The Quality Center's Patient Safety Organization 
November/ December Newsletter 
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The Quality Center PSO

TQC PSO Newsletter - November/December 2017


Upcoming Events at a Glance

Upcoming In-Person Learning Opportunities

PSO News
  • The Quality Center PSO Moves Toward the Future
  • A New Member on TQC PSO Team
  • The 2016-2017 PSO Progress Report

Feedback & Learning
  • Don't Overlook the Importance of Safety Culture
  • A Retrospective Look at the VA's ICU Adverse Events
Upcoming Virtual Learning Opportunities

Additional Member Resources
Upcoming Events At a Glance
  • 12/12 - Shared Responsibility for Clinical Workflow and Health Care IT: The Role of Human Factors  Webinar 
  • 12/13 - Using Technology To Improve Quality & Safety: A Pressure Ulcer Project Webinar
  • 12/14 - Concentrated Insulin Safe Table, NC Hospital Association Cary, NC 
Upcoming In-Person Learning Opportunities

Don't Miss an Opportunity to Attend Our Second Safe Table on...  

Concentrated Insulin: A Closer Look  

December 14, 2017: NC Hospital Center, Cary NC
9:45 AM - 1:30 PM

Register Here:

National and local patient safety event reviews reveal several challenges associated with the use of concentrated insulin during in-patient stays.  These events include use of incompatible syringe sizes, inadequate medication reconciliation practices,  availability of supplies to accommodate insulin pumps, challenges with unstable glucose levels and inconsistent use of endocrinologist and diabetes educators to support care transition between home and in-patient services. 

This Safe Table will allow us to take a closer look at the events that are occurring within our organizations and what is being done to prevent them. By digging deeper and wider we will identify the parts of the medication use process that members are struggling with, and discuss solutions. The NCQC PSO is working with other PSOs to identify the issues associated with this high risk medication and will develop resources such as webinars, procedures, training, toolkits, checklists, etc. 

Our Safe Table will also have a pharmacy subject matter expert from UNC Health in attendance to enrich our discussion of medication process improvements and best practices.

What is a Safe Table?

A Safe Table provides a forum for TQC PSO members to network and exchange patient safety experiences and best practices in an open, uninhibited and legally protected environment.  Safe Tables are legally protected under the Patient Safety and Quality Improvement Act of 2005 that allow health care providers to convene and have open dialogue about patient safety and quality of care issues.  All attendees are required to sign confidentiality agreements.  

Who should attend?

Attendance is restricted to TQC PSO member organizations. To enrich the conversation we ask that physician and nurse leaders, pharmacists, medical safety officers, risk managers,  endocrinologists, diabetes educators, care coordinators and other health care professionals affiliated with in-patient, out-patient, skilled nursing and long term care facilities attend this Safe Table and come prepared to share.   

What should I bring?

Attendees are required to bring 1 or 2 de-identified concentrated insulin events that occurred in their organization to share in an open discussion. Remove any patient or provider identifiable information. The Safe Table discussions take place within the NCQC Patient Safety Evaluation System to encourage open and robust dialogue about these events and what can be done to prevent them without fear of discovery. We also invite you to bring and share copies of procedures, checklists and trainings that are being used in your organizations for sharing.

What is the goal?

The goal is to learn from each other, share best practices, implement improvements within our organizations to mitigate patient harm and lastly, identify how the NCQC PSO can be of further assistance in addressing these patient safety issues.

There is no fee and a light lunch will be provided. Directions to the venue and meeting requirements will be included in the meeting confirmation.

For registration questions contact Laini Jarrett at or 919-677-4123.

PSO News

The NC Quality Center Moves Toward the Future 

Nearly 10 years ago, NC Quality Center embarked on its journey to become the first Patient Safety Organization in NC and the 25th in the nation. Over the years, under the leadership of Nancy Schanz, the NC Quality Center PSO has established a strong foundation with over 100 members and 154,000 reported events which has guided the improvement efforts providing content for peer to peer learning.  The NCQC PSO has become a national leader contributing to many best practices and assisted NC hospitals and health systems implement and enhanced their safety culture programs. As the healthcare market is changing and health systems are now moving across state lines, NCQC PSO is also enlarging our footprint. Under a business plan, we are charting a course to pace with our member expansion and plan to move toward a national model. This will allow for larger repository of events, access to a larger body of experts and peer network for sharing of best practice. In addition, we are expanding our reach beyond hospitals to include nursing homes, physician offices.

After a successful relisting process with AHRQ, we are now listed as “The Quality Center PSO” (TQC PSO), signifying a milestone in our journey to serve you as your PSO. You can expect to still have the same level of individualized service from our team and we will continue to make sure the local context of NC is kept a priority. For more information please contact Karen Southard
A New Member on the QC PSO Team: Welcome Claudia Paren, RN, MSN

Claudia Paren is a passionate nurse professional with a background in quality, regulatory and patient safety. Previously she served as Patient Safety Manager for Duke Raleigh Hospital and clinics where she was instrumental in enhancing the culture of safety through establishment of patient safety practices including daily safety briefings, walk rounds, and TeamSTEPPS training. Her nursing background includes medical-surgical, medical ICU, bone marrow transplant, and hospice care. She completed her Master’s of Nursing at Duke University School of Nursing and obtained her BSN and BS in Psychology from the University of Massachusetts Amherst. She is a Certified Professional in Patient Safety (CPPS), Certified Professional in Healthcare Quality (CPHQ), and an experienced Master TeamSTEPPS Trainer. You can reach Claudia at the following. 

Claudia Paren, Performance Improvement Specialist
Interested to know what your PSO has accomplished in the past year?
The Quality Center PSO has published the
2016 - 2017 PSO Program Summary

Check It Out! 

Feedback & Learning

 Don’t Overlook the Importance of Safety Culture!
For the last two consecutive years The Quality Center hosted a workshop on “Second Victims” featuring Susan Scott who spearheaded the forYOU program  at the University of Missouri. Two of our North Carolina Hospitals, UNC Hospitals and Mission Health also shared the evolution of their programs. Your organization may have started a similar program or be in the process of considering or creating one at your organization. These programs are based on the fact that:
  1. Adverse events are common in healthcare and often result in emotional trauma to patients, families, and healthcare providers involved in these incidents and
  2. Critical incident stress debriefing (CISD) is a way to reduce the negative psychological aftermath of these incidents for healthcare providers and is a useful strategy to promote resilience, recovery and the continuous provision of safe patient care.
  3. An organization's safety culture can provide the psychological safety needed by a team or individual involved in an adverse event
In an era of increasing regulations, demands on staff time and efforts to deliver high quality care, an important element of safety culture could quite easily be overlooked. That is the importance of the psychologic safety of the team who delivers the care that results in an adverse event. A variety of metrics assess an institution’s safety culture, inclusive of aspects related to team interaction and communication.
A fairly recently recognized area of needed effort, however, relates to the impact on care teams of unanticipated consequences during care-giving episodes. Reema Harrison and Albert Wu, authors of
Critical Incident Stress Debriefing After Adverse Patient Safety Events note, adverse events are not always related to patient mortality. They can be related to significant morbidities and/or complications that, in hindsight, may have been prevented, but, in real time, represent a coalescence of, at best, unfortunate circumstances and, at worst, missed opportunities and amplified failings of human and systems interactions. 

As mentioned in the article, a formalized structure to address acute and/or untoward events is a critical aspect of team support and gets to the necessity of the importance of humanism within the practice of patient care. The willingness to provide support to colleagues and coworkers at times of potentially gravely impacting circumstances is a critical component of maintaining team collegiality and interactions, and also supporting optimal team function. Every institution should evaluate its need for this type of support and provide a mechanism for peers and coworkers to share in mutual interactions that facilitate trust and resolution of emotional burdens emplaced by untoward circumstances.

A Retrospective Look at the VA’s ICU Adverse Events
ICUs have a great potential for adverse events given the complexity of the environment, multifaceted patient’s conditions and fragility of the patient. The Veteran’s Health Administration (VHA) retrospectively studied events from a two-year period that prompted a root cause analysis (RCA) in order to identify trends in event types, root causes and recommended actions.
There were 152 causes and 277 recommendations in the seventy (70) events studied. Results showed root causes involved rules, policies and procedure processes (28%), equipment/supply issues (16%) and knowledge deficits/education (15%).  Recommended actions included policy, procedure and process actions (34%) and training/education actions (31%).
In summary, regardless of event type, ICU adverse events had several root causes, with protocols and process-of-care issues as many of the root causes. Actions included standardization of processes and training/education. Recommended improvements in the ICU included standardization of care processes, conducting team training programs and simulation based training.
Corwin GS; Mills PD ; Shanawani H; et al. Root cause analysis of ICU adverse events in the Veterans Health Administration.  Joint Commission Journal of Quality & Patient Safety.  2017; 43.
Upcoming Virtual Learning Opportunities 
Human Factors and its Application To Healthcare Systems 
Fall Webinar Series

We could not think of a better way to celebrate the arrival of fall and the holidays than with a great learning series. Since October the NCQC PSO has been hosting Dr. Janey Barnes, Human Factors and Usability Specialist  to share her knowledge with PSO members across the country via the Human Factors in Healthcare Webinar Series. During this three part series participants have received an introduction to the field of human factors and the opportunity to apply human factors methods and tools to relevant issues facing the complex socio-technical environment of healthcare organizations, namely, alarm safety and work flow processes. Participants have also heard how the RCA process can be of assistance in identifying human factor contributions to events. 

It is not too late to join in on the learning. Register here now for the 3rd session.  

Shared Responsibility for Clinical Workflow and Health IT: The Role of Human Factors

Date: December 12, 2017 1-2 PM ET

Session Objectives
  • Knowledge of elements of clinical workflow [Systems Engineering Initiative for Patient Safety (SEIPS)] Framework
  • An outline of clinical workflow documentation
  • Use of RCA process to identify human factor contributions
  • Knowledge of methods of evaluating Healthcare IT (heuristic evaluation, cognitive walkthrough and user testing)
  • Recommendations for successful integration of Healthcare IT into clinical workflow

Using Technology To Improve Quality & Safety: A Pressure Ulcer Project
 December 13th at 3-4pm ET
Holly Kirkland-Kyhn, PhD, FNP-BC, GNP-BC, CWCN, NE-BC, Director, Skin Wound Assessment-Treatment Team; UC Davis Medical Center
Oleg Teleten, MS, RN, CWCN, Registered Nurse, Wound Care Quality Improvement & Research, UC Davis Medical Center
Summary: CMS has declined reimbursement for hospital acquired pressure ulcers (HAPUs) since 2008. A team of nurses successfully secured funding, used technology to measure outcomes, and converted Quality Improvement projects into comparative research. The application of the knowledge gained during the Quality Improvement comparative research cycle allowed UC Davis Health to lower their HAPU incidence while standardizing documentation and identifying those patients who are at highest risk for development of HAPU.
Save the Date - Registration Open Here Soon

Additional Member Resources 
Looking for More 
QC 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.
Recently Added Resources 
  • Concentrated Insulin Safe Table Takeaways
  • Human Factors in Health Care Webinar (Playback Link)
  • Shared Responsibility in Improving Alarm Safety: The Role of Human Factors Webinar (Playback Link)
  • Lean Six Sigma in an Accountable RCA Process Webinar (Playback Link)
Questions? Contact Us!
Nancy Schanz RN, MA, MBA, MHA
Performance Improvement Specialist

Claudia Paren, RN, BSN, MSN
Performance Improvement Specialist

Laini Jarrett, BS
Project Manager, NC 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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North Carolina Hospital Association · 2400 Weston Parkway · Cary, NC 27513 · USA