Patient Safety Episode 1

Tuesday, May 23, 2023, 8:00 AM - Friday, May 22, 2026, 11:59 PM

Topics for the Vital Signs podcast will include Sentara safety and quality initiatives that focus on improving patient care at Sentara facilities. Our faculty will be discussing the most recent developments in health care, and discussing best practices across the system. 

To Claim Credit for listening to this episode:

1. Click here and enter 13720 as the Activity ID (number). 

2. Then go to the MY CME tab and complete the evaluation.

3. Credit hours will be reflected on your transcript, or you may download your certificate.

1. Identify a focus topic of concern regarding practice, wellness, or mindfulness
2. Illustrate the specific topic and how options for improvement or knowledge are attained.
3. Describe evidence-based options to manage the identified topic of focus.

AMA PRA Category 1 Credits™ (0.25 hours), Non-Physician Attendance (0.25 hours)

Sentara Health is accredited by the Southern States CME Collaborative to provide continuing medical education for physicians.

Sentara Healthcare designates this Enduring Material activity for a maximum of 0.25 AMA PRA Category 1 Credit(s)^TM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Accessibility Statement
 
Sentara Healthcare is committed to ensuring that its programs, services, goods and facilities are accessible to individuals with disabilities as specified under Section 504 of the Rehabilitation Act of 1973 and the Americans with Disabilities Amendments Act of 2008.  If you have needs that require special accommodations, including dietary concerns, please contact the CME Conference Coordinator.

Copyright Information
Music: Phoenix Rising https://www.purple-planet.com

Bibliography/References

Amalberti, R., Auroy, Y., Berwick, D., & Barach, P. (2005). Five system barriers to achieving ultrasafe health care. Annals of Internal Medicine, 142(9), 756. https://doi.org/10.7326/0003-4819-142-9-200505030-00012

Brennan, T. A., Leape, L. L., Laird, N. M., Hebert, L., Localio, A., Lawthers, A. G., Newhouse, J. P., Weiler, P. C., & Hiatt, H. H. (1991). Incidence of adverse events and negligence in hospitalized patients. New England Journal of Medicine, 324(6), 370–376. https://doi.org/10.1056/nejm199102073240604

Chassin, M. R., & Loeb, J. M. (2011). The ongoing quality improvement journey: Next stop, high reliability. Health Affairs, 30(4), 559–568. https://doi.org/10.1377/hlthaff.2011.0076

Chassin, M. R., & Loeb, J. M. (2013). High-reliability health care: Getting there from here. The Millbank Quarterly, 91(3), 459–490. Retrieved January 20, 2021, from http://www.jstor.org/stable/23608781

Clapper, C., Merlino, J., & Stockmeier, C. (2019). Zero harm: how to achieve patient and workforce safety in healthcare. McGraw-Hill.

Conklin, T. (2019). The 5 principles of human performance: a contemporary update of the building blocks of human performance for the new view of safety. PreAccident Media.

Cook, R. I., & Woods, D. (1994). Operating at the sharp end: the complexity of human error. www.researchgate.net

Cooper, M., Hong, A., Beaudin, E., Dias, A., Kreiser, S., Ingersol, C. P., & Jackson, J. (2016). Implementing high reliability for patient safety. Journal of Nursing Regulation, 7(1), 46–52. https://doi.org/10.1016/s2155-8256(16)31041-9

Hollnagel, E. (2004). Barriers and accident prevention (1st ed.). Routledge.

Human Performance Improvement Handbook Volume 1: Concepts and Principles. (2009). https://www.standards.doe.gov/standards-documents/1000/1028-BHdbk-2009-v1/@@images/file

James, J. T. (2013). A new, evidence-based estimate of patient harms associated with hospital care. Journal of Patient Safety, 9(3), 122–128. https://doi.org/10.1097/pts.0b013e3182948a69

Kaplan, K., Mestel, P., & Feldman, D. L. (2010). Creating a culture of mutual respect. AORN Journal, 91(4), 495–510. https://doi.org/10.1016/j.aorn.2009.09.031

Kohn, L. T., Corrigan, J. M., & Donaldson, M. S. (Eds.). (2000). To err is human. National Academies Press. https://doi.org/10.17226/9728

Leape, L. L. (1994). Error in medicine. JAMA: The Journal of the American Medical Association, 272(23), 1851–1857. https://doi.org/10.1001/jama.1994.03520230061039

Leape, L. L., Brennan, T. A., Laird, N., Lawthers, A. G., Localio, A., Barnes, B. A., Hebert, L., Newhouse, J. P., Weiler, P. C., & Hiatt, H. (1991). The nature of adverse events in hospitalized patients. New England Journal of Medicine, 324(6), 377–384. https://doi.org/10.1056/nejm199102073240605

Makary, M. A., & Daniel, M. (2016, May 3). Medical error- the third leading cause of death in the US. BMJ, 3(1), 1–5. https://doi.org/10.1136/bmj.i2139

McCarthy, D., & Klein, S. (2011). Sentara healthcare: making patient safety an enduring organizational value. The Commonwealth Fund, 8, 1–19. https://www.commonwealthfund.org/sites/default/files/documents/___media_files_publications_case_study_2011_mar_1476_mccarthy_sentara_case_study_final_march.pdf

Reason, J. (1997). Managing the risks of organization accidents. Ashgate Publishing Limited.

Roberts, K. H. (1990). Some characteristics of one type of high reliability organization. Organization Science, 1(2), 160–176. https://doi.org/10.1287/orsc.1.2.160

Rochlin, G. I., La Porte, T. R., & Roberts, K. H. (1998). The self-designing high-reliability organization. Naval War College Review, 51(3(8)), 1–16. https://digital-commons.usnwc.edu/nwc-review/vol51/iss3/8/

Rochlin, G. L. (1993). Defining high reliablity organizations in practice: a taxonomic prologue. In New challenges to understanding organizations (pp. 11–32). Macmillan.

Safer together: A national action plan to advance patient safety. (2020). Institute for Healthcare Improvement. Retrieved October 11, 2020, from http://www.ihi.org/Engage/Initiatives/National-Steering-Committee-Patient-Safety/Pages/National-Action-Plan-to-Advance-Patient-Safety.aspx

SPS network: 2019 year in review [PDF]. (2019). Children’s Hospitals’ Sollutions for Patient Safety. https://www.solutionsforpatientsafety.org/wp-content/uploads/SPS_YearInReview-2019-v6.pdf

Sutcliffe, K. M. (2011). High reliability organizations (HROs). Best Practice & Research Clinical Anaesthesiology, 25, 133–144. https://doi.org/10.1016/j.bpa.2011.03.001

Wears, R., & Sutcliffe, K. (2019). Still not safe. Oxford University Press. https://doi.org/10.1093/oso/9780190271268.001.0001

Weick, K. E. (1987). Organizational culture as a source of high reliability. California Management Review, 29(2), 112–127. https://doi.org/10.2307/41165243

Weick, K. E., & Sutcliffe, K. M. (2006). Mindfulness and the quality of organizational attention. Organization Science, 17(4), 514–524. https://doi.org/10.1287/orsc.1060.0196

Weick, K. E., & Sutcliffe, K. M. (2015). Managing the unexpected: Sustained performance in a complex world (3rd ed.). Jossey-Bass.

Mitigation of Relevant Financial Relationships

Sentara Healthcare Continuing Medical Education adheres to ACCME Standards for Integrity and Independence in Accredited Continuing Education. Any individuals in a position to control the content of an accredited activity, including faculty, planners, reviewers or others are required to disclose all relevant financial relationships with ineligible entities (commercial interests). All relevant conflicts of interest have been mitigated prior to the commencement of the activity.