemented a policy to define the proper use of cell phones. Recognizing that there are occasions where it is necessary to keep in touch with family or friends during emergencies, the ambulatory surgery center’s employees, sales representatives, physicians, and other healthcare providers are asked to refrain from cell phone use in patient care areas. All providers and staff, including physicians who are on-call to other facilities, are asked to use their cell phones in non-patient care areas.
Jesseye Arrambide, Executive Director of the Oregon Outpatient Surgery Center, noted that distributing research articles on the contamination of cell phones helped providers and staff accept the new policy. Jesseye is available to any of Oregon’s healthcare organizations that may have questions related to the design or implementation of such a policy. She can be contacted via email at .(JavaScript must be enabled to view this email address).
Resources on Cell Phone Contamination
- Brady, R.R., Wasson, A., Stirling, I., McAllister, C., Damani, N.N. (2006). Is your phone bugged? The incidence of bacteria known to cause nosocomial infection on healthcare workers’ mobile phones. Journal of Hospital Infection, 62(1), 123-125.
- Borer, A., Gilad, J., Smolyakov, R., Eskira, S., Peled, N., Porat, N.,…Riesenberg, K. (2005). Cell phones and Acinetobacter transmission. Emerging Infectious Diseases, 11(7), 1160-1161.
- Jeske, H.C., Tiefenthaler, W., Hohlrieder, M., Hinterberger, G., Benzer, A. (2007). Bacterial contamination of anaesthetists’ hands by personal mobile phone and fixed phone use in the operating theatre. Anaesthesia, 62, 904-6.
- Sadat-Ali, M., Al-Omran, A.K., Azam, Q., Bukari, H., Al-Zahrani, A.J., Al-Turki, R.A., Al-Omran, A.S. (2010). Bacterial flora on cell phones of health care providers in a teaching institution. American Journal of Infection Control, 38(5), 404-405.
- Ulger, F., Esen, S., Dilek, A., Yanik, K., Gunaydin, M., Leblebicioglu, H. (2009) Are we aware how contaminated our mobile phones with nosocomial pathogens? Annals of Clinical Microbiology and Antimicrobials, 8(7). Doi:10.1186/1476-0711-8-7
