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Welcome to the Indiana Patient Safety Center

The Indiana Patient Safety Center was formed in July 2006.  The main function of the center is to provide education, training, and other tools to foster cultures of safety in the complex work environments of Indiana’s hospitals.

The center’s plan is to encourage and facilitate evidence-based practices to reduce delivery system failures that could cause harm to patients.

Patient Safety Update

2008 Indiana Medical Error Reporting System
The Indiana State Department of Health released the 2008 Indiana Medical Error Report on August 20.

ISDH to Host Event on Health Care Associated Infections March 2
The ISDH invites each comprehensive care facility and hospital to send two representatives to the conference. Each facility may select the individuals attending the conference on behalf of their facility. The ISDH recommends individuals such as the facility administrator, director of nursing, or compliance officer attend. Corporate offices of facilities are also invited to send appropriate representatives. A brochure and registration information are posted on the ISDH Web site. Click here to learn more.

Free Tool Improves Safety Leadership
Indiana hospitals are being offered a free opportunity to evaluate board and leadership engagement in quality and safety improvement. A new Web-based survey, the Hospital Leadership and Quality Assessment Tool, helps hospitals to identify and improve leadership structures and processes that are associated with high-performance in clinical quality measures. Participating hospitals will receive a hospital-level HLQAT report that provides valuable benchmarks. Hospitals should repeat the survey in 12-18 months. To participate, hospitals should assemble a team of at least 13 people, comprising board members, c-level executives, and clinical executives. Interested hospitals should contact Betsy Lee at blee@ihaconnect.org or 317/423-7795.

IHA Promotes Idealized Design for Perinatal Care
At its June 10 meeting, the Council on Quality and Patient Safety of the Indiana Hospital Association approved a motion to promote awareness of the Institute for Healthcare Improvement’s research regarding the perinatal care “bundles” and its white paper Idealized Design of Perinatal Care.

Implementing policies regarding induction prior to 39-weeks of gestation is among the bundle interventions that IHI is encouraging hospitals to adopt for better patient outcomes. You may download a copy of IHI’s white paper here.

Implementation Toolkit for Wristband Standardization Now On-Line
The implementation toolkit for standardizing wristband colors is now online; click here. IHA recommends all hospitals consider using six standard colors for alert wristbands to improve patient safety. The goal is to complete implementations by Dec. 31, 2009.

IHA Council Makes Recommendation on Emergency Codes
At its June 10 meeting, the IHA Council on Quality and Patient Safety recommended that hospitals continue to use plain language for emergency codes, if this is the hospitals standard practice. However, if using colors, the council recommends that hospitals implement the use of red, blue, and amber by January 2010. Hospitals are not required to comply with this policy. The recommendation will be taken to the IHA Board for adoption in September.

Stop BSI: Indiana Hospitals to Participate in 28-State Collaborative
The IPSC is encouraging all Indiana hospitals to participate in a national project to reduce central line associated blood stream infections. IPSC in conjunction with faculty at Johns Hopkins University will assist participating hospitals implement an improvement model which has been proven to significantly reduce CLABSI incidence. The initiative goes beyone the central line bundle implementation to assist units in promoting cultures of safety. Hospital teams interested in participating in the Stop BSI project should contact Betsy Lee at blee@ihaconnect.org or 317/423-7795.

The Sprint! - Adopt the WHO Surgical Safety Checklist
The World Health Organization and the Institute for Healthcare Improvement launched a project in December to increase the use of the WHO’s Surgical Safety Checklist. A recent study demonstrated use of the checklist resulted in significant reductions in surgical complications and mortality. WHO and the IHI challenged hospitals to adopt the use of the checklist in at least one operating room by April 1, 2009. Fifty-seven Indiana hospitals and surgery centers reported that they tested or intend to test the checklist by that date. Download the checklist and update your hospitals status at www.ihi.org.

IHA Launched Health Status Improvement Task Force
IHA has launched a Health Status Improvement Task Force to improve six key measures targeted for community-based improvements. Toolkits will be developed to help hospitals impact improvement in these health metrics through a two-pronged approach for employee incentives and community efforts. The targeted measures include: smoking rates; obesity rates; adults with diabetes; prenatal care in the first trimester; childhood immunizations; and self-reported poor mental health.The first toolkit to promote tobacco cessation in hopsital employees and the community is available at www.ihaconnect.org

The Indiana Patient Safety Center will also align its activities in 2009 with the National Priorities Partnership, which was convened by the National Quality Forum. Information can be found at http://www.nationalprioritiespartnership.org/Priorities.aspx.

Get Your Patient Safety News by RSS Feed or Email
You can now subscribe to the Patient Safety RSS Feed. A link to subscribe is on the home page at www.ihaconnect.org or you can find at www.indianapatientsafety.org. Once you get to the patient safety news section, click on the orange button to subscribe to the feed. It works similar to an internet “favorite.” IPSC will post news as we get it, and you can check the RSS feed to see what we have posted.

E-mail Alternative: If you prefer, you can also click on the link to the Patient Safety News page and check the “notify me” button. Then, when news is posted you will receive an email update.

Regional Safety Coalitions Updates
Regional patient safety coalitions are active in Indianapolis, Evansville, Northeast Indiana, and the Michiana region. Coalitions in the state are working on standardizing practices such as common universal protocols, wristband colors, infection prevention bundles, IV pump concentrations, and many other safety efforts to engage front-line staff. If you are interested in forming a regional patient safety coalition in your area or connecting to one, contact Betsy Lee, director, Indiana Patient Safety Center, at blee@ihaconnect.org or 317/423-7795.

Statewide Culture Survey--Over 43,00 Surveyed
The IPSC provides Indiana hospitals the opportunity to conduct employee patient safety culture surveys using a Web-based application of the Agency for Healthcare Research and Quality culture survey tool. Participation in the statewide culture survey will allow hospitals to compare their results to the state aggregate. 43,000 employees from over 75 Indiana hospitals have participated.

What is Just Culture?

The just culture paradigm addresses the weakness of a blame-free approach to errors and near-misses but also runs counter to an overly-punitive culture. One of the leading authorities on the topic, David Marx, describes it this way:

"On one side of the coin, it is about creating a reporting environment where staff can raise their hand when they have seen a risk or made a mistake. It is a culture that rewards reporting and puts a high value on open communication—where risks are openly discussed between managers and staff. It is a culture hungry for knowledge.

On the other side of the coin, it is about having a well-established system of accountability. A Just Culture must recognize that while we as humans are fallible, we do generally have control of our behavioral choices, whether we are an executive, a manager, or a staff member. Just Culture flourishes in an organization that understands the concept of shared accountability—that good system design and good behavioral choices of staff together produce good results. It has to be both."

To learn more, visit http://www.justculture.org/