Christopher Jerry lost his beautiful two-year-old daughter, Emily, after a fatal medication error in March of 2006. After the tragic loss, he created The Emily Jerry Foundation to increase public awareness of the systemic aspects of medicine, as well as, addressing key patient safety related issues by identifying technology and best practices that are proven to minimize the “human error” component of medicine. Mr. Jerry is a relentless patient safety advocate who spreads a message of hope, change, forgiveness, compassion, collaboration, and how to turn a tragedy into honoring Emily by inspiring positive change in our nation’s medical facilities

Eric Cropp has 16 years of experience working in the field of pharmacy, the majority of that time in the oncology field. For several years he managed a compounding pharmacy that specialized in the treatment of cancer patients. Shortly before the incident that is the subject of this program, he had begun finishing his PharmD degree, with which he intended to specialize in pediatric oncology.

Mr. Cropp was a pharmacist at an Ohio Hospital on February 26, 2006, when a pharmacy technician under his supervision made an error in mixing a saline/chemotherapy solution intended for two-year-old Emily Jerry. Emily, who was undergoing treatment for a spinal malignancy, died three days after the solution was intravenously administered. Mr. Cropp was ultimately convicted of involuntary manslaughter.

Since finishing his sentence of six months in jail and six months of home arrest, Mr. Cropp has been working with several organizations (ISMP, PharmCon)  telling his and Emily’s stories. He has also lectured to several large companies about the importance of patient safety as well as of safe conditions in the work place. He shows his audience all the areas at Rainbow Children’s that could have been improved to ensure a safe outcome. He has recently begun to work with Chris Jerry, Emily’s father, to further teach families and medical professionals the importance of creating the safest environment for both the patient and the caregiver.

Safe patient hand-offs are a critical moment in time for everyone involved in the care of patients. The call to action inspired by the IOM White Paper, “To Err is Human,” emphasized the need to develop standardized methodologies that promote consistent communication amongst health care providers across the care continuum. As I reflect on this seminal work, I’ve come to realize that it’s been 13 years since publication and I ask myself, “How far have we come?” We are in an era when millions of people have technology at their fingertips via personal devices with thousands of instantly downloadable applications. However, how often when we drill down patient safety events do we find communication as the root cause?

My organization has been documenting patient care in an electronic medical record since 1996. I’m proud to say we are a front runner and well positioned to tackle the challenges of Meaningful Use. Yet when we observed nurses’ hand off methodologies one glaringly obvious gap was the way in which essential patient information was exchanged. Yes, we’d implemented a standard form and format for verbal hand-offs of care – “Situation, Background, Assessment, Recommendations” (SBAR). However, nurses still had to hand write information already documented in the EMR on a paper SBAR form. Finally, IT resources were dedicated to partner with nurses to create an electronic SBAR report sheet. This tool pulls essential patient information contained within the EMR into a clear, succinct document used to facilitate bedside hand-offs.

Since implementation, the “eSBAR” has standardized and streamlined hand-offs of care between shifts and during transfers between units. It’s been so well -received that we’ll soon use it for transfer to extended care facilities and from our Emergency Department. As opportunities to leverage technologies arise, it is critical that nurse leaders leverage their influence to insist that IT applications are resourced in ways which support front line caregiver communication.

- Trece Gurrad, MSN, RN, Regional Director, Acute Care Services at PeaceHealth St John Medical Center, Longview

Estes Park Institute Senior Fellow

Patient Safety Leadership Fellow

As a physician with leadership experience for over 20 years, Dr. Lin brings clarity, inspiration, and provocative challenges to her audiences by integrating practical clinical experience, systems thinking around organizational resilience, and essential information of the current patient safety and quality landscape.

Dr. Lin is an inaugural National Patient Safety Foundation/Health Forums Patient Safety Leadership Fellow (2002) and continues as core faculty for the program. She is also adjunctive faculty for the Institute for Health Care Improvement (IHI), faculty for the Jefferson School of Population Health’s Quality and Safety Leadership Series (QSLS), and on the founding steering committee for the VHA West Coast Patient Safety Fellowship. She has written books about patient safety strategies through Rapid Response Teams, Sedation/Analgesia and the Surgical Care Improvement Project.

Dr. Lin works with organizations and hospitals in their Board, MEC, joint leadership and patient safety seminars. She is also active with leading community collaboratives and is currently the Hawaii Physician Lead for the CUSP: STOP BSI initiative. Dr. Lin continues an active clinical practice in anesthesiology in Honolulu being named in the Best Doctors list since 2002.

• Establish a ‘culture of dissatisfaction’ – always be on the lookout and find all the ways to fail.
• Embrace the safe work-arounds, and measure their effect. We know that staff are remarkably creative at developing work-arounds, which exist largely because what we try to impose does not work. If the work-around is safe, learn from it.
• Standardize that which can be standardized, and nothing more; allow improvisation and adaptation; cultivate a culture where these adaptations are not ‘breaking the rules.’ Insist on discussing and learning from both standardization and adaptation.
• What appears safe and reliable is often an infrequent event just waiting to happen; “non-events” do not demonstrate that the system is safe.
• Two questions that leaders can ask of staff:
  • ‘Have you ever been in a situation where you couldn’t follow a policy/procedure designed to make care safe?’
  • ‘Have you ever been in a situation where you have had to manage off-service patients on your unit (e.g., orthopedic surgery patients on a neuro floor)? How did you manage to safely care for them? ‘ Carol pointed out that we wouldn’t want to put up a billboard saying “You’ll get safe care at our hospital…as long as you are only taken care of on the floor specific to your condition, and cared for exclusively by staff who take care of only patients with your condition.”

A concept Carol presented that opened my eyes is what I’ll call “safety creep” although its official name is “System Migration to Boundaries.” First, there is a right way of doing things: this is an expected ‘safe space’ of action defined by professional standards. For example, two nurses check each unit of blood before administering it, and one checks the patient’s ID band: this is the safe space of action.

Over time the behavior starts to creep over to the “illegal but normal” real life standards, aka usual way of doing things: when we’re busy, we still have two nurses check the bag, but it’s ok not to check the ID band (we know who are our patients are, right?).

Creep continues into the ‘illegal illegal’ or very unsafe space, with increasing chance of accidents. For example, now we don’t find a second nurse to check the bag, nor do we check the ID band. Most of us would call that ‘an accident waiting to happen.’ These are the circumstances where, when something bad happens, anyone can say in retrospect, “Why did they keep doing that? Didn’t everyone see how unsafe it was?”

One reason for erosion in safe practices is that as new staff enter this work environment, they are oriented not to the ‘safe space’ or right way of doing things, but to the ‘illegal but normal’ standards that are the practice in that setting. Thus they perceive these standards as the safe space of action, when in fact they are illegal but normal. Unless we continually work to move back to the expected safe space from the usual space, and orient/train to the safe space, we are allowing safety to degrade.

Best wishes for a safe and happy new year.

Thoughts? Share with me here…

Group 1

Concentrated on structural issues to support the two selected clinical topics—prevention of surgical site infection, and prevention of venous thromboembolism—what do we need to go forward? There is lack of coordination of topics at the state level—how do we take this work (of the Coalition) into the future, coordinate efforts, keep topics from fading from interest?

• Continue the core planning group, form Steering Committee and add other members (business community, consumer, etc.)
• Have a conference at least annually
• Steering Committee should take the recommendations and flesh them out within Washington, e.g., address geographic issues

Topic 1: Surgical Site Infection

• Link with the work of the national surgical infection collaborative work—perhaps Steering Committee can endorse
• Identify a return on investment (ROI) for preventing surgical infection
• Collaborative work will be the basis for ongoing measurement around this recommendation

Topic 2: Thromboembolism

• Interest group to meet in the summer, focus on continuum of care from inpatient to outpatient care; get Medicare Part A and B talking about it.
• Identify ROI for the recommendation.

Group 2

1. Consumer Education

• Reference JCAHO Speak Up and National Patient Safety Foundation (NPSF) documents for basic information to share.
• Share the above groups (JCAHO & NPSF) information with table members and get consensus then send the participants at the meeting for group input and consensus.
• Utilizing the numerous educational avenues listed on our flip chart information begin to spread the use of the new tool for Patient Safety In Washington State
• Engage physicians by educating at State-Wide meetings, as well as taking this to the medical schools to incorporate into their education process
• Engage nursing and other professionals through their educational offerings
• Continually reinforce the message like “Speak Up” on an ongoing basis utilizing the various tools for education – flyers/brochures in offices, DMV, Post Office, etc. Utilize TV, radio, and newspapers for Public Service Announcements (PSA’s), posters in hospitals and physician offices
• Teach physicians and staff to encourage the dialogue with patients and families – can utilize scripting as appropriate (i.e. can I answer any other questions for you?, here is a notepad to write down any questions you may have and when the doctor comes to see you I will help you get those questions answered).

Goals/timeframes:

Overall goal is to accomplish the information blitz within next two years.

2. Informed Consent

• With a more educated and engaged patient/family population the roll out of improving informed consent would be a natural flow
• Provide a source for evidence-based information to assist in the explanation of procedures and surgeries.
• Create education materials keeping in mind literacy issues and cultural diversities

Goals/timeframes:
Natural flow after initial first 12 months of above project

Group 3

The Foundation for Health Care Quality was volunteered by Dorothy Teeter, FHCQ CEO, for continued organizational and staff support.

Topic 1: Prevention of surgical site infection

• Goal: 95% of all patients get the right antibiotic
• How to achieve?
  • Within 6 months: establish a way for all hospitals to commit to participate
    • Identify the educational tool(s) and uniform data collection tool for hospitals
    • Establish the statewide baseline
    • Help hospitals improve performance
    • Establish data repository
  • Within 18 months: remeasuare

Topic 2: Improve consumer involvement in their care and safety

• Focus on polypharmacy
  • The State Coalition will support this effort
  • Target those over 50 years old
  • Use statewide information blitz

At 12 months: survey patients > 50 years – has anything changed? Plan followup activities

Group 4

Improve the capture of errors and events

• Non-alignment emerged around the potential use and misuse of data
• What are we doing to share our improvements: hospitals want to talk about the good things, and insurers and the State want to hear about the good things.
• Improve partnerships between insurers and hospitals
• Identify neutral third-party forum to share
• Use an existing user group – add consumer and payer perspectives; put out a newsletter so everyone can benefit.
• Hospitals/providers want some protection in the marketplace.
• Others want assurance that providers/hospitals are working aggressively to make improvements
• Payers would focus on evidence-based measures and support anonymous reporting.
• Summary: a voluntary collaborative to share information; collaborative would include providers, consumers, payers, et al.

Group 5

Patient safety relies on information, and need to get consumers involved: focus is on information to the consumer.

Develop Patient Safety Coalition

• Address the top three LeapFrog initiatives first, then broader issues.
• How?
  • Identify the Coalition
  • Align knowledge and constituencies
  • Want a common goal and focused goals
    • Who needs to be there? Who are the stakeholders?
    • Convene a neutral and time-sensitive body
    • Develop a single set of measures and priorities for the Coalition
    • Need ‘gain-gain’
  • Individual commitment
    • How to communicate better with hospitals
    • Share best practices & measures
    • Talk to hospital leadership, get buy-in
• In two years:
  • The LeapFrog initiative will have ‘gained traction.’
  • Physician leaders around patient safety
  • Patient-to-patient safety meetings?
  • Financial commitment
  • CEO commitment
  • Need steering committee and quarterly meetings

Group 6

1. Intensivists in Intensive Care Units

• The wording in the recommendation is overly-specific.
• Standard should be the “percent of hospitals who apply this to their ICU patients”.
• The Coalition needs to make itself known as an entity, then get a group to own the language around this standard, articulate it and its rationale.
• Talk to all of the interested parties about it, e.g, LeapFrog and the professional organizations that define ‘intensivists’ – take a ‘Walk in the Woods’ by February 200

2. Patients involved in their care and documentation

• The Coalition must be in existence and serve as champion: identify the groups that would be partners in this, e.g., consumers, AMA, WSMA, and facilitate that discussion; there is already some alignment of interests among the parties. Target date is Fall 2002.
• The role of the Coalition is to make sure this all happens.
• The measure will be defined by that group.

Group 7

1. Antibiotics and surgical site infections

• Each hospital adopts the CDC standard for defining what a surgical site infection is. (Possible resistance from hospitals that use their own definition of infection.) Target: 1 year
  • Evaluate which hospitals are using it
  • Determine why, if not using
  • Help hospitals adopt its use
  • Report who has adopted
• Eventual expansion of use of definition to other settings, e.g., outpatient surgery
• Develop best practices using hospital stakeholders using consensus process
• Implement best practice using various methods, e.g., statewide collaborative
• Consider peer-reporting of adherence to best practice (2 years) or public reporting (3 years)

2. CPOE

• So many stakeholders agree on it but big issue is funding – ultimately need to seek funding for acquisition.
• Six month goal: increase shared understanding among the stakeholders about barriers (a Walk in the Woods approach), then seek funding together.

Responses From Panel

Troy Hutson, Washington State Hospital Association:

• Great work; impressed with effort and the quality of the recommendations
• Leadership: how do we get leadership to continue?
• Need to be inclusive – get all stakeholders involved
• Voluntary collaboration – let’s build on what we know how to do, our willingness to work together, and use existing models for improvement, e.g. collaboratives, COAP
• Need to take that Walk in the Woods together with LeapFrog
• JCAHO, National Public Safety Foundation – how do all the efforts fit together?
• Strategic vision: let’s figure out how to use this structure to look at patient safety comprehensively, which will eliminate need to respond to multiple requests

Maxine Hayes, Department of Health:

• Very good use of her time
• DOH could provide leadership and use its voice in Olympia for advocacy
• Need to legitimatize the Coalition, then can assign work. All of the sponsors should commit to ongoing support.
• Part of the DOH’s mission is to assure patient safety, but can’t do it alone. All of our efforts are very interdependent.
• Will contribute their credibility to the formation of the Coalition.
• All sponsors want to be very supportive
• Recognized Mary Selecky’s presence today.
• DOH is not a purchaser but does have, for example, the Diabetes Collaborative expertise

Steven Seitz, Agency for Healthcare Research & Quality, User Liaison Program:

• AHRQ has been to five states dealing with state policymakers, and is working with LeapFrog is help some of the states get started
• Most states did ‘talking head’ events, but one had a pre-determined political agenda it wanted to advance: outcome of the event was “here’s what we are not going to do.”
• Other states’ work compared to Washington?
  • We have the better chance of getting something to actually happen
  • We started by dealing with the internal processes of the stakeholders – where do we disagree?
  • Many of our reports ended up pretty specific – they have ‘stickiness.’
  • Can consolidate all into an action plan

Tuesday, May 15, 2012 - Hilton Seattle Airport & Conference Center

Our 10th regional conference focuses on the topic of “Safety in Transition.” Presentations by nationally-recognized speakers, breakout discussions in workshop formats, a poster session, and networking opportunities, provide a full-day event that will challenge participants’ assumptions about best practices, and provide tools and methods that can be quickly put to use in participants’ care settings. Topics may cover a wide range from safety during transition to electronic health records, to the effect of health care disparities on safety to patient identification during transfers and transitions, and much, much more…

Conference registrants are invited to a book-signing and lecture by Dr. Abraham Verghese, author of Cutting for Stone, on Monday afternoon, May 14 (4:15-6 p.m.) at the conference site, followed by a reception. Registrants will receive priority seating and complimentary parking.

Members: $250; Non-members: $325; Full-Time Students and Poster Presenters: $150

We are honored that Qualis Health will present its annual Awards of Excellence in Healthcare Quality again in 2012 at the Northwest Patient Safety Conference.

Featured Speakers

	Keynote Speaker John J. Nance John J. Nance is a well-known international advocate of crew resource management and expanded human performance training and is a dynamic professional speaker/consultant, presenting pivotal programs on Teamwork, Risk Management, Motivation, Coping with Competition, and other topics. Read More
	Della Lin, MD As a physician with leadership experience for over 20 years, Dr. Lin brings clarity, inspiration, and provocative challenges to her audiences by integrating practical clinical experience, systems thinking around organizational resilience, and essential information of the current patient safety and quality landscape. Read More
	Chris Jerry & Eric Cropp – The Emily Jerry Story In 2006 Mr. Jerry’s daughter died as the result of improperly-prepared chemotherapy in an Ohio hospital. Mr. Cropp, the supervising pharmacist, ultimately was jailed for six months for involuntary manslaughter and his license was revoked. Chris and Eric will speak together about error, forgiveness, system failure, and their shared efforts to improve patient safety. Read More

Kaiser Permanente transition bundle

Carol Barnes, MS, PT, GCSNational Executive Consultant Strategic Programs, Kaiser Permanente

Kaiser Permanente Northwest’s Transition Bundle is improving patient satisfaction, reducing unnecessary readmissions, and increasing timeliness of primary care provider appointments and exchange of clinical information.  We will share our successful results of transition improvement and measurement strategy across our regions.

Learning Objectives

• Identify the elements of an effective Transitions Bundle
• List ways to measure Transition Care improvement
• Understand how to spread successful practices

Maximizing patient-centered care: clinical pharmacy management of the high-risk patient

Melissa Hull, PharmD, CACP, CLS.  ACC and Lipid Clinic Supervisor, The Polyclinic Kristen Dittmeier, RN, BSN. Quality Improvement Consultant for Patient Safety and Clinical Pharmacy Collaborative, Qualis Health

This session provides the fundamentals of HRSA’s Patient Safety and Clinical Pharmacy Services Collaborative (PSPC), which is transforming delivery systems to improve processes, health and safety outcomes and care transitions for high-risk, high-cost patients by integrating clinical pharmacy services throughout patient care.

Learning Objectives

• Describe the national PSPC collaborative, and consider how your organization can get involved;
• Access national, evidence-based resources for improving medication safety and overall management of high-risk patients, including a package of change ideas with examples of how they have been implemented nationally;
• Apply the experiences of a local team to quality improvement activities at the attendee’s local organization.

Opening the lines of communication between hospitals and outpatient community care settings: examples of collaboration to improve quality of care, patient safety, and patient outcomes

Meg Kilcup, PharmD. Coordinator, Transition of Care, Group Health Cooperative

Dana Kahn, PharmD, BCPS. Medication Safety Specialist, Virginia Mason Medical Center

Transitioning patients from the hospital to outpatient settings is one of the most complicated yet pivotal transitions for safe and quality patient care. Group Health Cooperative (GHC) and Virginia Mason Medical Center (VMMC) closely collaborated to break down institutional barriers in tackling three critical medication-related initiatives.

Learning Objectives

• Understand the importance of collaboration between hospitals and outpatient care settings for ensuring quality care and patient safety in transitions.
• Identify how collaboration between hospital and community clinics allows for sustainable programs, allowing for decreased hospital readmissions, significant financial savings, and patient and provider satisfaction.
• Identify key methods to lay the groundwork and plan processes using cross-institutional teamwork in addressing the transition of care and patient experience from hospital to outpatient care.

Bridging the gap: discharge clinics providing safe transitions for high-risk patients

Shay Martinez, MD Medical Director, Aftercare Clinic, Harborview Medical Center

With the disappearing model of primary care providers caring for their own patients while hospitalized, there has been a growing recognition of the disconnect between hospital-based and outpatient clinic care. One solution to this problem is the post-discharge transitional care clinic. This workshop introduces the concept of hospitalist involvement in outpatient post-hospitalization care, and provides practical knowledge of how to establish a hospitalist-run post-discharge clinic.

Learning Objectives

• Recognize that timely outpatient follow-up after hospital discharge is important for patient safety and quality of care
• Identify the roles that hospitalists can play in post-discharge patient care.
• How to design a discharge clinic based on the specific needs of your institution.

What works for preventing hospital readmissions? A review of the current evidence and best practices

Steve Riddle; BS Pharm, BCPS, FASHP Vice President of Clinical Affairs, Pharmacy OneSource

This presentation will review the most relevant published data on readmissions, such as validated risk factors and predictors of readmission, as well as key elements of successful care models. The focus will be on practical information that will assist the attendees in establishing or better refining current services targeting readmissions reduction.

Learning Objectives

• Describe common causes for readmissions and the patient risk factors associated with these events.
• Describe three specific service interventions that successful programs have used to reduce hospital readmissions
• Explain how to build a scalable model of services that is effective in reducing readmission and sustainable based on successful clinical and fiscally sound practices in place in the U.S.

Meeting accreditation standards for effective patient-centered care: implications and strategies for improving patient safety and quality of care during care transitions

Ira SenGupta, MAExecutive Director, Cross Cultural Health Care Program

The Joint Commission and other accreditation standards include requirements that promote effective communication between patients and their caregivers, cultural competence, and patient-centered communication. This presentation will focus on strategies for meeting such accreditation requirements and standards while enhancing patient safety during the transition between hospital and home or a post-acute care settings.

Learning Objectives

• Gain strategies to understand and implement the 2012 Joint Commission and other patient- centered communication standards.
• Understand how to strengthen patient and family understanding and engagement in their care in the context of cultural and linguistic differences.
• Leave with a template for a culturally and linguistically competent transition checklist.

Safety-focused, patient-centered care will succeed or fail in the boardroom:  engaged boards are leading the way -  all stakeholders have a role to play

Tom Van Dawark, BA, MBACEO, Orca Partners LLC

Boards that transition to an unrelenting focus upon patient safety are making a real difference. Learn what is working, to make governance work for you.

Stakeholders will learn about the powers they have to drive change, and how to get to know their board; board members and stakeholders will learn that governance really does matter.

Learning Objectives

• Stakeholders will be able to engage and better support their boards in safety and quality improvement
• Board members and stakeholders will be inspired, gain the courage to change and be able to lead the way by learning what has worked for others
• Participants will leave with 12 actions that they can take to make an immediate impact.

Safe passage: opportunities to avoid harm and provide care at the end of life

Hope Wechkin, MDMedical Director, Evergreen Hospice and Palliative Care

This session will focus on the American palliative and hospice care systems as both models and beneficiaries of the patient safety movement.  The first half of the discussion will address everyday aspects of hospice and palliative care that intersect with patient safety concerns. The second half of the discussion will take into consideration a particular patient with a limited prognosis as she moves from outpatient care to the hospital to home to an inpatient facility.

Learning Objectives

• Participants will be able to initiate conversations with patients and/or family members regarding goals of care, using a general format and checklist that will be discussed.
• Identify common safety challenges at the end of life, and be able to discuss effective approaches to those challenges.

Typically, though, there are suggestions of having nurses attend the safety committee so leaders understand what is happening on the unit. Leaders ask those nurses what they can contribute to preventing patient events and ask if practice matches the policies and procedures. Often we will hear the barriers they come across or what their wish list might be to assist with the success of reducing patient events.

That is great information, but not a true representation of how far the understanding has reached the front line staff.

One experience I can share is when I was rounding and talking to staff. I happened to ask a nurse about how she prevented her patient from falls. She was able to articulate the interventions and show how she documented fall risk, etc. I asked her how many falls her unit had in the past month and she was unsure. I asked her how many falls occurred house-wide last month and she said, “ Maybe two or three”? Her response indicated to me that she did not have an accurate understanding of the fall rate.

I proceeded to ask random staff on different shifts and realized the information reached management, but not necessarily those at the bedside.

Take your staff to the safety board and show them: “ Here are the data on falls, you will see a graph each month indicating how we are doing.” Don’t assume staff can read graphs. The data should tell a story that can be digested. Ask staff to use post-it notes to place suggestions for improving patient safety and affix them to the safety board. Find out what information they need to know. Look for gaps and then bring the information back to them.

Poor communication is a common cause of medical errors in healthcare. We need better communication about medical errors in order to work as a team to prevent them.