Please see Alerts, Topics in Patient Safety (TIPS) Newsletters, and view PowerPoint: Information on Research Databases for additional information.
Hazard Summaries | Healthcare Failure Mode and Effect Analysis | Ensuring Correct Surgery | Hand Hygiene | PSAT | Mental Health Environment of Care Checklist | The Daily Plan®
Oxygen (Compressed Gas) Cylinder Hazard Summary
- The Basics of Healthcare Failure Mode and Effect Analysis (PDF) (Word)
- HFMEA Power Point Presentation
- Instructional Materials to Accompany the HFMEA Videotape (PDF) - Complete booklet for use with videotape. (10.5 MB)
- HFMEA Worksheets (Word)
- HFMEA Worksheet, Steps 4 & 5 (Excel)
- © Joseph DeRosier, PE, CSP; Erik Stalhandske, MPP, MHSA; James P. Bagian, MD, PE; Tina Nudell, MS: Using Health Care Failure Mode and Effect Analysis: The VA National Center for Patient Safety's Prospective Risk Analysis System. (PDF) (HTML)The Joint Commission Journal on Quality Improvement Volume 27 Number 5:248-267, 2002. Posted with permission.
- Joint Commission Executive Briefings on the Patient Safety Standards: Designing Safer Health Care Systems. 2001. Joint Commission Resources, pp 92-95.
- McDermott, Robin E., Raymond J. Mikulak, and Michael R. Beauregard. 1996. The Basics of FMEA. Portland, OR: Resources Engineering, Inc.
- Stamatis, D.H. 1995. Failure Mode and Effect Analysis: FMEA from Theory to Execution. Milwaukee, WI: ASQ Quality Press.
- The Patient Safety Improvement Handbook, 2001. VHA National Center for Patient Safety. Ann Arbor, MI.
- ISMP Sample Case for PCA Pump (Word)
- Erik Stalhandske, MPP, MHSA; Joseph DeRosier, PE, CSP; Ryan Wilson, MS; Joe Murphy, APR, MS: Healthcare FMEA in the Veterans Health Administration (PDF). Patient Safety & Quality Healthcare, Volume 6, Issue 5: 30-33, 2009. Posted with permission.
VHA Directive 2010-023: Ensuring Correct Surgery and Invasive Procedures Supplemental Training Materials based on VHA Directive 2010-023
Hand Hygiene Information and Tools - a collection of reference documents and tools to help health care providers and others to understand and respond appropriately to: The CDC Guideline on Hand Hygiene in Health Care Settings; the Joint Commission National Patient Safety Goal on Preventing Nosocomial Infections; and the VHA Directive on Hand Hygiene Practices.
Hand Hygiene Information and Tools: Frequently Asked Questions
The Patient Safety Assessment Tool (Excel) (PSAT) - a cognitive aid to assist managers and staff conduct an objective assessment of a patient safety program. The tool covers program administration and management and provides walk-around sections focusing on the patient care environment.
The Mental Health Environment of Care Checklist (XLS, 410KB) (MHEOCC) was developed for Veterans Affairs Hospitals to use to review inpatient mental health units for environmental hazards. The purpose is to identify and abate environmental hazards that could increase the chance of patient suicide or self-harm. The checklist has been used in all VA mental health units since October 2007. Contact Peter.Mills@va.gov for more information.
The Daily Plan® enhances patient safety by involving patients in their care; a single document is discussed with the patient that outlines what can be expected on a specific day of hospitalization.
By importing provider orders from the VA electronic health record into a health summary, patients receive an itinerary for each day in a single printed document. The Daily Plan® is essentially a road map that lets patients see, in black and white, what’s going to happen to them on a particular day.
A facility or nursing unit can customize the document and include a number of relevant items:
- Diagnostic tests
- Medications
- Nutrition
- Appointments
- Allergies
The plan encourages patients and their families to better understand their care; patient involvement is an integral aspect of the program. Patients are encouraged to ask questions if something seems different than planned, which enables them to become more active members of their healthcare team.
Potential errors can be prevented when nurses and patients review The Daily Plan® together. By doing so, the patient and the healthcare team are able to recognize and correct any discrepancies. These can include errors of omission or commission.
The patient is the only constant in the health care systems that is always present and yet least likely to be included as a resource. The Daily Plan® changes that!
History
The initial pilot of The Daily Plan® received positive responses from patients and staff during the evaluation periods of 2007/2008, at five VA hospitals. This prompted further attention and NCPS began Phase 2 of the pilot program in 2009. In Phase 2, evaluations were completed by 198 hospitalized patients and 85 nurses.
Nearly seventy five percent of the patients agreed or strongly agreed that having the plan made it easier for them to ask questions, increased their understanding of their hospital stay, helped them feel more comfortable and provided them with information that helped improve their care.
Over forty seven percent of the patients reported that either they or their family member found and asked about a discrepancy in their planned care. Patients received The Daily Plan® an average of 5 days in the hospital.
Nurses were asked to reflect upon their assigned patients receiving the plan during their shift and completed a single end-of-shift accumulated evaluation. Over seventeen percent of the nursing evaluations reported one or more errors/shift was detected.
Nurses found that reviewing The Daily Plan® with their patients was an appropriate use of their time and took approximately 10 minutes or less.
For additional information:
http://www.va.gov/opa/publications/vanguard/vanguard_11_janfeb.pdf (please see page 32)
http://www.patientsafety.gov/TIPS/Docs/TIPS_JulAug09.pdf
http://www.patientsafety.gov/TIPS/Docs/TIPS_NovDec08.pdf
Healthcare professionals may also be interested in this publication. Nursing Management, March 2012, page 15-18: The Daily Plan®: Including patients for safety’s sake by Beth J. King, BSN, RN, CCM; Peter D. Mills, PhD, MS; Amanda Fore, MS, RN; and Cheryl Mitchell, MSA, BSN, RN.