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March/April 2018 Newsletter
In This Issue. . . 
Upcoming Events At-A-Glance

PSO Safety Topics

- Inpatient DNR Identification
- When Clinicians Drop Out and Start Over after Adverse Events

Feedback and Learning
- Inpatient DNR Survey Results
- HIT Patient Safety Best Practices
- Free Opioid Training to Educate & Empower

Upcoming In-Person Learning Opportunities
- Caring for Behavioral Health Patients in Non-Behavioral Health Settings: A Primer     for Clinical & Non-Clinical Professionals
- Root Cause Analysis and Action
- Safe Table Discussions
- NCHA Quality and Patient Safety Symposium

Upcoming Virtual Learning Opportunities
- Fall Webinar Learning Series: Patient Safety Culture

Additional Member Resources

Questions? Contact Us!

Upcoming Events At-A-Glance

3       Webinar: NextPlane tutorial on Insights 
5       Webinar: Member Feature: National Patient Safety Awareness Week Activities
9       Workshop: Caring for Behavioral Health Patients in Non- Behavioral Health Settings: A Primer for              Clinical & Non-clinical Professionals - NCHA - Cary, NC
25      Webinar: NextPlane tutorial on Exchange Uploading & Mapping

8       Safe Table: Handoffs and Care Transitions - Rocky Mount, NC
31     Safe Table: Patient & Staff Violence - NCHA - Cary, NC

14      Workshop: Root Cause Analysis 2 - Cary, NC 

18       SafeTable: Elopement Risk - DSOHF Staff Only- Burlington, NC 

TBD    Webinar: Standardizing Safety Practices: Beyond Checklists

2         Safe Table: Bar-Coded Medication Admin. Workarounds - Gastonia, NC
15-16  Conference: Quality and Patient Safety Symposium - Chapel Hill, NC
TBD    Webinar: Learning Environment & Good Catches

1         Webinar: Socializing Measures of Harm - NextPlane Measures Program

PSO Safety Topics

Inpatient DNR Identification
Recently, DNR identification methods made headlines after a New England Journal of Medicinecase-study detailed the ethical challenges encountered when a 70-year-old, unconscious patient tattooed with Do Not Resuscitate on
his chest, presented to a Florida hospital. At the heart of the matter was a patient attempting to visually communicate his resuscitation wishes to any and all potential caregivers.The similar, albeit less newsworthy, challenge of effectively, visually identifying patient wishes occurs daily in hospitals. In the absence of technology solutions that eliminate or reduce potential errors associated with misidentification, what are the best practices for ensuring a patient only receives the life sustaining treatment s/he desires? Full Article
The Quality Center PSO assisted with participant recruitment for this recently published study on the effects of adverse errors on clinicians.

Read the article:  When Clinicians Drop Out and Start Over after Adverse Events
Jason Rodriquez, PhD; Susan D. Scott, PhD, RN, CPPS
The Joint Commission Journal on Quality and Patient Safety 2018; 44:137–145

The impact of adverse clinical events on health care workers has become a growing topic of research. Previous research has confirmed that after adverse clinical events, clinical staff often feel as though they failed not only their patient but also themselves, resulting in second-guessing of their clinical skills, competencies, and even career choices. This exploratory study reports on the experiences of health care providers who changed career paths as a consequence of an adverse clinical event. Full Article

Feedback and Learning

Inpatient DNR Survey Feedback
Thank you to all who responded to our Inpatient DNR Wristband Survey!
We received 21 responses from hospitals. 
The primary methods used to identify inpatient code status: 
  • Physician order in the EHR (67%) 
  • Colored wrist-band (19%)
  • Paper order (9%)
  • Secondary methods of identification included colored wristbands (38%) and colored wristband indicators (14%).
  •  “Other” methods included indicating patient preference within the electronic health record using a color or icon, communicating during handoffs, and displaying purple ECG tracings on telemetry monitors. 
HIT Patient Safety Best Practices
A special thank you to Nash Hospital for hosting our February Safe Table on Health Information Technology: Frustrations & Fixes.
Janey Barnes, Human Factors subject matter expert joined our the discussion and shared some valuable pearls for tackling HIT frustrations.
Participants Learned:
  1. Over-reliance on technology can have unintended consequences. Check out this great ISMP Safety Alert on Over-Reliance
  2. Most products and technology undergo rigorous user-centered testing before making it to the market. Take the time to communicate back to the vendors when you encounter struggles with equipment or technology.
  3. Utilize a diverse group (new staff members, experienced staff members, early adopters, reluctant adopters, etc.) to assist with piloting any new technology or processes.

Janey will join us October 2nd at CaroMont for Safe Table on BCMA Workarounds .
Free Opioid Training to Educate & Empower

Looking for resources to support opioid education throughout your organization?

CME: NC licensed physicians and PAs are required to complete 3 hours of controlled substance CMEs. Use this voucher (PDF) for 3 FREE HOURS of CME (appropriate for prescribers and dispensers of controlled substances)!

Need more resources on the North Carolina law (the STOP -Strengthen Opioid Misuse Prevention- Act of 2017)? Visit Here 

CNE: The American Psychiatric Nurses Association offers free online webinars through July 30, 2018 for RNs (1.25 CNEs), APRNS (3.5 CNEs), and Psychiatric Mental Health Nurses (1.25 CNE). Visit Here

Upcoming In-Person Learning Opportunities

Last Chance to Register for Caring for Behavioral Health Patients in Non-Behavioral Health Settings: A Primer for Clinical & Non-Clinical Professionals
Date: April 11, 2018
Time: 8am- 4:30pm
Location: NC Healthcare Association, Cary, NC
Registration Fees: Discounted TQC PSO Member Rate: $45, NCHA Member Rate: $80

This interactive workshop will feature an open panel discussion with local experts and will address common mental illness presentations, communication techniques, physical safety considerations, and unique NC challenges.
Register for Behavioral Health Course Here
Root Cause Analysis and Action (RCA²)

Date: Thursday, June 14, 2018
Location: NC Healthcare Association - Cary, NC 
Registration Fees
$85.00 TQC PSO Member rate
$170.00 NCHA Member rate
$180.00 Non-NCHA Member Rate
RCA2: Improving Root Cause Analyses and Actions to Prevent Harm is a framework for root cause analysis endorsed by the NPSF. As the name suggests, the framework puts an emphasis on action – underscoring that discovering the cause of a problem is only useful if change happens as a result. With RCA² the approach is different – and so are the outcomes. Come learn about the RCA2 process, tools and barriers and how it can improve your safety culture. This course will be lead by Jessica Behrhorst, MPH, CPHQ, CPHRM, System Director of Quality and Patient Safety at Ochsner Health System, a 13-hospital health care system. Jessica  has presented at NPSF conferences on her team’s experiences in implementing the RCA2 process.
Register for RCA2 Here
Safe Table Discussions
Join us for a few hours of learning and light-lunch with your colleagues 
Time: 9:45am- 1:30pm    Safe Table FAQ        
Handoffs and Care Transitions  - May 8thRegister Here
Location: Nash Health Care - Rocky Mount, NC
Overview: While on the surface, hand-off appears to be a simple process, but the successful transfer of information is complex and critical to patient safety. Recently, The Joint Commission acknowledged the importance of high quality hand-offs in its Sentinel Event Alert #58. Despite structured tools and frameworks, tackling the handoff process can be overwhelming. Join us to talk though it all. 

Patient-Staff Violence - May 31 - Register Here
Location: NC Healthcare Association , Cary, NC  
Overview: Have you experienced physical violence (hitting, biting, scratching) or verbal violence (insults, threats, cursing) from a patient? Chances are you have or you know someone who has. Such disruptive patient behaviors is increasingly common, and it is important for staff to report such experiences, and likewise, for staff to feel supported by their organization.

Elopement Risks - DSOHF Staff Only - July 18 - Register Here
Location: Alamance Community College - Burlington, NC
Overview: How does your organization identify and safe-guard patients at risk of elopement or wandering? What do you do if a patient goes “missing?

Bar-Coded Medication Administration Workarounds October 2
Location: CaroMont Health - Gastonia, NC
Save the Date 
NCHA Quality and Patient Safety Symposium 

Date: October 15- 16, 2018
Location: Friday Center, Chapel Hill,  NC 

Upcoming Virtual Learning Opportunities

2018 TQC PSO Safety Culture Fall Webinar Learning Series

November 1st 1-2pm: Socializing Measures of Harm - NextPlane Measures Program - Register Here

Date TBD: Standardizing Safety Practices: Beyond Checklists

Date TBD: Learning Environment & Good Catches

Additional Member Resources

Looking for More 
TQC PSO Resources?
Visit our website.
Here you can find:
  • Information on how to keep your membership information current with our team.
  • Information about upcoming events and activities being held online and in your area. 
  • Playback links for the recording of past webinars.
  • Resources from past Safe Tables and other learning events.
  • Updates on important regulatory changes that affect patient safety within your organization.
  • Listing of other TQC PSO members you can network and collaborate with.

Questions? Contact Us!

Nancy Schanz RN, MA, MBA, MHA
Patient Safety Specialist

Claudia Paren, RN, BSN, MSN
Patient Safety & Culture Specialist

Laini Jarrett, BS
PSO Project Manager, The Quality Center

The Quality Center PSO
2400 Weston Parkway • Cary, NC 27513
Copyright © 2017 The North Carolina Quality Center, All rights reserved.

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