Catalog Number : ngd1438
Title : 2011 Patient Safety Update
Speaker : Sue Dill
Duration : 90 minutes
Webplay Recording Date : 11-15-2011
Webplay Price : $ 200 for two weeks viewing
Webinar Overview:
Preventable
medical errors are actually on the risk by 1% per year according to the 2010 revised
National Quality Forum publication on 34 Safe Practices for better healthcare. There are
18 types of medical error that account for 2.4 million extra hospital days and 9.3 billion
in excess care. A November 2010 OIG study found that 15,000 Medicare patients every month
experience an adverse event during healthcare delivery that results in death. One of every
seven discharges (13.5%) results in an adverse event.
This program will cover the patient safety
issues along with CMS Hospital CoP and the Joint Commission requirements on patient
safety. It will be discussed what hospitals need to do to create a patient safety culture.
It will discuss the balance of a nonpunitive environment for medical errors with the Just
Culture theory. It will cover the patient safety recommendations of the revised April,
2010 NQF 34 Safe Practices and will discuss how to prevent medical errors from occurring.
CMS will start reporting each hospitals scores and reduce payments by 1 percent to
hospitals with the highest rate of medical errors and infections in 2015. Hospitals should
start evaluating ways to proactively reduce errors and adverse events
Webinar Objectives:
- Describe the CMS hospital CoP requirements including that near misses must be included
in the definition of what constitutes a medication error
Discuss the Joint Commission requirements
for the patient safety program including that a FMEA must be done every 18 months
Recall that the 2010 34 Practices for Better
Healthcare recommendations including that a culture survey should be done
Recall that AHRQ has published 10 patient
safety tips for hospitals
Discuss the system analysis theory and that
there should be a non punitive system for system failures
Discuss what is meant by Just Culture
A few of the topics to be
discussed:
- CMS hospital CoP standard on non-punitive environment
- Requirement for voluntary non-punitive
environment
- Standard revised Tag 508 June 20, 2011
- Medication errors and adverse drug events
- Must include near misses or close calls
- Corrective actions to prevent reoccurrences
TJC leadership standards on non-punitive
behavior and organization safety standards , system performance, and culture survey
- Patient safety program requirements
- Near misses or close calls
- FMEA and RCA requirements
- Patient safety plan and scope of the program
- System or process failures
- Sentinel event requirements
- External reporting of significant adverse
events
National Quality Forum 2010 34 Safe
Practices for Better Healthcare standard on culture of safety
- Leadership structures and systems
- Patient safety program
- Patient safety officer
- Patient safety committee
- Board responsibility in patient safety
- Two toolkits for leadership on walk abouts
- Culture measurement
Just Culture theory as a balance
OIG Study on adverse events with Medicare
patients
CMS reduction of 1% for hospitals with
highest rate of medical errors and infections
The IOM Study on Medical Errors
Patient Safety Issues
Definition of Patient Safety
Other names for Medical Error
Error prevention and Just Culture
Establishing a culture of safety
High Reliability Organizations
Key Features of Culture of Safety (AHRQ)
AHRQ Patient Safety Primer on Safety Culture
10 domains of patient safety
AHRQ 10 Patient Safety Tips for Hospitals
System Approach
Human factor engineering
Root cause analysis
Active verses latent conditions
Errors at the sharp end verses the blunt end
Slips verses mistakes
Patient safety outcomes
Human error
Culture of safety components
Developing a culture of safety
Target Audience:
- Patient Safety Team Members
- Patient Safety Officer
- Quality Management Coordinator
- Joint Commission Coordinator
- Nurse Educator
- Chief Nursing Officer
- Nurse Managers
- Nurse Educators
- Risk Manager
- Hospital Legal Counsel
- Physicians
- VP of Medical Staff
- Consumer Advocate
- Nurse Managers
- Nurse Supervisors
- Clinic Managers
- Nurses
- CEO
- Compliance Officer
- Pharmacist
- anyone else involved in improving patient safety in
healthcare facilities
Contact Hours:
- Nursing participants: Instruct-online has approved this program for 1.8 contact hours, Iowa Board of Nursing Approved Provider Number 339.
- All other participants: Must attend the entire Webinar and complete a Webinar critique to receive a 1.5 Hour Attendance Certificate for each program.
Completion of offering required prior to awarding certificate.
Refund Policy:
Full tuition is refunded immediately on request if the participant has not been
sent the program materials and instructions. Once the instructions (including access codes) have been sent, a full refund will be issued only after the program runs and it is verified that the participant did not access the program
.