TIPS | Patient Safety Improvement Handbook | Falls Toolkit | Moderate Sedation Toolkit | Cognitive Aids | Other Publications
TIPS is our bimonthly newsletter that offers readers a wide range of topics on patient safety and suggestions on actions that can improve patient safety. Our objective for TIPS is to provide useful and timely topics concerning patient safety.
The latest issue:
May / June 2013 covers Clinical Team Training: Building High-Reliability in VA Health Care, Chief Resident in Quality and Safety, and A Synopsis of Patient Safety Awareness Week Programs, March 5-7, 2013. (PDF)
Previous issues can be found in the TIPS Archive.
NCPS Patient Safety Improvement Handbook
- the handbook developed at the National Center for Patient Safety
Many facilities are working to find ways to reduce the number
of falls as well as the severity of the falls that do occur.
In an effort to help facilities, we created the Falls Toolkit.
To assist VA facilities in assuring that the practice of moderate sedation is reliable and safe, the VA National Center for Patient Safety (NCPS) has developed a Moderate Sedation Toolkit for Non-Anesthesiologists, based upon work done at the Durham VAMC Patient Safety Center of Inquiry.
The toolkit is composed of nine components:
- Facilitator's Guide This introductory guide describes the moderate sedation toolkit components and provides guidelines for the sedation training facilitator including answers to frequently asked questions..
- Learner Objectives These 18 objectives describe the knowledge, skills and behaviors that should be demonstrated by individuals who administer moderate sedation.
- Curriculum Guide This document provides detailed information about moderate sedation practice. Topics include:
Pre-Procedure Evaluation Template This template identifies key features of patient evaluation that should be performed prior to beginning a procedure that requires moderate sedation. Facilities may use this as a guide for creating CPRS templates.
Moderate Sedation Study Aid This colorful graphic summary includes key elements of moderate sedation practice, including many of the topics from the curriculum guide. This 8.5- by 11-inch front and back reference guide may be posted for practitioners in all sites where moderate sedation is administered.
Moderate Sedation Cognitive Aid Modeled after the NCPS Cognitive Aid for Anesthesiology, this colorful 8.5- by 11-inch front and back reference guide provides bulleted guidelines for managing common complications of moderate sedation (hypotension, hypertension, bradycardia, tachycardia, hypoxemia and agitation/difficult to sedate). Each complication is addressed in three parts: initial response; follow-up response; and things to consider. It is intended to be available to practitioners in all sites where moderate sedation is administered.
Call for Help Card This template identifies key resources for assistance. Facilities must customize this card for local use. The local version should be posted and CLEARLY VISIBLE in all sites where moderate sedation is administered.
High-Fidelity Simulation Cases Four cases are available for use in facilities that have the capability to conduct simulation training using a high-fidelity medical simulator. The cases demonstrate the common and important problems encountered during sedation practice.
- Introduction - general principles of moderate sedation
- Pharmacology of commonly used medications
- Relevant anatomy and physiology
- Principles of pre-procedural patient assessment and education
- Monitoring guidelines and techniques
- Intra-Procedure Guideline - required safety equipment and common complication recognition and treatment
- Special situations and high-risk patients
Table Top Simulation Cases Four cases are available for use in all facilities, specifically those that do not have the capability to conduct simulation training using a high-fidelity medical simulator. These cases cover the same material available in the high-fidelity sedation simulation cases described above.
- Case 1: Orientation to Simulator and Training Sessions
- Case 2: Upper Airway Obstruction
- Case 3: A Difficult to Sedate Patient
- Case 4: Medically Compromised Patient
Ordering the NCPS Cognitive Aids
- Triage Cards - presents
questions RCA teams need to know the answer to when completing RCAs and describes how to use the 5 Rules of Causation
when developing causation statements.
- Fall Prevention and Management - tips and suggestions on how to initiate and implement fall prevention interventions and strategies.
- Escape and Elopement Management - tips and suggestions on interventions that may be used to prevent patients from escaping and eloping.
- The Healthcare Failure Mode Effect Analysis Process - provides tips, hints, and directions
on how to complete a proactive risk assessment using the NCPS developed model.
- Root Cause Analysis Tools - provides tips, hints and directions on how to complete an RCA
using the NCPS developed analysis process including use of Event Flow and Cause and Effect diagramming.
- The NCPS 2006 Profile offers readers a detailed understanding of the full range of our programs and initiatives. It includes a number of charts that help illustrate the breadth of the program and specific examples of safety challenges we have addressed since the organization was founded in 1999
- Using Health Care Failure Mode and Effect Analysis: The VA National
Center for Patient Safety's Prospective Risk Analysis System © (PDF) (HTML) by
Joseph DeRosier, PE, CSP; Erik Stalhandske, MPP, MHSA; James P. Bagian, MD, PE; Tina Nudell, MS. The Joint Commission Journal on Quality Improvement
Volume 27 Number 5:248-267, 2002. Posted with permission.
- VISN 8 Patient Safety Center of Inquiry Fall Incident Report including Morse Fall
The Fall Incident Report form was developed in VISN 8, as a joint effort of the VISN 8 Quality Management/Risk Management, under the leadership of Joanne
Elkins, MSN, RN, CPHQ, and Lula Williams, MN, RN, CPHQ, together with the VISN 8 Evidence-based Fall Prevention Program, under the leadership of Pat Quigley,
ARNP-C, PhD, and Andrea M. Spehar, MS, DVM, MPH. The development of new reporting forms was initiated by the VISN 8 Patient Safety Improvement Board, consisting
of the VISN 8 QMs and RMs and members of the VISN 8 Patient Safety Center.
- Developing a Culture of Safety in the Veterans Health Administration published
in Effective Clinical Practice