Health/Public Health and Safety/Patient Safety Health/Public Health and Safety/Organizations Health/Health Care/Organizations Patient safety organization health http://www.chpso.org/ manual http://www.chpso.org/images/chpsofull.png http://www.chpso.org/ 144 58 California Hospital Patient Safety Organization (CHPSO) Dedicated to eliminating preventable harm and improving the quality of health care delivery in California hospitals. en-us Copyright © 2009-2012, California Hospital Patient Safety Organization rjaffe@calhospital.org (Rory Jaffe) rjaffe@calhospital.org (Rory Jaffe) http://www.rssboard.org/rss-specification pics-1.1 "http://www.icra.org/pics/vocabularyv03/" l gen true for "http://chpso.org" r (n 0 s 0 v 0 l 0 oa 0 ob 0 oc 0 od 0 oe 0 of 0 og 0 oh 0 c 0) gen true for "http://www.chpso.org" r (n 0 s 0 v 0 l 0 oa 0 ob 0 oc 0 od 0 oe 0 of 0 og 0 oh 0 c 0)) http://www.chpso.org/newsletter/201202.pdf http://www.chpso.org/newsletter/201202.pdf The second 2012 monthly edition of CHPSO Patient Safety News has been released. Jaffe, Rory 2012-02-02T11:00:00-08:00 3a57e287-6cfa-4556-ba0b-bc292d8ccd4d Breakdowns in patient "handoff" communication continue to be a leading cause of preventable patient harm. The California Hospital Patient Safety Organization (CHPSO) is offering a series of webinars for its members that provide strategies to improve patient safety when one provider hands over the responsibility of care to another. The four-part series will address handoff tools, technology use, training programs, metrics, and hospital successes. The first webinar takes place Jan. 24 from 12:30-1:30 p.m. (PT), and covers handoff tools and the results of a handoff survey that CHPSO conducted last fall in collaboration with the North Carolina Center for Hospital Quality and Patient Safety. Subsequent webinars will be held from 9:30-10:30 am, PST, Feb. 28, March 27, and April 24. Space is limited. To register for these member-only webinars, contact Colleen Meacham, cmeacham@chpso.org, (916) 552-7651. CHPSO membership is available at no charge for members of CHA and the Regional Associations. For membership information call CHPSO Executive Director, Rory Jaffe, M.D., M.B.A., (916) 552-7568. Jaffe, Rory 2012-01-18T12:45:00-08:00 http://www.chpso.org/newsletter/201201.pdf http://www.chpso.org/newsletter/201201.pdf The first 2012 monthly edition of CHPSO Patient Safety News has been released. Jaffe, Rory 2012-01-02T12:30:00-08:00 http://www.chpso.org/newsletter/201112.pdf http://www.chpso.org/newsletter/201112.pdf The twelfth 2011 monthly edition of CHPSO Patient Safety News has been released. Jaffe, Rory 2011-12-02T15:00:00-08:00 http://www.chpso.org/newsletter/201111.pdf http://www.chpso.org/newsletter/201111.pdf The eleventh 2011 monthly edition of CHPSO Patient Safety News has been released. Jaffe, Rory 2011-11-02T14:00:00-07:00 http://www.chpso.org/rsi/index.php http://www.chpso.org/rsi/index.php We are collecting information to help us understand how and why items are left behind. Learning from both near misses and actual events will help us better protect our patients. Information collection forms and instructions are available at <a href="//www.chpso.org/rsi/index.php">www.chpso.org/rsi/index.php</a>. Jaffe, Rory 2011-10-11T11:30:00-07:00 http://www.chpso.org/newsletter/201110.pdf http://www.chpso.org/newsletter/201110.pdf The tenth 2011 monthly edition of CHPSO Patient Safety News has been released. Jaffe, Rory 2011-10-07T15:45:00-07:00 http://www.caringisourcalling.org/ http://www.caringisourcalling.org/ California Hospital Association has launched a patient safety awareness campaign. The campaign features television ads, web-based video, patient safety issue briefs, and digital and social media activities. Jaffe, Rory 2011-10-06T08:30:00-07:00 http://www.chpso.org/newsletter/201109.pdf http://www.chpso.org/newsletter/201109.pdf The ninth 2011 monthly edition of CHPSO Patient Safety News has been released. Jaffe, Rory 2011-09-01T08:50:00-07:00 http://www.chpso.org/meds/index.php b4515eab-67df-4c0b-af32-ceadce333112 The document <a href="//www.chpso.org/meds/fentpatch.pdf">High Alert Medication Guideline - FentaNYL Transdermal Patch</a>, developed by the California Hospital Association Medication Safety Committee, summarizes safer practices to reduce the preventable harm to patients in the hospital setting. Jaffe, Rory 2011-08-23T10:30:00-07:00 http://www.chpso.org/newsletter/201108.pdf http://www.chpso.org/newsletter/201108.pdf The eighth 2011 monthly edition of CHPSO Patient Safety News has been released. Jaffe, Rory 2011-08-02T15:50:00-07:00 http://www.chpso.org/newsletter/201107.pdf http://www.chpso.org/newsletter/201107.pdf The seventh 2011 monthly edition of CHPSO Patient Safety News has been released. Jaffe, Rory 2011-07-01T12:50:00-07:00 http://www.chpso.org/newsletter/201106.pdf http://www.chpso.org/newsletter/201106.pdf The sixth 2011 monthly edition of CHPSO Patient Safety News has been released. Jaffe, Rory 2011-06-01T09:00:00-07:00 http://www.chpso.org/newsletter/201105.pdf http://www.chpso.org/newsletter/201105.pdf The fifth 2011 monthly edition of CHPSO Patient Safety News has been released. Jaffe, Rory 2011-05-03T11:50:00-07:00 http://www.chpso.org/newsletter/a20110405.asp http://www.chpso.org/newsletter/201100405.asp US Marshals raided H&P Industries, which makes alcohol wipes and other products distributed by Triad Group. Jaffe, Rory 2011-04-05T16:30:00-07:00 http://www.chpso.org/newsletter/201104.pdf http://www.chpso.org/newsletter/201104.pdf The fourth 2011 monthly edition of CHPSO Patient Safety News has been released. Jaffe, Rory 2011-04-04T11:00:00-07:00 http://www.chpso.org/newsletter/a20110321.asp http://www.chpso.org/newsletter/201100321.asp Povidine Iodine prep pads are being recalled due to possible bacterial contamination. Jaffe, Rory 2011-03-21T17:00:00-07:00 http://www.chpso.org/newsletter/201103.pdf http://www.chpso.org/newsletter/201103.pdf The third 2011 monthly edition of CHPSO Patient Safety News has been released. Jaffe, Rory 2011-03-03T11:00:00-08:00 http://www.chpso.org/newsletter/201102.pdf http://www.chpso.org/newsletter/201102.pdf The second 2011 monthly edition of CHPSO Patient Safety News has been released. Jaffe, Rory 2011-02-01T10:00:00-08:00 http://www.chpso.org/newsletter/a20110106.pdf http://www.chpso.org/newsletter/a20110106.pdf Alcohol prep pads, swabs, and swabsticks are being recalled due to possible bacterial contamination. Jaffe, Rory 2011-01-06T11:00:00-08:00 http://www.chpso.org/newsletter/201101.pdf http://www.chpso.org/newsletter/201101.pdf The first 2011 monthly edition of CHPSO Patient Safety News has been released. Jaffe, Rory 2011-01-05T11:00:00-08:00 http://www.chpso.org/newsletter/201012.pdf http://www.chpso.org/newsletter/201012.pdf The tweflth 2010 monthly edition of CHPSO Patient Safety News has been released. Jaffe, Rory 2010-11-02T09:00:00-08:00 http://www.chpso.org/dirqual.pdf http://www.chpso.org/dirqual.pdf The Director Quality and Patient Safety will foster multi-facility collaboration for patient safety improvement and facilitate patient safety initiatives throughout California. As an expert resource for members, the Director will identify patient safety best practices, models, and other proven and effective strategies and provide assistance to members seeking to expand their safety efforts; enable peer-to-peer connectivity to facilitate learning and sharing of experiences; and bring practitioners and industry leaders together to share knowledge and foster innovations in quality and patient safety. Jaffe, Rory 2010-11-30T14:15:00-08:00 http://www.chpso.org/newsletter/a20101118.asp http://www.chpso.org/newsletter/a20101118.asp Further information to help protect from having unexpected settings on patient air mattresses. Jaffe, Rory 2010-11-18T13:00:00-08:00 http://www.chpso.org/newsletter/a20101111.asp http://www.chpso.org/newsletter/a20101111.asp Some air mattresses may change settings when unplugged, potentially contributing to pressure ulcer formation. Jaffe, Rory 2010-11-12T08:30:00-08:00 http://www.chpso.org/newsletter/201011.pdf http://www.chpso.org/newsletter/201011.pdf The eleventh 2010 monthly edition of CHPSO Patient Safety News has been released. Jaffe, Rory 2010-11-02T09:00:00-08:00 http://www.chpso.org/webinar/20101008.asp http://www.chpso.org/webinar/20101008.asp A recording, synchronized with the slides, is now available on the CHPSO web site for those who missed the teleconference. Jaffe, Rory 2010-10-19T14:15:00-07:00 http://www.chpso.org/newsletter/201010.pdf http://www.chpso.org/newsletter/201010.pdf The tenth 2010 monthly edition of CHPSO Patient Safety News has been released. Jaffe, Rory 2010-10-01T09:00:00-07:00 http://www.chpso.org/newsletter/201009.pdf http://www.chpso.org/newsletter/201009.pdf The ninth 2010 monthly edition of CHPSO Patient Safety News has been released. Jaffe, Rory 2010-08-31T10:30:00-07:00 http://www.chpso.org/ 5f827343-5205-49b0-8762-746393ab0a72 There has been a recent flurry of articles detailing the adverse effects of elective delivery at 37 and 38 weeks gestational age. The CHPSO Perinatal Care Page now has two slide presentations for download: making the case for eliminating elective delivery before 39 weeks, and successfully changing the practice. The page also has links to 17 articles discussing the adverse effects and change models. Many of those articles are freely available to non-subscribers and are marked (free full access). The CHPSO WHO Surgical Checklist Page now has links to twelve modified checklist versions. These include customizations for specialized surgical procedures (e.g., cataract surgery, radiological interventions, adult cardiac surgery), Joint Commission requirements and Surgical Care Improvement Project (SCIP) measures. Jaffe, Rory 2010-08-16T14:00:00-07:00 http://www.chpso.org/newsletter/201008.pdf http://www.chpso.org/newsletter/201008.pdf The eighth 2010 monthly edition of CHPSO Patient Safety News has been released. Jaffe, Rory 2010-07-30T18:00:00-07:00 http://www.chpso.org/newsletter/a20100713.asp http://www.chpso.org/newsletter/a20100713.asp Luer fittings on a variety of lines poses a risk for misconnections. Enteral tube misconnections can be particularly dangerous. This alert details the issue. Jaffe, Rory 2010-07-14T08:30:00-07:00 http://www.chpso.org/newsletter/201007.pdf http://www.chpso.org/newsletter/201007.pdf The seventh 2010 monthly edition of CHPSO Patient Safety News has been released. Jaffe, Rory 2010-06-30T17:30:00-07:00 http://www.chpso.org/newsletter/201006.pdf http://www.chpso.org/newsletter/201006.pdf The sixth 2010 monthly edition of CHPSO Patient Safety News has been released. Jaffe, Rory 2010-05-28T09:00:00-07:00 http://www.chpso.org/newsletter/201005.pdf http://www.chpso.org/newsletter/201005.pdf The fifth 2010 monthly edition of CHPSO Patient Safety News has been released. Jaffe, Rory 2010-05-02T18:30:00-07:00 http://www.chpso.org/newsletter/201004s.pdf http://www.chpso.org/newsletter/201004s.pdf A special supplement to CHPSO Patient Safety News has been released. This supplement describes Kaiser Pemanente Northen California's high alert medication program and details its implementation. Jaffe, Rory 2010-04-15T12:00:00-07:00 https://www.psoppc.org/web/patientsafety/version-1.1 https://www.psoppc.org/web/patientsafety/version-1.1 Common Formats Version 1.1 is now available, and replaces Version 1.0. Through a contract with the Agency for Healthcare Research and Quality (AHRQ), the National Quality Forum (NQF) solicited feedback on the formats from private sector organizations and individuals. The NQF, a nonprofit organization that focuses on healthcare quality, then convened an expert panel to review the comments received, and provide feedback to AHRQ. Based on the expert panel's feedback, AHRQ further revised and refined the Common Formats that are now available as Version 1.1. This version includes electronic standards. Jaffe, Rory 2010-04-02T08:30:00-07:00 http://www.chpso.org/newsletter/201004.pdf http://www.chpso.org/newsletter/201004.pdf The fourth 2010 monthly edition of CHPSO Patient Safety News has been released. Jaffe, Rory 2010-03-31T08:30:00-07:00 97d80561-5daa-4797-86ca-fe6db202ee66 To better serve members, the California Hospital Patient Safety Organization (CHPSO) has allied with several other hospital association-sponsored patient safety organizations (PSOs) and Quantros to share incident report data with identifiers of hospital and providers removed. The new Nationwide Alliance of PSOs (NAPSO (tm)) already includes 700 hospitals. This alliance will accelerate progress toward identifying and understanding risks, and acting to eliminate preventable harm to hospital patients. The data sharing is made possible through provisions in the Patient Safety and Quality Improvement Act, and will maintain strict and extensive protections afforded information reported to PSOs. Jaffe, Rory 2010-03-22T16:20:00-07:00 b1acf2f0-9c93-40fe-949a-468e1407e5ae CHPSO will be having a teleconference April 22 10-11 am. We will be demonstrating how to enter incident data directly into the CHPSO/Quantros web site. Direct entry is advantageous in several situations, including: 1. When a hospital that currently does not have an electronic incident reporting system wants to use the CHPSO/Quantros site to manage their incident reports, though the site does not have all the functions of an electronic incident reporting system (such as work-flow assistance). 2. When a hospital with an electronic incident reporting system wishes to enter a few reports into the CHPSO system prior to developing an automated reporting process. These functions are provided at no charge to CHPSO members. To sign up, please contact La Shon Tate at <a href="mailto:ltate@calhospital.org">ltate@calhospital.org</a> or (916) 552-7616. Jaffe, Rory 2010-03-22T10:20:00-07:00 d6a8f50b-149b-41b0-8cfe-370057a6759e CHPSO will be having a teleconference March 31 10-11 am. We will be discussing some of the more advanced features of the CHPSO/Quantros web site, including the reporting functions and the Root Cause Analysis tool. These functions are provided at no charge to CHPSO members. The teleconference is open to everyone at no charge. To sign up, please contact La Shon Tate at <a href="mailto:ltate@calhospital.org">ltate@calhospital.org</a> or (916) 552-7616. Jaffe, Rory 2010-03-15T09:45:00-07:00 http://www.chpso.org/newsletter/201003.pdf http://www.chpso.org/newsletter/201003.pdf The third 2010 monthly edition of CHPSO Patient Safety News has been released. Jaffe, Rory 2010-02-25T14:00:00-08:00 http://www.chpso.org/newsletter/201002.pdf http://www.chpso.org/newsletter/201002.pdf The second 2010 monthly edition of CHPSO Patient Safety News has been released. Jaffe, Rory 2010-02-02T08:30:00-08:00 http://www.chpso.org/newsletter/201001.pdf http://www.chpso.org/newsletter/201001.pdf The first 2010 monthly edition of CHPSO Patient Safety News has been released. Jaffe, Rory 2010-01-04T09:40:00-08:00 http://www.chpso.org/newsletter/200912.pdf http://www.chpso.org/newsletter/200912.pdf The tenth monthly edition of CHPSO Patient Safety News has been released. Jaffe, Rory 2009-12-02T09:20:00-08:00 9f381872-b1fe-486e-ad86-9044be45d13a The California Hospital Patient Safety Organization (CHPSO) has established a central information resource area on the <a href="http://www.chpso.org/">CHPSO web site</a> to assist hospitals in their patient-safety and quality-improvement initiatives. Topics currently addressed online include catheter-associated urinary tract infections, central line-associated blood stream infections, <em>C. difficile </em> infections, deep venous thrombosis and pulmonary embolism, hand hygiene, medication safety, multi-drug resistant organisms, sepsis, surgical safety and ventilator-associated pneumonia. Topics will continue to be added, and current topics will be regularly updated and augmented. Hospitals also may use the site to share implementation examples. By sharing "lessons learned," hospitals will reduce resource expenditures through more efficient implementation. Implementation examples may be sent to CHPSO at <a href="mailto:info@chpso.org">info@chpso.org</a>. For a form to assist hospitals in creating a report that can be shared, visit the CHPSO website at <a href="http://www.chpso.org/impexes.doc">http://www.chpso.org/impexes.doc</a>. Jaffe, Rory 2009-11-19T13:30:00-08:00 456d63c7-85b2-41e2-a73a-347c38eb4c22 The California Hospital Patient Safety Organization (CHPSO) and its data partner, Quantros, will hold two complimentary teleconferences to introduce hospitals to CHPSO information services. For more information and to register, contact La Shon Tate at <a href="mailto:ltate@calhospital.org">ltate@calhospital.org</a> or (916) 552-7616). Jaffe, Rory 2009-11-05T08:40:00-08:00 http://www.chpso.org/newsletter/200911.pdf http://www.chpso.org/newsletter/200911.pdf The ninth monthly edition of CHPSO Patient Safety News has been released. Jaffe, Rory 2009-10-30T15:20:00-07:00 http://www.who.int/patientsafety/safesurgery/en/ 4eb7ea5c-686a-4d72-8767-5e20db9b10d8 The 2009 edition of the WHO Surgical Safety Checklist, implementation manual and WHO Guidelines for Safe Surgery are now available for download. The changes from the original 2008 version are minor, but do help to clarify the steps to performing the checklist. Jaffe, Rory 2009-10-30T15:15:00-07:00 http://www.chpso.org/newsletter/200910.asp#story_2 http://www.chpso.org/newsletter/200910.asp#story_2 CHPSO has worked out an arrangement with Quantros to provide patient-safety event management software access at deeply discounted pricing for California health care providers with 50 beds or fewer to make it affordable for even the smallest hospitals. Jaffe, Rory 2009-10-12T10:45:00-07:00 http://www.chpso.org/newsletter/200910.asp#story_6 http://www.chpso.org/newsletter/200910.asp#story_6 CHPSO has opened a public forum on the Facebook social network. This network is useful for getting news updates, networking with peers, sharing ideas and learning from others. To participate in the CHPSO Facebook group, go to <a href="http://www.facebook.com/group.php?gid=130728094433">www.facebook.com/group.php?gid=130728094433</a>. Jaffe, Rory 2009-10-01T14:45:00-07:00 http://www.chpso.org/newsletter/200910.pdf http://www.chpso.org/newsletter/200910.pdf The eighth monthly edition of CHPSO Patient Safety News has been released. Jaffe, Rory 2009-09-28T13:00:00-07:00 https://www.psoppc.org/web/patientsafety/paperforms 4d6630ec-860e-4e3f-a1b0-731d3d421c2d Common Formats Version 1.0 is now available, and it replaces Version 0.1 Beta. Through a contract with AHRQ, the National Quality Forum (NQF) solicited feedback on the formats from private sector organizations and individuals. The NQF, a nonprofit organization that focuses on health care quality, then convened an expert panel to review the comments received and provide feedback to AHRQ. Based upon the expert panel's feedback, AHRQ, further revised and refined the Common Formats that are now available as Version 1.0. AHRQ 2009-09-03T08:35:00-07:00 http://www.chpso.org/newsletter/200909.asp#story_10 http://www.chpso.org/newsletter/200909.asp#story_10 CHPSO has opened a public forum on the LinkedIn social network. This network is useful for getting news updates, networking with peers, sharing ideas and learning from others. To participate in the CHPSO LinkedIn group, go to <a href="http://www.linkedin.com/groups?gid=2174322">www.linkedin.com/groups?gid=2174322</a>. Jaffe, Rory 2009-09-01T14:45:00-07:00 http://www.chpso.org/newsletter/200909.pdf http://www.chpso.org/newsletter/200909.pdf The seventh monthly edition of CHPSO Patient Safety News has been released. Jaffe, Rory 2009-08-31T13:00:00-07:00 http://www.chpso.org/newsletter/200909.asp#story_8 452096ca-3bb1-46dc-8f14-cee86bbbb21c As part of its ongoing goal to help hospitals develop effective strategies for improving patient safety, the California Hospital Patient Safety Organization (CHPSO) is evaluating resources (toolkits, action plans, etc.) to assist with patient safety action priorities. The priorities under discussion are: surviving sepsis; improving surgical care; improving PE and VTE prevention; improving medication management safety; reducing <em>Clostridium difficile</em> and multi-drug resistant organism infections; preventing hospital-acquired pressure ulcers; reducing patient harm from falls; preventing central-line blood stream infections; and preventing ventilator-associated pneumonia. Hospitals are encouraged to send comments and suggested resources to CHPSO. Jaffe, Rory 2009-08-27T15:00:00-07:00 http://www.chpso.org/clbsi/index.asp http://www.chpso.org/clbsi/index.asp California has been selected as one of the states, and the California Hospital Association and CHPSO are proud to lead the effort. Three collaborative meetings are required as part of this project; much of the rest of the interactions will be by teleconference. To make the program available to as many hospitals as possible, the in-person meetings will be held in both the San Diego region and the Central Valley. Jaffe, Rory 2009-08-27T09:00:00-07:00 http://www.prnewswire.com/cgi-bin/stories.pl?ACCT=104&STORY=/www/story/08-17-2009/0005078594&EDATE= http://www.prnewswire.com/cgi-bin/stories.pl?ACCT=104&STORY=/www/story/08-17-2009/0005078594&EDATE= The California Hospital Patient Safety Organization (CHPSO) has selected Quantros, a leading health care information software company, as its technology provider. "A critical element in our selection was that the technology partner provide hospitals with a nearly effortless reporting system," said CHPSO Executive Director Rory Jaffe, M.D. "We recognize the significant reporting burden hospitals currently bear, and do not want data reporting to be a barrier to CHPSO participation." Jaffe, Rory 2009-08-19T09:30:00-07:00 http://www.chpso.org/providerpol/navig.asp http://www.chpso.org/providerpol/navig.asp Ann O'Connell's slides, an abridged recording, and all the handouts from the August 6, 2009 presentation on the interaction between the PSO rule and California privileges, protections and reporting requirements are now available on the CHPSO web site. O'Connell, Ann Jaffe, Rory 2009-08-06T14:30:00-07:00 http://www.chpso.org/providerpol/psesexamp.pdf http://www.chpso.org/providerpol/psesexamp.pdf Example Patient Safety Evaluation System (PSES) that addresses the issues raised in the CHPSO white paper on navigating privileges, protections and reporting requirements. Jaffe, Rory 2009-08-04T16:00:00-07:00 http://www.chpso.org/providerpol/chpsowppr.pdf http://www.chpso.org/providerpol/chpsowppr.pdf This white paper has been prepared on behalf of the California Hospital Patient Safety Organization (CHPSO) to assist California hospitals and their counsel in evaluating some of the implications of participating in a Patient Safety Organization (PSO). O'Connell, Ann 2009-08-04T16:00:00-07:00 http://www.chpso.org/newsletter/200908.pdf http://www.chpso.org/newsletter/200908.pdf The sixth monthly edition of CHPSO Patient Safety News has been released. Jaffe, Rory 2009-08-04T12:00:00-07:00 http://www.chpso.org/just/eventinv.pdf http://www.chpso.org/just/eventinv.pdf Just Culture event investigation training now available. Jaffe, Rory 2009-08-04T12:00:00-07:00 http://www.chpso.org/newsletter/200907.asp#story_2 http://www.chpso.org/newsletter/200907.asp#story_2 CHPSO is calling for submission of best practices for implementing the Joint Commission Universal Protocol and the World Health Organization Surgical Checklist. Jaffe, Rory 2009-08-04T12:00:00-07:00