Generating a Future Vision of Patient Safety: A Pilot Program to Test the Integration of Certified Professional in Patient Safety™ Curriculum into Undergraduate Medical Education.

Preventable healthcare-associated harm results in significant morbidity and mortality in the United States, costing nearly 400 000 patient lives annually. The Institute for Healthcare Improvement provides high-quality educational resources tailored for working healthcare professionals. One such resource is the Certified Professional in Patient Safety (CPPS™) review course, which equips professionals with advanced proficiency in 5 core patient safety domains. The CPPS™ certification is the only interprofessional, patient safety science credential recognized worldwide. In 2010, the Lucian Leape Institute at the National Patient Safety Foundation described the critical need for medical students to participate in patient safety solutions as well. However, equivalent patient safety credentialing remains challenging for students in the preclinical and clinical stages of training to obtain. To address this growing dilemma, the Texas College of Osteopathic Medicine (TCOM) piloted the first-of-its-kind CPPS™ course with 10 medical students to test a novel, academic-level approach to patient safety curriculum. Medical students showed large gains in performance on the post-test (83.18% ± 26.12%) compared to the pre-test (46.46% ± 27.18%) (P < .001, η2 p = .368), representing increased knowledge across all learning domains. On the national certification examination, students had a 90% first-time pass rate, exceeding the current national average of 70% for first-time examinees. In satisfaction surveys, students expressed the value of pilot curriculum for their medical training, the importance of similar Patient Safety Education and CPPS certification for all medical students, their confidence as future healthcare change agents. Content analysis of open response questions revealed 3 key areas of strength and opportunity for guiding future iterations of the course. This pilot generates a future vision of patient safety, equipping students with critical knowledge to systematically improve healthcare quality.

Knowledge Discovery and Data Mining: Implications for Nurse Leaders.

As systems evolve, their tendency is to become more complex. Studies in the field of complex systems have generated new perspectives on the application of management strategies in health systems. This is the 2nd in a series of articles addressing the mounting challenges faced by nursing leaders demanding insights from the vast amounts of information collected and stored by their organizations.

Simulation in the Executive Suite: Lessons Learned for Building Patient Safety Leadership.

INTRODUCTION: Simulation is a powerful learning tool for building individual and team competencies of frontline health care providers with demonstrable impact on performance. This article examines the impact of simulation in building strategic leadership competencies for patient safety and quality among executive leaders in health care organizations. METHODS: We designed, implemented, and evaluated a simulation as part of a larger safety leadership network meeting for executive leaders. This simulation targeted knowledge competencies of governance priority, culture of continuous improvement, and internal transparency and feedback. Eight teams of leaders in health care organizations-a total of 55 participants-participated in a 4-hour session. Each team performed collectively as a new chief executive officer (CEO) tasked with a goal of rescuing a hospital with a failing safety record. Teams worked on a modifiable simulation board reflecting the current dysfunctional organizational structure of the simulated hospital. They assessed and redesigned accountability structures based on information acquired in encounter sessions with confederates playing the role of internal staff and external consultants. RESULTS: Data were analyzed, and results are presented as qualitative themes arising from the simulation exercise, participant reaction data, and performance during the simulation. Key findings include high degrees of variability in solutions developed for the dysfunctional hospital system and generally positive learner reactions to the simulation experience. CONCLUSIONS: This study illustrates the potential value of simulation as a mechanism for learning and strategy development for executive leaders grappling with patient safety issues. Future research should explore the cognitive or functional fidelity of organizational simulations and the use of custom scenarios for strategic planning.

2009 Annual National Patient Safety Foundation Congress: conference proceedings.

On May 20 to 22, 2009, the National Patient Safety Foundation (NPSF) held its Annual NPSF Patient Safety Congress in National Harbor, Md. Entitled Patient Safety in Challenging Times: Now More Than Ever, A Critical Need, the meeting focused on the need to strengthen efforts to improve patient safety and quality in the midst of the extraordinary economic challenges facing the nation. The Congress was cochaired by the following distinguished individuals: Janet Corrigan, PhD, MBA, president and chief executive officer, National Quality Forum, Lillee Gelinas, RN, MSN, FAAN, vice president and chief nursing officer, VHA, Inc., Doug Bonacum, MBA, BS, vice president for safety management, Kaiser Permanente, and a member of the Board of Directors of NPSF. The main conference was preceded by 3 concurrent day-long workshops: Leadership Day, Patient Safety 101, and Community Engagement from the Patient and Family Perspective. The Congress featured 4 plenary sessions and 35 breakout sessions. This article provides summaries of the plenary sessions.

Nursing measures: implementation considerations: lessons learned from the field.

With today's focus on performance measurement, pay for quality, and other data-driven initiatives in the health care industry, measurement developers and researchers interested in testing these metrics need to keep in mind the needs of those end users that will be tasked with collecting, submitting, and in many cases analyzing the information that flows from these measures. This article will highlight a number of key issues learned from the field and suggest opportunities for research into the design and deployment of these measures.

The effect of workforce issues on patient safety.

The workforce of any health care organization is vital to its continued survival, but a highly competent and committed workforce is vital to its success. The evidence is clear: employees influence not only the financial performance of the organization, but also the safety and quality of the clinical care provided to patients. Health care organizations must understand these important linkages and have in place corporate strategies to manage workforce issues with a systems focus that ensures excellent leadership and operational processes, a healthy culture, and optimum patient outcomes. New levels of knowledge, resources, and implementation are needed to move health care in the United States to the next level of quality performance. Staff satisfaction and retention should be at the heart of the clinical improvement strategies. Such an approach will allow organizations to cope and thrive in an environment of workforce shortages and increasing consumer demand for quality. To quote Robert Waller, MD, of the Mayo Clinic, "The goal is the best care for every patient, every day. Our patients deserve nothing less.