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About lzipperer

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    Patient safety and knowledge sharing entrepreneur that helps experts "get things done!"
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    Zipperer Project Management
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  1. Content Article
    Ah – a new year. A new decade. People around the world celebrate such affairs with fireworks, noisemakers, champagne and resolutions they’ll never keep. In America, we revel with all those things and ... the ’Granddaddy of them all‘... The Rose Bowl. The Rose Bowl is an annual college football face-off between two champion teams held in Pasadena, California. The event is huge, complicated, prestigious and widely anticipated. This musing on Rose Bowl activities and how they might highlight safety concepts ‘kicks off’ my 2020 Letter from America series. A renowned part of the franchise is the Tournament of the Roses parade. The 2020 parade theme was the ’Power of Hope‘. Volunteers, sponsors and organisations collaborate to produce a 5.5 mile spectacle involving over 40 floats, numerous marching bands and millions of flowers for viewer enjoyment. Collaboration is key to achieve medication safety too. In a recent study published in the Quality Management in Healthcare journal, a community health organisation’s successful method of frontline staff committee engagement generated process changes that culminated in reduced medication errors and increased near misses. Continuous quality improvement initiatives supported by these committees included technical handling and administration of medication, medication reconciliation, and enhancements to standardised treatment protocols. Following the pomp and beauty of the parade comes the gridiron... the grit... the sweat... the teamwork. College teams are selected based on their performance during the year. Their individual and team competencies are what get them to Pasadena and give their fans hope for a win. Competencies are important for developing reliability no matter what field you play on. The Society to Improve Diagnosis in Medicine (SIDM) has identified key competencies that should be considered for inclusion in health professions education programmes to improve the quality and safety of diagnosis in clinical practice. They fill a noticeable gap in health professional education by embedding reasoning and partnering skill development into healthcare curricula. The SIDM approach emphasises individual, team and system level skills to hone clinician diagnostic abilities and orientation to diagnosis as a team. In football and in healthcare, teams follow processes and plans but should be empowered to adapt when the situation calls for it. For example, TeamStepps is a US-government developed team training programme originally designed to enhance communication in acute care. A recent pilot study tested its application in mental health teams in schools to reduce staff burnout and turnover. This unique health environment adapted the TeamStepps method to improve organisational culture and provide support for the wide array of practitioners that provide care in schools. The success of the initiative improved team-based care delivery at the organisation. Football holds for the teams, management and consumers the potential not only for spectacular performance but for mistakes that can result in injury. Fatigue and distractions can often be a factor in football injury on the pitch; so too can these factors result in injury in healthcare. The Pennsylvania Patient Safety Authority (PSA) released a 4-year analysis of newborn falls in the hospital following birth. Parental fatigue was a primary contributory factor that emerged from the investigation. The PSA describes educational tactics to help parents understand the potential risks for infant drops and encourages them to ask for nursing assistance in feeding if they feel overly tired to keep their babies safe. Keeping track of disruptive behaviour is a relatively new effort for healthcare. Until recently, there was no way to raise a flag to indicate poor behaviour that can distract from team cohesion, coordination and communication. In a recent study, a large US health system devised a tool to evaluate disruptive behaviour among its ranks, measure its effect on teamwork, burnout and patient safety, and use that data to define improvement targets. In the sample, researchers found disruptive behaviour to exist in approximately 98% of work settings. The upside of this discouraging figure is that the tool effectively tracked disruptive behaviours so they can be addressed. There is hope for improvement – once a problem can be measured work can commence to fix it. While not a strategy, hope motivates, as presented by Sidney Dekker in his movie: Safety Differently. Hope situates the future in possibility, instils learning from what goes array and sustains efforts to stay true to goals. Let’s keep hope alive as we work to score touchdowns for safety in 2020.
  2. Content Article
    Developed by Agency for Healthcare Research and Quality (AHRQ) and the US Department of Defense, TeamSTEPPS® offers core strategies for use in a variety of healthcare environments coupled with approaches for distinct areas of care such as dental, long term care and office practice. The program collectively offers free training modules, webinars, train the trainer strategies and a bibliography of research describing how the tools have been used.
  3. Article Comment
    Is there an official analysis available looking at these incidents?
  4. Community Post
    I do see some value in having a specialist with the right training as a hub to span boundaries and apply the safety sciences to the work of envisioning, designing and implementing safety strategies. See this white paper by the American Institute for Safe Medication Practices on the value of a medication safety officer...some similar arguments could be made here to support the UK strategy.
  5. Community Post
    What do hub members think about use of the term "near miss" vs "close call" vs "good catch" to describe errors that are caught before the reach or harm the patient? If you have a favorite, can you say why?
  6. Content Article
    Movies from 1939 are engrained in American culture. They share narrative, characters and quotes that people are aware of even if they, alas, haven’t seen the films. The list of films produced in what some consider the finest year in Hollywood history speaks for itself; it includes Stagecoach, Ninotchka, Destry Rides Again, Mr Smith Goes to Washington, The Wizard of Oz and both my and the Academy’s favourite, capping the impressive output with a December 1939 release, Gone with the Wind. While recognising that certain characterisations in these movies haven’t aged well, the films have made an indelible mark on Hollywood history. The films of 1939 laid the groundwork for great things to come. They launched the careers of artists that have made a cultural mark worldwide: need I say more than John Wayne or Judy Garland? Another capstone to a productive year is the end of the 20th year post the publication of To Err in Human. The widely influential 1999 US publication showed us how to fight for patient safety – our Tara. It outlined approaches to address the seemingly reoccurring tornadoes in healthcare built to instead point toward home – a safe health system. Scarlett’s tenacity, her force of personal will and sustained belief in Tara is what pulled her through the maelstroms of civil war Georgia. Clinicians, however, cannot rely on grit and willpower alone to address clinical and organisational threats to safety. The lack of control to minimise systemic pressures on their moral imperative to do a job well in non-supportive situations reduces a clinician’s ability to practice safely. Building on the To Err is Human legacy, The US National Academy of Medicine (NAM) is committed to understanding factors that contribute to unsafe care. A NAM recent report on burnout lays out a system-focus strategy for organisations to reduce conditions that degrade physician health and, thus, safe practice. Dorothy’s quest to return home energised her instead to engage a multidisciplinary team. The skills of Scarecrow, Tin Man, Cowardly Lion and, yes, even Toto got them through the forest to safety. Without their individual commitment to the mission, humanness and competence the team would have never gotten to Oz. The American Association of Medical Colleges (AMMC) recently released a set of competencies expected in physicians to support quality practice. By suggesting what educators embed in their training efforts, the AAMC helps ensure learning opportunities that build competencies are embedded in programmes on the yellow brick road to safe care provision. Transparency helps us to see situations as they really are. Peaking behind the curtain enables exploration that, if used appropriately, can drive improvement. Toto pulled back the curtain to expose a threat that, once clarified, launched a collaboration that got Dorothy back to Kansas. The US-based Leapfrog Group has also forged a partnership to look behind the curtain. The latest release of the Hospital Safety Score data has focused attention on what isn’t working to support safety while celebrating hospitals that demonstrate sustained safety and quality. The scores track weaknesses in hand hygiene, infection control, and patient falls as elements of whether a hospital is safe. There have been challenges: wicked witches, budget constraints, refusal to accept change and conflicts. It has not been an easy road to Tara since Err is Human was released. Experts in the field have shared their dismay in the lack of progress. Yet stories of resilience, partnership and teamwork continue to motivate the resolve of Dorothy and Scarlett to keep going. Goal-focused efforts can backfire and not live up to their expected purpose. The South didn’t win the Civil war though they believed it was their destiny to do so. Scarlett never won back Ashely no matter how hard she tried. A recent article published in Health Affairs highlights the lack of correlation between the US Medicare and Medicaid programme reimbursement initiative and direct impact on patient safety in the state of Michigan. Its impact is questionable—which for a large-scale solution embedded throughout the system—is humbling. Questionable actions can be a human reaction to stress that needs to be called out and managed to reduce their presence and impact. While centering her as a force for action, Scarlett’s spoiled and selfish behaviour also destroyed her most meaningful relationship. Such destructive behaviours degrade relationships needed for the safety of care. A large US study published in NEJM found that harassment and inappropriate behaviours effect one-third of general surgery residents surveyed, particularly women. The mistreatment and bias generated by both patients/families and medical team members were identified as a key factor in burnout and physician suicide. The stories from great films of 1939 illustrate the power of grit, resolve, focus and leadership as elements of achievement. They share with us memorable characters that live with us long after the movie theatre lights come up. Through the embodiment of the tenacity of Scarlett and the team-focus of Dorothy we can and will work through the known barriers to reduce patient harm due to medical care. We have not yet arrived at Tara, but we continue to work tomorrow toward getting over the rainbow.
  7. Community Post
    As just a conceptual observer of RCAs, these reads by US authors immediately came to mind when I saw this thread. These authors have tried to examine the RCA process or build out the model to make it more effective. I will add the resources to the hub area referred to above but list them here now due to keep them close at hand for the conversation: RCA2: Improving Root Cause Analyses and Actions to Prevent Harm. Boston, MA: National Patient Safety Foundation; 2015. Hagley G, Mills PD, Watts BV, Wu AW. Review of alternatives to root cause analysis: developing a robust system for incident report analysis. BMJ Open Qual. 2019 Aug 1;8(3):e000646. This review is likely to be on point as it lists tools identified by a literature review that sought to highlight RCA incident review alternatives to RCAs. Two PSNet articles that provide background : Root Cause Analysis Gone Wrong: 2018 Rethinking Root Cause Analysis: 2016 I hope these are helpful in feeding the "fire"! Lorri
  8. Content Article Comment
    Thank you to the reporter for sharing this story. I am saddened that 20 years after To Err is Human and subsequently An Organisation with a Memory this sort of response still occurs. I am troubled by the leadership failure here!
  9. Community Post
    "There is an aspect of information exchange that has attracted less attention and fewer resources: that patients are experts in their experience and know much more than clinicians about their own health and the needs and goals important to them." From: https://catalyst.nejm.org/information-asymmetry-untapped-patient/ Such an important point to see patients as knowledge hubs on their own care experiences.
  10. Community Post
    The US-based Leapfrog Group is a nonprofit organisation that routinely gauges hospital performance to inform purchaser choices as they navigate the healthcare system. While there are discussions on the value of the ratings ... they still pack a punch for organizations who do or don't do well. The latest set of numbers are out: Megan Brooks. One Third of US Acute-Care Hospitals Get 'A' on Patient Safety: Survey - Medscape - Nov 07, 2019.
  11. Community Post
    This is such an important question .. I am looking forward to the responses. I see it as a distinct leadership quality to effectively recognize employees/peers that are brave enough to raise the red flag when they feel uncomfortable about something they have seen or heard. Heck -- its hard enough to speak up some times ... even when people know they should. See this insight from the IHI on that topic:
  12. Article Comment
    Retained foreign objects are a persistent challenge in the US too. Accreditation giant the Joint Commission in Illinois has stats drawn from voluntarily submitted reports that indicate their hospitals struggle with the problem too.
  13. Content Article
    Colour is a hallmark of Autumn across the US. A more spectacular set of colours, in a variety of shapes and sizes, paint the sky at daybreak every October in New Mexico. The Albuquerque International Balloon Fiesta is the largest gathering of its kind. In 2019, its 48th year, the fiesta hosted 550 hot air balloons, 650 pilots and entertained close to 900,000 visitors. The event holds a place on the bucket lists of travellers around the world. It is hard to describe the feeling of glee standing amid a mass ascension until you’ve been there amongst the early morning crowds. You might think it’s all fun, funnel cakes and floating but—like any aviation activity—ballooning entails risk. Make no mistake, the balloonists and their teams, the organisers, law enforcement, and even participants play a role in the safety of the event. Before sunrise each day, the “dawn patrol” of 8–10 hot air balloonists lift off. These experienced pilots gage the safety of the sky prior to the authorities giving the signal for the assent to begin. Only after that, does the wave after wave of multiple balloons unpack, gear up, inflate and take off from the field. Crews mull about, patiently navigating their designated space amongst onlookers and their cameras to get ready for flight. They implement standard procedures to safely gear-up for flight. Healthcare, too, prepares teams for complex situations to ensure safety through standardisation and practice. The US healthcare accreditation agency, the Joint Commission, shared insights on reducing maternal harm due to postpartum haemorrhaging that summarises best practices centered on readiness, recognition, response and reporting to support systems learning. Stanford Medicine in California recently held a series of “dress rehearsals” prior to opening a new hospital. The test of the space gave clinicians, administrators and patient advisors a chance to make sure conditions were right for a safe opening day. The fiesta organisers also deploy tactics to learn from what doesn’t go well. They use technology to gather input from crews and the public to identify areas for improvement. Traffic into the 360-acre launch site creates ineffective and potentially dangerous situations given the swell of people arriving in town. Attendees almost double the size of the city for the 10-day event. Public input gathered online helped planners to redesign this year’s park and ride shuttle system after it failed in 2018 to reliably get people to the festival. Hospitals also use information technology to learn how to improve the safety of the care experience. Researchers in Washington State developed a 4-step model built on inpatient experiences with undesirable events. They used patient and family knowledge to design informatics solutions that engage patients as contributors to safety. The model supports raising awareness of problems, encouraging prevention actions, managing emotional harms and reducing barriers to reporting .A rare situation stalled the festival this year: fog. Yes, fog is not something New Mexican’s encounter often but it shut down opening day morning—none of the balloonists could take off. This unique occurrence would have been all the more problematic had teams not heeded safety advice in this less-than-ideal situation. Practices and protocols keep patients safe too but only if they are followed. A unique set of circumstances led to the death of a patient awaiting care in a Pennsylvania emergency department. Protocols weren’t followed limiting situation awareness, communication and process completion. Balls were dropped and the results were tragic. Complex systems can manifest unintended consequences from strategies designed to protect people. Balloon fiesta has its share of mishaps. Pilots end up in the Rio Grande, drift into powerlines, bones get broken and, rarely, lives are lost. The expert crews mean well but failures happen. A nurse in Tennessee who made a medication mistake that resulted in patient death was charged criminally. While lawmakers may feel this is a just approach, it is a threat to healthcare transparency. A series of incidents involving misdiagnosis of child abuse is raising concerns in the US. While specialised paediatricians can readily identify patient conditions that indicate abuse, sometimes those judgements are made in error. The decisions made to protect children instead accuse innocent parents or family members of harm. The safe flight of those families then tumbles to the ground. The pace is back to normal in Albuquerque. Balloons still float above us in the morning and afternoon—'tis the season. They brighten the clear blue skies with the Sandia mountains as a backdrop. But you can bet that what did go wrong this year will be folded into the event planning so all that participate in the 2020 festival will be as safe as possible.