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The Emergency Medicine Patient Safety Foundation’s Education Committee recommends the following resources:
EMPSF 2nd Annual Patient Safety Summit:
On March 22 & 23, 2012, EMPSF held its 2nd Annual Patient Safety Summit: From Insights to Outcomes: Getting Results! The meeting brought together key stakeholders and thought leaders from across the emergency care continuum. Among the distinguished panel of speakers were the presidents of the American College of Emergency Physicians, Emergency Nurses Association, National Patient Safety Foundation and the American Society for Healthcare Risk Management. The meeting represented a cross-section of the emergency medicine community with representatives and patient safety experts from over 21 states and Canada participating.
Summit Program & Agenda program 12.pdf
To View Speaker Presentations – Click here
EMPSF 1st Annual Patient Safety Summit:
Patient Safety in Emergency Care: Excellence in Outcomes was held at the Four Seasons Hotel, May 5-6th, 2011 in Las Vegas, NV. As the inaugural emergency care patient safety conference, the Summit created a focused environment for attendees and patient safety experts to come together to discuss challenges, hear about solutions and integrate with their peers to advance patient safety in emergency care.
Summit Agenda & Speakers program11.pdf
EMPSF 1st Annual Patient Safety Summit Presentations. Patient Safety in Emergency Care:
Excellence in Outcomes. May 5-6, 2011
- Crowding: Causes, Consequences, Cure (PPT 1.9mb)
Jesse Pines, MD, MBA, MSCE, Associate Professor in the Departments of Emergency Medicine and Health Policy, George Washington University, Washington, DC - Boomer Risk: Decreasing Risk and Improving Patient Safety for the Geriatric Patient in the ED (PPT 8.8mb) – Graham Billingham, MD, FACEP, President & CEO EPIC, RRG, Immediate Past Chairman, EMPSF
- Optimizing Hand-offs to Assure Safety in Transitions of Care: From the Field to the Unit (PPT 1.1mb) – John (Jack) Kelly, DO and David Jaslow, MD, MPH, EMT-P, Department of Emergency Medicine, Albert Einstein Medical Center, Philadelphia, PA (2 PowerPoints
- Building a Conceptual Model for ED Procedural Safety: Implications for Practice (PPT 2.4mb) - Jesse Pines, MD, MBA, MSCE, Associate Professor in the Departments of Emergency Medicine and Health Policy, George Washington University, Washington, DC
- The Importance of Communication and Teamwork in Emergency Care (PPT 15.2 mb) - Mary Patterson, MD, MEd, Medical Director, Cincinnati Children's Center for Simulation and Research; Attending Physician, Associate Professor of Clinical Pediatrics, Emergency Medicine, Cincinnati, OH
- Effective Use of Technology in the ED (PPT 15mb) - Rollin J. (Terry) Fairbanks, MD, MS, FACEP, Director National Center for Human Factors Engineering in Healthcare, MedStar Health, Washington, DC
- Creating a Safe Environment for Patients and Providers – The Escalation of Violence in the ED (PPT 5mb) – Anticipating, Planning and Eliminating the Risk - AnnMarie Papa, DNP, RN, MS, Clinical Nurse Specialist at the Hospital of the University of Pennsylvania in Philadelphia, PA, President of ENA
- Reducing Medication Errors in the ED –The Value of Adding a Pharmacist to the Team (PPT 3.9mb) - Joe Spillane, Pharm.D, DABAT, Shands Hospital at The University of Florida, Jacksonville, FL
Patient Safety Briefings
- Working Effectively with Radiology
- Joint Commission Patient Flow Tracer
- Joint Commission Patient Flow Standards
- Intravenous (IV) Smart Pumps
- Reprocessing of Rigid Laryngoscopes
- Restraint & Seclusion - Updated July 2012
New for July
- Hydromorphone - Have You Ensured its Safe Use?
- CMS Final Hospital CoP Changes
- The ED Benchmarking Alliance Annual Data Survey
- The Joint Commission New Patient Flow Standards
- Safe Injection Practices - Updated
- CMS Requirements on Standing Orders
New for September
New for October
New for November
- Drug Shortages - The Challenges of Hospital Pharmacies - Updated January 2013
New for January 2013
EMPSF Forum:
"The Newsletter for Members of the Emergency Medicine Patient Safety Foundation"
EMPSF E-Newsletter:
EMPSF - Medication Safety Form
In support of National Patient Safety Awarness Week, the EMPSF Education Committee developed a medication safety form for patients to complete and share with their medical providers.
Click on this link to access the form
Optimizing Physician-Nurse Communication in the Emergency Department: Strategies for Minimizing Diagnosis-Related Errors:
ed_white_paper_min_diagnosis_errors.pdf Used with permission by: CRICO/Risk Management Foundation of the Harvard Medical Institutions
The Education Committee of the EMPSF would like practitioners to know that there is a new interactive video that every healthcare provider should see. The video is available at no cost. The video was produced by HHS to prevent Healthcare-Associated Infections (HAIs) and is called:
Partnering to Heal: Teaming Up Against Healthcare-Associated Infections. It is available at http://www.hhs.gov/partneringtoheal.
MITTS (Medically Induced Trauma Support Services) Clinician Support Toolkit:
Clinician_Support_Tool_Kit_for_Healthcare_Final_1.pdf
mitss_organizational_assessment_tool_for_clinician_support_12-30-20102.pdf
Agency for Healthcare REsearch (AHRQ):
10 Patient Safety Tips for Hospitals
Agency for Healthcare and Quality (AHRQ):
Multifaceted Program Increases Reporting of Potential Errors, Leads to Action Plans to Enhance Safety. The Good Catch Program http://www.innovations.ahrq.gov/content.aspx?id=273
Physicians on Call:
California's Patchwork Approach to Emergency Department Coverage prepared for the California Healthcare Foundation by Performance Alliance with the University of Southern California, Center for Health Financing, Policy & Management, Feb 2011 http://www.chcf.orgBooks:
Patient Safety in Emergency Medicine [Hardcover]
Pat Croskerry (Editor), Karen S Cosby (Editor), Stephen M Schenkel (Editor), Robert L Wears (Editor)
http://www.amazon.com/Patient-Safety-Emergency-Medicine-Croskerry/dp/0781777275
Understanding Patient Safety (LANGE Clinical Medicine) [Paperback]
Robert Wachter (Author)
http://www.amazon.com/Understanding-Patient-Safety-Clinical-Medicine/dp/0071482776
The Patient Safety Handbook [Hardcover]
Barbara Youngberg (Editor) and Martin Hatlie (Editor)
http://www.amazon.com/Patient-Safety-Handbook-Barbara-Youngberg/dp/0763731471
Safe Patients, Smart Hospitals: How One Doctor’s Checklist Can Help Us Change Health Care from the Inside Out [Hardcover]
Peter Pronovost (Author), Eric Vohr (Author)
http://www.amazon.com/Safe-Patients-Smart-Hospitals-Checklist/dp/159463064X
Human Error [Paperback]
James Reason (Author)
http://www.amazon.com/gp/search?index=books&linkCode=qs&keywords=0521314194
Just Culture: Balancing Safety and Accountability [Paperback]
Sidney Dekker (Author)
http://www.amazon.com/Just-Culture-Balancing-Safety-Accountability/dp/0754672670
Government Publications:
To Err Is Human: Building a Safer Health System
Linda T. Kohn, Janet M. Corrigan, and Molly S. Donaldson, Editors
Committee on Quality of Health Care in America
Institute of Medicine (IOM), National Academy Press, Washington, D.C.
http://www.nap.edu/openbook.php?isbn=0309068371
Patient Safety and Quality: An Evidence-Based Handbook for Nurses
http://www.ahrq.gov/qual/nurseshdbk/
The Future of Emergency Care in the United States Health System
Committee on the Future of Emergency Care in the United States Health System
Board on Health Care Services, Institute of Medicine,
Washington, D.C.: The National Academies Press; 2006
http://www.iom.edu/Activities/Quality/emergencycare.aspx
Journal Articles:
"Improving Handoffs in the Emergency Department"
05 October 2009, February 2010 (Vol. 55, Issue 2, Pages 171-180), Annals of Emergency Medicine,
Dickson S. Cheung, MD, MBA, MPH, John J. Kelly, DO, Christopher Breach, MD, Ross P. Berkeley, MD, Robert A. Bitterman, MD, Robert I. Broida, MD, William C. Dalsey, MD, MBA, Heather L. Farley, MD, Drew C. Fuller, MD, MPH, David J. Garvey PhD, MD, Kevin M. Klauer, DO, Lynne B. McCullough, MD, Emily S. Patterson, PhD, Julius C. Pham, MD, PhD, Michael P. Phelan, MD, JD, Jesse M. Pines, MD, MBA, MSCE, Stephen M. Schenkel, MD, MPP, Anne Tomolo, MD, MPH, Thomas W. Turbiak, MD, John A. Vozenilek, MD, Robert L. Wears, MD, MS, Marjorie L. White, MD.
, American College of Emergency Physicians Section of Quality Improvement and Patient Safety
Annals Emerg Med 2010, Feb; 55(2):17180.
http://www.annemergmed.com/article/S0196-0644(09)01261-X/abstract
"Emergency Physician Perceptions of Patient Safety Risks"
Sklar, DP, Crandall, CS, Zola, T, Cunningham, R, Annals of Emergency Med., 2009;55:336-340.
http://www.journals.elsevierhealth.com/periodicals/ymem/article/S0196-0644(09)01447-4/abstract
"The Nature and Causes of Unintended Events Reported at Ten Emergency Departments"
Smits, M., Groenewegan, PP, Timmermans, DRM, vanderWal, G., Wagner, C., BMC Emerg Med 2009:9:16
http://www.biomedcentral.com/1471-227X/9/16
"ED Overcrowding is Associated with an Increased Frequency in Medication Errors"
Kulstad, EB, Sitka, R., Sweiss, RT, Kelley, KM, Rzechula, KH, Am Journal of Emerg Med 2010, 28:304-309
http://www.ncbi.nlm.nih.gov/pubmed/20223387
"Do Emergency Physicians Attribute Drug Related Emergency Department Visits to Medication Related Problems?"
Hohl, CM, Zed, PJ, Brubacher JR, Abu-Labam, RB, Loewen, PS, Purssell, RA, Annals Emerg Med., 2010;55:493-502
http://www.ncbi.nlm.nih.gov/pubmed/20005010
"Wait Times at Emergency Departments Continue to Increase Nationwide"
http://www.fiercehealthcare.com/story/wait-times-emergency-departments-continue-increase-nationwide/2010-07-22
Websites:
Emergency Care Websites:
- American Academy of Emergency Physicians (AAEM) at http://www.aaem.org
- American College of Emergency Physicians (ACEP) at http://www.acep.org
- Association of Emergency Physicians at http://www.aep.org
- Emergency Department Benchmarking Alliance at http://www.edbenchmarking.org
- Emergency Department Practice Management Association at http://www.edpma.org
- Emergency Medical Services Agency Research Network at http://www.emsarn.org
- Emergency Medicine Patient Safety Foundation (EMPSF) at http://www.empsf.org
- Emergency Medicine Residents’ Association at http://www.emra.org
- EMS associations and memberships at http://www.firstresponder.gov
- Emergency Nurses Association (ENA) at http://www.ena.org
- ENA Institute for Quality, Safety & Injury Prevention (IQSIP) at http://www.ena.org/IQSIP/Pages/about.aspx
- National Association of EMS Physicians at http://www.naemsp.org
- National Association of Emergency Medical Technicians at http://www.naemt.org
- National Emergency Medicine Association at http://www.nemahealth.org
- Society for Academic Emergency Medicine (SAEM) at http://www.saem.org
- Academy of Administrators in Academic Medicine
- Academy for Women in Academic Emergency Medicine
- Academy of Emergency Ultrasound
- Association of Academic Chairs of Emergency Medicine
- Clerkship Directors in Emergency Medicine
- Global Emergency Medicine Academy
- Simulation Academy
- Urgent Matters at http://www.urgentmatters.org
Adverse Drug Events:
- AHRQ Website on Adverse Drug Events at http://www.ahrq.gov/qual/aderia/aderia.htm
- FDA reporting of Adverse Drug Events at http://www.fda.gov/Safety/MedWatch/default.htm
- FDA’s Safe Use Initiative at http://www.fda.gov/Drugs/DrugSafety/SafeUseInitiative/default.htm
- Institute for Health Care Improvement on Medication Systems at http://www.ihi.org/IHI/Topics/PatientSafety/MedicationSystems/
- Institute for Safe Medication Practices: http://www.ismp.org/
- Advisory Committee on Consumer Protection and Quality at http://www.hcqualitycommission.gov/
- Australian Patient Safety Foundation at http://www.apsf.net.au/
- AHRQ Web Site at http://www.ahrq.gov
- Institute for Healthcare Improvement (IHI) trigger tools at http://www.ihi.org/knowledge/Pages/Tools/IntrotoTriggerToolsforIdentifyingAEs.aspx
- AHRQ Medical Errors and Patient Safety website at http://www.ahrq.gov/qual/errorsix.htm
- AHRQ Patient Safety Network (PSNet) at http://psnet.ahrq.gov/
- AHRQ Patient Safety and Quality: An Evidenced Based Handbook for Nurses at http://www.ahrq.gov/qual/nurseshdbk/
- AHRQ Patient Safety Primer (Agency for Healthcare Research and Quality) at http://psnet.ahrq.gov/primerHome.aspx
- AHRQ Patient Safety Toolkits at http://www.ahrq.gov/qual/pips/
- AHRQ National Guideline Clearinghouse at http://www.guideline.gov/
- AHRQ TeamSTEPPS at http://teamstepps.ahrq.gov/index.htm
- AHRQ M&M (Morbidity and Mortality Rounds) at http://www.webmm.ahrq.gov/
- AIS Virtual Patient at http://www.aisvirtualpatient.com
- American Association of Critical Care Nurses (AACN) at http://www.aacn.org/
- American College of Radiology (ACR) Practice Guidelines and Technical Standards at http://www.acr.org or http://www.acr.org/SecondaryMainMenuCategories/quality_safety/guidelines.aspx
- American Hospital Association at http://www.aha.org
- American Nurses Association (ANA) at http://www.nursingworld.org/
- American Society for Anesthesiologists Standards, Guidelines, and Statements at http://www.asahq.org/publicationsAndServices/sgstoc.htm
- American Society for Healthcare Risk Managers (ASHRM) at http://www.ashrm.org
- American Society for Health System Pharmacist (ASHP) at http://www.ashp.org/
- American Society of PeriAnesthesia Nurses (ASPAN) at http://www.aspan.org/Home/tabid/2981/Default.aspx
- Anesthesia Patient Safety Foundation (APSF) at http://www.apsf.org
- Association for Professionals in Infection Control and Epidemiology at http://www.apic.org/AM/Template.cfm?Section=Practice or http://www.apic.org
- Association of periOperative Registered Nurses (AORN) at http://www.aorn.org
- British Medical Journal Medical error and patient safety (BMJ) at http://www.bmj.com/cgi/collection/medical_error_patient_safety
- BEACON-California Bay Area Patient Safety Collaborative at http:/www.beaconcollaborative.org
- Canadian Patient Safety Institute (CPSI) at http://www.patientsafetyinstitute.ca or http://www.patientsafetyinstitute.ca/English/Pages/default.aspx
- CDC on Health care-associated Infections at http://www.cdc.gov/HAI/infectionTypes.html or http://www.cdc.gov
- CDC National Healthcare Safety Network at http://www.cdc.gov/nhsn/
- CMS Conditions of Participation for Hospitals (all manuals) at http://www.cms.hhs.gov/manuals/downloads/som107_Appendicestoc.pdf
- CMS Survey and Certification Memos at http://www.cms.hhs.gov/SurveyCertificationGenInfo/PMSR/list.asp
- CMS Transmittals at http://www.cms.hhs.gov/SurveyCertificationGenInfo/PMSR/list.asp
- Consumers Advancing Patient Safety (CAPS) at http://www.patientsafety.org/
- Council on Surgical and Perioperative Safety (CSPS) at http://www.cspsteam.org/
- Dana Farber Center for Patient Safety at http://www.dana-farber.org/Adult-Care/Treatment-and-Care-for-Adults-with-Cancer.aspx
- Department of Defense Patient Safety Program at http://www.health.mil/dodpatientsafety
- Department of Veterans Affairs National Center for Patient Safety at http://www.patientsafety.gov
- ECRI Institute at http://www.ecri.org or https://www.ecri.org/Pages/default.aspx
- Emergency Medicine Patient Safety Foundation (EMPSF) at http://www.empsf.org
- EMT Training and Career Headquarters - http://www.emttrainings.com
- Food and Drug Administration (FDA) at http://www.fda.gov
- Health Grades at http://www.healthgrades.com/
- Health Research and Educational Trust (HRET) at http://www.hret.org/
- Institute for Clinical Systems Improvement (ICSI) at http://www.icsi.org/index.aspx
- Infection Control toolkits at http://www.infectionpreventiontools.com/home
- Institute for Healthcare Improvement (IHI) at http://www.ihi.org
- Institute for Safe Medication Practices (ISMP) at http://www.ismp.org
- Institute of Medicine (IOM) at http://www.iom.edu/
- Leapfrog Group for Patient Safety at http://www.leapfroggroup.org/
- Joint Commission at http://www.jointcommission.org/standards_information/npsgs.aspx or http://www.jointcommission.org
- Massachusetts Coalition for Prevention of Medication Errors at http://www.macoalition.org/
- MedWatch FDA reporting program at http://www.fda.gov/Safety/MedWatch/default.htm
- MedQIC Quality Improvement Organization and transition resources at http://www.qualitynet.org
- Medically Induced Trauma Support Services at http://www.mitss.org
- Minnesota Department of Health Patient Safety at http://www.health.state.mn.us/patientsafety/
- Missouri Center for Patient Safety at http://www.mocps.org/
- National Center for Human Factor Engineering in Healthcare MedStar Health at http://medicalhumanfactors.net/
- National Committee for Quality Assurance at http://www.ncqa.org
- National Patient Safety Agency (England, NHS) at http://www.npsa.nhs.uk/
- National Patient Safety Foundation at http://www.npsf.org
- National Priority Partnership at http://www.nationalprioritiespartnership.org/Home.aspx
- National Quality Forum (NQF) at http://www.qualityforum.org/Topics/Safety.aspx
- National Safety Council (NSC) at http://www.nsc.org/Pages/Home.aspx
- North Carolina Center for Hospital Quality and Patient Safety at http://www.ncqualitycenter.org/index.lasso
- Partnership for Healthcare Excellence at http://www.partnershipforhealthcare.org/
- Partnership for Patient Safety (p4ps) at http://www.p4ps.org/Home.html
- Pennsylvania Patient Safety Authority (PPSA) at http://patientsafetyauthority.org/Pages/Default.aspx
- Pennsylvania Patient Safety Authority (PPSA) toolkits at http://patientsafetyauthority.org/EducationalTools/PatientSafetyTools/Pages/home.aspx
- Premier Safety Institute at http://www.premierinc.com/all/safety/publications/subscribe.jsp or http://www.premierinc.com/index.jsp
- Safety Leaders and TMIT at http://www.safetyleaders.org/
- Society of Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA) Compendium of Strategies for Prevention of Healthcare-Associated Infections in Acute-Care Hospitals at http://www.shea-online.org/about/compendium.cfm
- Society to Improve Diagnosis in Medicine at http://www.improvediagnosis.org
- The Commonwealth Fund: Why Not the Best? http://www.whynotthebest.org/contents/index/
- Trauma Center Association of America at http://www.traumafoundation.org
- Utah Patient Safety Initiatives at http://health.utah.gov/psi/
- University of Michigan System Patient Safety Toolkit at http://www.med.umich.edu/patientsafetytoolkit/
- VA National Center for Patient Safety (NCPS) at http://www.patientsafety.gov/
- World Health Association (WHO) at http://www.who.int/en/
- WHO Patient Safety at http://www.who.int/patientsafety/en/
- Wrong site surgery at http://www.wrongsitesurgery.com
Culture of Safety:
- AHRQ’s Patient Safety Network on Culture of Safety at http://psnet.ahrq.gov/primer.aspx?primerID=5
- Commonwealth Fund Case Study: Creating a Culture of Safety in the U.S. Department of Veterans Affairs Health Care System at http://www.commonwealthfund.org/Content/Innovations/Case-Studies/2008/Sep/Case-Study--Creating-a-Culture-of-Safety-in-the-U-S--Department-of-Veterans-Affairs-Health-Care-Syst.aspx
- Institute for Healthcare Improvement Toolkit for Developing a Culture of Safety at http://www.ihi.org/IHI/Topics/PatientSafety/SafetyGeneral/Changes/Develop+a+Culture+of+Safety.htm
