Lessons Learned

Watch Out for This Four-Letter Word

Sifting through safety reports at your facility in search of significant issues is daunting. CHPSO shares the challenge: we have about 870,000 reports and more arrive daily.

This challenge is also an opportunity, as we aggregate information from hundreds of providers, and can observe patterns and commonalities in risks and causes that may not be obvious at a single site.


Ask Me When I Last Washed My Hands

Semmelweis’s run chart showing mortality rate decrease following start of hand hygiene.

Over 150 years ago, physician Ignaz Semmelweis determined that health care workers in a Viennese teaching hospital transmitted hospital-acquired diseases. The odor coming from the hands of doctors and students disturbed Semmelweis. He observed that they were not adequately washing their hands after performing autopsies and before their rounds on the delivery suite. “Cadaverous particles” were transferred from doctors and students to mothers, causing puerperal fever.


Update on PSO Reporting System with NextPlane Solutions

CHPSO member hospitals have uniformly experienced a transition to NextPlane Solutions’ reporting system with ease. With the aims of streamlining data submission to CHPSO and saving members the resources of specialized solutions, staff members will only need to export a plain text report from their reporting system. Member column names will be assigned to AHRQ fields and the row contents will be assigned to standardized answers. The entire process takes a few hours for the initial submission.


Multi-Disciplinary RSI Reduction — New AORN Recommended Practices

Surgical-safety events usually are caused by problems with the way we do things (practices) and how we share knowledge and information about what we want to do (communication). No surprise that this is true for retained surgical items (RSIs).1 To date, surgical sponges have been the most common RSI2 and we have the most information about these types of cases.


CHPSO Annual Reports Available January 2016

CHPSO will release the 2015 Annual Report at the end of January 2016. Like the 2014 Annual Report, highlights on future plans will be included as well as an analysis of reported events. In addition to the Annual Report, individualized hospital-specific reports will be mailed to hospital patient safety leaders and CEOs. These reports include the number of reported events by category for the specified hospital and an aggregate for CHPSO, feedback on completion of reports, and a harm scale. Please contact CHPSO if you have any questions at info@chpso.org


Shared Learning Series for 2016

CHPSO has teamed with other PSOs across the nation to provide quarterly patient safety webinars. The North Carolina Quality Center PSO will kick off the Shared Learning Series in February with a webinar on “Stronger Action Planning: The Next Chapter in Risk Management and Patient Safety” presented by Alan Card, PhD, MPH of Evidence-Based Health Solutions, LLC. CHPSO’s Rory Jaffe, MD, MBA, will host a webinar with an update on small bore connectors in May. Dates and details to follow. CHPSO members will be notified of the schedule and topics.