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  • Letter from America: A spark for improvement – Patient Safety Awareness Week

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    March’s Letter from America highlights insights from the field shared during Patient Safety Awareness Week earlier this month and touches on improving transitions, managing implicit bias and using evidence. Letter from America is the latest in a Patient Safety Learning blog series highlighting new accomplishments in patient safety from the United States.

    *Please note, this letter was written before WHO announced that COVID-19 was a pandemic, just a few short weeks ago. We acknowledge that the world has changed since then but we feel this content is still relevant to safer patient care, maybe even more so now.


    Each year in March, Patient Safety Awareness Week (PSAW) serves as a spark for increasing safety. Initiated in 2002, the concept of PSAW was formed by New York State-based founder of the Pulse Center for Patient Safety Education and Advocacy, Ilene Corina. In 2003, Ilene then collaborated with the Society to Improve Diagnosis in Medicine founder Dr. Mark L. Graber and the National Patient Safety Foundation to establish the annual event. PSAW triggers the sharing of resources and experiences to initiate partnerships that propel patient safety work forward. Many in the field take advantage of the opportunity to build awareness of their inventiveness and motivate collective action toward enhancing patient safety.

    PSAW uses a wide range of communication methods to create energy and rejuvenate effort through the sharing of lessons learned and common goals. Buttons, posters, in-house newsletter articles, blogs, webinars, employee recognition awards, and poster presentations are all used to increase awareness. Earlier this month, The Institute for Healthcare Improvement (IHI) partnered with the Agency for Healthcare Research and Quality (AHRQ) to host a Twitter chat that surveyed the experiences of participants on transitions, challenges and successes. Programmes highlighted during the discussion include the bundled handoff method I-PASS developed by a team at Boston Children's Hospital and Harvard Medical School to enhance team communication. Twitter chat participants noted the importance of being able to adapt transitions tool to their environments. I-PASS leaders noted efforts to develop local champions to assist with the application of the bundle for use in the variety of situations patients and providers encounter throughout the care journey.

    The California Patient Safety Organization (CHPSO) hosted five free webinars during PSAW on a range of topics.  One webinar focused on mitigating unconscious influences, or cognitive biases, that degrade relationships, decision making and care delivery. The speaker, Michelle van Ryn, President and Founder of the Institute for Equity & Inclusion Science, highlighted specific tactics, tools and educational programming to combat unconscious biases generated by gender and racial differences. She reviewed organisational conditions that facilitate biased interaction such as unsafe psychological culture and overwork. Dr van Ryn discussed valuable skill development tactics for increasing an individual’s management of their potential for implicit bias that focused on mindfulness, empathy, inclusion and partnership-building behaviours.

    Another high point of the week was the release of AHRQ’s Making Health Care Safer III report. This publication summarises the current evidence base on 47 patient safety practices targeting 17 areas of concern. For example, the  chapter on sepsis discusses the evidence on manual or electronic screening tools for sepsis. The authors discuss the performance of currently used methods to determine patient susceptibility to sepsis to help ensure timely treatment initiation. While they concluded more evidence is required to determine outcome measures associated with screening methods, the authors shared links to examples of robust tools currently being used in US hospitals. Another focuses on infections due to multi-drug resistant organisms. One distinct practice review discusses hand hygiene, of particular relevance due to the COVID-19 outbreak. The authors discuss the persistent weakness in hand-hygiene practice due to workload, lack of education and easily accessible supplies. The World Health Organization’s My Five Moments for Hand Hygiene programme is highlighted in this evidence covered as an important approach for implementing hand hygiene completeness into frontline care. Thirdly, patient and family engagement is covered as a patient safety practice relevant across the spectrum of care delivery. The authors discuss difficulties in tracking the evidence on engagement as a distinct element of patient safety. They highlight several studies on the topic and share resources to encourage adoption of activities that encourage patient involvement in their care.

    hub members should refer to the search strategies in the report (included as an appendix in each chapter) designed to review each discussed best practice. Leaders can use these vetted search strategies to keep current on the emerging evidence related to the initiatives they are implementing in their own organisations, targeting the specific challenges they are confronting in their own improvement work.

     Connecting with experts and recognising their contribution to change can motivate action. By providing stimuli, Patient Safety Awareness Week re-energises those on the front-line of safety. It facilitates expert conversation, knowledge sharing and evidence identification to keep our patient safety efforts and our patient safety leaders moving forward.

    About the Author

    Lorri Zipperer is the principal at Zipperer Project Management in Albuquerque, NM. Lorri was a founding staff member of the US-based National Patient Safety Foundation (NPSF). She has been monitoring the published output of the patient safety movement since 1997. Lorri is an American Hospital Association/NPSF Patient Safety Leadership Fellowship alumnus and an Institute for Safe Medication Practices (ISMP) Cheers award winner. She develops content to engage multidisciplinary teams in creative thinking and innovation around knowledge sharing to support high quality, safe patient care.

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    Great article and a very important topic Lorri.

    We have just been named as one of the '10 Digital Health Ideas for a UK National Covid-19 Response' by Healthcare UK (a joint initiative of NHS England, UK Departments of Health and International Trade) and it would be very good to discuss how patient safety approaches can make a big difference in the crisis.

    During the pandemic, we are deploying a risk-assessment tool, sythesized from our patient safety system and reductions in AKI of over 90% (publisihed approach in BJN and winning an HSJ Patient Safety Award) and HAP by 60%.

    Long story short is that those patients acquiring these conditions are blocking beds for up to 8 days extra on average.  Those beds are needed for Covid-19 patients and so reducing these conditions is a critical part of the patient safety vision you've supported for so long Lorri.  

    A 50% reduction in these conditions in US hospitals would free enough capacity for an extra 67,000 C-19 patients in the next 3 months.

    Could you find time for a discussion?

    AKI HAP Overivew 002.pdf

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