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Win a free registration to AHAP ’09

In an effort to make this year’s AHAP Conference as accessible and fun as possible, we’ve decided to run a contest–and each week, we’ll hold a drawing for a free registration to the conference! All you have to do to enter is submit a Tip of the Day for the AHAP Blog.

The rules are simple: write up an accreditation-related tip on the topic of your choosing-a tool you’d like to share with other AHAP members, a story about a recent survey, a short post about how you’ve improved staff education on infection control or how you’re meeting a National Patient Safety Goal, for example. Simply email your tip to me at I’ll post it to the blog as each entry arrives, and you’ll be entered to win a weekly drawing for registration to the conference!

We’ll announce the winners each Friday morning. The contest will run through Friday, April 24th. Questions? Feel free to email me for details. Looking forward to hearing from you!

Has your facility decided to join a Patient Safety Organization?

Though the Final Rule went into effect on January 19, 2009, many organizations are still researching the decision to join a Patient Safety Organization (PSO). PSOs have been almost four years in the making–they are a product of the Patient Safety and Quality Improvement Act of 2005 and anxiously awaited by many in the patient safety field. As of today there are 52 listed PSOs from which healthcare organizations can choose from, many of which are from specific states. If you’d like to find out more information about PSOs, visit the AHRQ Web site by visiting

The following is an excerpt from an article I wrote for the March issue of Briefings on Patient Safety on the topic of PSOs. Although a big attraction for hospitals to join PSOs is the added protection that data submitted to a PSO receive, the ultimate goal of PSOs is to increase the quality of patient care on a national scale

Most facilities are interested in joining a PSO not simply because they can now receive analysis on protected data. The underlying reason for joining a PSO is to keep patients safer.

“As information is shared, especially information on rare events that we see, when you start aggregating larger amounts of data, you really start seeing some contributing factors to those events, and that helps you figure out what needs to be fixed within a system to prevent them from happening,” says Amy Goldberg-Alberts, MBA, FASHRM, program director at the ECRI Institute, a nonprofit organization that has been involved with patient safety and event reporting for decades and has created its own PSO.

“The big benefit is to improve patient safety,” says Ronni Solomon, JD, executive vice president and general counsel of the ECRI Institute. “What the law and final regulations do is pave the way to get closer to that goal.” Although the regulations are mostly focused on reporting of data and incidents, the rule is really about understanding why incidents happen and how to change our systems to account for this understanding, Solomon says.

Additionally, PSOs can help facilities reduce the cost of learning by allowing individual facilities to take advantage of collective learning, says Rohde.

“For a small facility, the PSO allows them to combine their knowledge with other facilities’ knowledge and -really benefit from the collective learning of a much larger organization,” says Ken Rohde, consultant for The Greeley Company. The goal of any good reporting system is to fix a problem before is occurs. Any organization that has the opportunity to learn from another’s mistakes can benefit financially, he says.

Representatives for the Peminic-Greeley PSO and the ECRI Institute’s PSO say one of the biggest benefits to joining a PSO is not just data aggregation, but the PSO’s ability to provide solutions for identified trouble spots.

Rohde, who is part of the Peminic-Greeley PSO shared some comments with me about the topic. If you click the link below you’ll hear Ken describing the goal of PSOs, and also some of the benefits of data sharing which is a part of joining a PSO through the Network of Patient Safety Databases. To hear more of what Ken Rohde has to say about PSOs,

Get the Flash Player to see the wordTube Media Player.

And we thought doctors’ ties were dirty

Who knew we should be washing our cell phones? According to a recent study in the Annals of Clinical Macrobiology (reports,  cell phones can–and frequently are–covered in bacteria.

Researchers at Ondokuz Mayis University in Samsun, Turkey tested employee cell phones to discover the following alarming statistic: 94.5 percent of the phones they tested were contaminated with bacteria.

Worse yet–some of these phones were contaminated with drug-resistant “superbugs.”

We’ve known for a while now that certain everyday objects that are not washed or cleaned every day–lab coats and ties, for example–can house bacteria  and help it move around the hospital. But how many hospitals are screening cell phones? Is yours? If so, how do you screen phones? What sorts of policies do you have in place to maintain this practice?

MRSA: Not just for hospitals anymore

Not that this is news, per se–but hospitals have been receiving the bulk of MRSA-related press lately. Here’s an unusual bit of news related to the superbug:

While hospitals receive the bulk of attention in the battle to prevent methicillin resistant Staphylococcus aureus (MRSA), the “superbug” can arise in unexpected places-and recently, that unexpected place was the San Diego Zoo, the LA Times reports.

As many as 20 human caretakers were infected at the zoo. The most likely cause appears to be the first known transmission of MRSA from a zoo animal to a human. It appears that a human handler infected a baby elephant, which was being hand-raised by zookeepers because the mother elephant was unable to care for it. The calf then in turn passed the infection back to other zookeepers.

More than a third of the workers involved in caring for the calf were infected with MRSA, developing for the most part mild symptoms.

If you’re interested in reading the full Times article, it can be found here.

FDA issues warning about MRI burns

The Food and Drug Administration (FDA) issued a warning yesterday about the risk of burns to patients who wear transdermal patches. These are medicated patches most often associated with smokers who are trying to quit smoking. These patches have been catching fire during MRI scans because many of them contain a metal backing that’s not always visible to the wearer, or the person administering the scan.

While the FDA is compiling a list of those patches that could ignite during a scan, it has issued the following advice to healthcare workers:

  •  identify those patients who are wearing a patch before the patients have the MRI scan
  • advise those patients about the procedures for removing and disposing of the patch before the MRI scan
  • advise those patients about replacing the patch after the MRI scan

To read the full advisory, click here.

Patient Safety Awareness Week starts March 8th

Patient Safety Awareness Week logoAs many of you may know, Patient Safety Awareness Week is coming up, beginning on Sunday March 8 and running through Saturday March 14. This annual observance, sponsored by the National Patient Safety Foundation (NPSF), serves as a great opportunity for hospitals to not only offer unique and creative patient safety-related programming, but it provides a chance for hospital staff members to connect with the outside community to emphasize patient safety.

This year’s theme, “A Prescription for Patient Safety: One Partnership, One Team” highlights this need to better involve patients in their own care. If you visit the NPSF’s Patient Safety Awareness Week web site, you’ll find a host of suggested activities for patients, staff members, and other community members to take part in as a means of building awareness about patient safety topics. The NPSF also just announced the release of a Universal Compact, which is aims to foster clearer lines of communications among patients and their clinicians.

“The Universal Patient Compact is an evolution of the concept of the Patient’s Bill of Rights,” said Diane Pinakiewicz, MBA, president of the NPSF in an interview. “It will focus on the patient and provider working together as a team. We want to get the patient’s voice inside the provider team, and build a partnering between the parties.”

The Association for Professionals in Infection Control and Epidemiology (APIC) has also released some helpful reminders specifically for those people visiting hospitalized patients in honor of the week. Some of these include:

  • Sanitize hands before and after your visit
  • Stay home if you’re sick
  • Before you bring the kids, flowers, or food, check to make sure they are allowed
  • Don’t contribute to the clutter by bringing unnecessary personal items

Click here to find the full list.

I know lots of facilities use Patient Safety Awareness Week as a chance to host hospitalwide events that focus on keeping patients safe and engage both staff members and community members in creative ways. What is your hospital doing? What have you been a part of in the past as far as event programming?

Sebelius chosen to replace Daschle as HHS secretary

For those anxiously awaiting President Obama’s second nomination for Secretary of Health and Human Services (HHS), the wait is over. The governor of Kansas, Kathleen Sebelius, democrat, is the president’s next choice for the position. Sebelius, who I mentioned in this posting on the Patient Safety Monitor blog as a possible candidate as secretary of HHS, has a track record of working closely with health insurers in her home state. In fact, prior to working as the governor, Sebelius served as Kansas’ state insurance commissioner. Her nomination has received praise from both republicans and democrats alike. Unlike Obama’s first nomination for HHS secretary, Tom Daschle, Sebelius will not serve as both HHS secretary and “healthcare czar,” a position that will specifically focus on reforming healthcare.

Should Sebelius be confirmed, she will have a lot on her plate as soon as she starts. A commissioner of the Food and Drug Administration has yet to be named, mostly because of the delay in confirming an HHS secretary. Known for her pro-abortion and stance and bipartisan policies, Sebelius successfully blocked the sale of Blue Cross Blue Shield of Kansas to Anthem Inc. because she said it would have raised insurance premiums for residents of the state.

You can read more about Sebelius in these articles from the Wichita Tribune and New York Times.

Do you have any initial thoughts about President Obama’s choice?

Joint Commission releases sentinel event statistics through 2008

The Joint Commission has released its latest statistics for sentinel events through December 31, 2008. Perhaps not surprisingly, wrong-site surgery tops the list at 13.2% of reported events. The data released by The Joint Commission date back to 1995, and the database contains 5,632 total events. Second to wrong-site surgery is suicide at 12.4%.

Does this list reflect the most reported events at your hospital?

If you’d like more details about the specific events on this list, you can click here and find options for looking at trends by year and by state.

Only 80 days until the AHAP conference

Just wanted to let you all know that there are only 80 days between now and the AHAP conference on May 14 and 15! For those who have already signed up, I hope you are as excited as we are to get together with peers and learn about the latest trends in accreditation. I’m particularly interested to sit in on the panel scheduled that will have speakers from The Joint Commission, DNV, and HFAP to discuss accreditation options.

For those who haven’t signed up yet and are interested, you can check out the agenda and any related registration information by clicking here. The early-bird rate is still available and will be through March 13.

It’s sure to be a good time with fellow healthcare accreditation buffs, Vegas style!

Working group calls: Save the date

Our next round of working group calls are coming up this month. This time around we’ll be talking about infection control issues. Jodi Eisenberg will facilitate the first call, 2/24, at 2:30 pm EST (1:30 Central, 11:30 Pacific). We’d like to welcome Marsha Barnden, MSN, RNC, an infection control expert and former Joint Commission surveyor, who will facilitate the second call on 2/26 (12:30 EST, 11:30 Central, 9:30 Pacific).

We’re looking forward to an active, lively discussion both days. Hope you can join us!