ECRI

In this episode, we're talking about postincident investigations, which are a crucial part of a risk and safety program in any healthcare setting. The primary purpose of the initial investigation of an incident or near miss is to collect facts, which the organization will later analyze with the ultimate goal of improving care and services. Thus, thorough investigations are the foundation of efforts to learn from incidents and near misses. Even when an investigation is required (e.g., statute, regulation, an accreditor), aging services providers should optimize the opportunity to learn and improve. When done well, internal incident reporting and initial investigations help to enhance quality and prevent incidents and resulting harm. The facts collected facilitate many postincident response practices. Check out our white paper on <a href= "https://www.ecri.org/landing-incident-investigation-aging-services"> Incident Investigation in Aging Services</a>. Interested in learning more? Contact us at 610.825.6000 or email <a href="mailto:clientservices@ecri.org" target="_blank" rel="noopener">clientservices@ecri.org</a>.

Postincident Investigations

The idea of the “five rights” for medication safety has been taught in nursing school since at least World War II, used as a memory tool that nurses should rely on to administer medications safely. Even though no one can identify where the five rights came from, the idea is embedded in medication safety programs and appears frequently in error reports submitted to ECRI and the ISMP Patient Safety Organization.As our guest Susan Paparella, Vice President, Services, Institute for Safe Medication Practices (ISMP), points out, the five rights are inadequate as a safety tool. Because they do not address the system-level errors that contribute to medication errors, those errors can occur even when the five rights have been followed. In the latest episode, we discuss more about the shortcomings of the five rights, and better starting points for medication safety programs.Learn more about <a href="https://www.ismp.org/" rel="noopener noreferrer" target="_blank">ISMP</a> and the <a href="https://www.ecri.org/solutions/medication-safety/" rel="noopener noreferrer" target="_blank">ECRI-ISMP Medication Safety memberships</a>.

Susan Paparella

Vice President, Services, Institute for Safe Medication Practices (ISMP)

In this episode, we discuss the shortcomings of the five rights, and better starting points for medication safety programs.


The Myth of the Five Rights for Safe Medication Administration

In this episode, Tim Gibson, Senior Manager, Functional Equivalents, and Andy Poole, Associate Director, Strategy and Innovation, ECRI, describe strategies for enhancing the supply management process in non-acute organizations like nursing homes, ambulatory surgery centers, and physician practices. They describe the importance of building a robust data set and dedicating real staff time to this care-critical activity.

Tim Gibson

Senior Manager, Functional Equivalents, ECRI

Andy Poole

Associate Director, Strategy and Innovation, ECRI

In this episode, we discuss strategies for enhancing the supply management process in non-acute organizations like nursing homes, ambulatory surgery centers, and physician practices.


Managing the Supply Chain in Non-Acute Care Settings

In the latest episode of our podcast, we speak to Karen Garvey, Vice President, Safety and Clinical Risk Management, and J.D. Buchert, Workplace Safety Manager, Parkland Health (Dallas, Texas). They describe their data-driven approach to identifying and combatting workplace violence, including the importance of keeping frontline staff involved in and aware of those efforts.

J.D. Buchert

Workplace Safety Manager, Parkland Health (Dallas, Texas)

Karen Garvey

Vice President, Safety and Clinical Risk Management, Parkland Health (Dallas, Texas)

In this episode, we speak to safety leaders from Parkland Health about their data-driven approach to identifying and combatting workplace violence, including the importance of engaging frontline staff.


Addressing Workplace Violence in Healthcare

In this episode, we talk with nurse leaders from Allegheny Health Network (Pittsburgh, Pennsylvania) about their innovative blended staffing model that encourages LPNs to return to acute care, along with other programs to help bolster staffing, like incentivizing nurses who have left the workforce to return to practice.

Claire Zangerle, DNP, MBA, RN, NEA-BC, FAONL, FAAN, is the Chief Nurse Executive for Allegheny Health Network, responsible for the integrating nursing practice and strategy across the continuum. As a member of AHN's executive leadership team, she supports and facilitates the patient-centered care delivery model by creating an environment that promotes high quality and consistency in the standard of practice across all AHN facilities and clinics. She serves as the executive nursing voice of AHN’s more than 6,000 nurses.

Claire Zangerle, DNP

Chief Nurse Executive

Erin Toth, MSN, RN, is Nurse Manager of the 5 North/Respiratory Unit at Jefferson Hospital, part of Allegheny Health Network. She previously served as Manager of Hospital Operations at Jefferson Hospital, and has a background as a registered nurse in oncology and critical care.

Erin Toth, MSN, RN

Nurse Manager

In this episode, we talk with nurse leaders from Allegheny Health Network about their innovative blended staffing model that encourages LPNs to return to acute care, along with other programs to help bolster staffing.


Innovative Staffing Models to Overcome Nursing Shortage

Providing equitable care for a diverse population requires providers to meet patients where they are—including if they are experiencing homelessness. In this episode, Dr. Jose Ramos, of Pomona Valley Health Centers, describes his team’s outreach efforts to homeless individuals, how those efforts were affected by the onset of the COVID-19 pandemic, and strategies for implementing similar programs elsewhere.

Board-certified family physician José Ramos, MD is motivated to provide respectful, culturally responsible, high-quality and patient-centered care that focuses on each person’s individual needs and goals. He is involved in Physicians for Social Responsibility and provides volunteer care to immigrants, mentors under-represented minorities seeking healthcare careers, and volunteers with a street-medicine ministry in the Arroyo Seco homeless encampments.

José Ramos, MD

Associate Program Director, Pomona Valley Hospital Sponsored Family Medicine Residency Program

Providing equitable care for a diverse population requires providers to meet patients where they are—including if they are experiencing homelessness. In this episode, Dr. Jose Ramos, of Pomona Valley Health Centers, describes his team’s outreach efforts to homeless individuals, how those efforts were affected by the onset of the COVID-19 pandemic, and strategies for implementing similar programs elsewhere.


Fighting Healthcare Disparities | Outreach to those Experiencing Homelessness

In this episode, Dr. Jose Ramos, of Pomona Valley Health Centers, describes his team’s outreach efforts to homeless individuals, how those efforts were affected by the onset of the COVID-19 pandemic, and strategies for implementing similar programs elsewhere.


In this episode, our guest, Emily Transue, MD, MHA, FACP, Medical Director for the Washington State Health Care Authority (HCA), discusses how shared decision-making can be more than a tool to engage patients in their care, and can also help in the fight against care inequities and disparities.

Emily Transue, MD, MHA, FACP is a Medical Director for the Washington State Health Care Authority.  She received her B.S. from Yale University, M.D. from Dartmouth Medical School, and Master of Health Administration from the University of Washington.  She is a general internist who practiced for 15 years as a primary care provider before shifting to roles in leadership and policy.  She is the author of two books, On Call and Patient by Patient, about the experience of practicing medicine.  At the Health Care Authority, her role includes being medical director for the Employee and Retiree Benefits division, oversight of the Shared Decision-Making program, and supporting quality measurement and improvement.

Emily Transue, MD, MHA, FACP

Medical Director, Washington State Health Care Authority

In this episode, our guest, Emily Transue, MD, MHA, FACP, Medical Director for the Washington State Health Care Authority (HCA), discusses how shared decision-making can be more than a tool to engage patients in their care, and can also help in the fight against care inequities and disparities.


Fighting Healthcare Disparities | Utilizing Shared Decision-Making

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Welcome to Smart Healthcare Safety from ECRI, where we discuss real healthcare safety issues. The goal of this podcast is to bring ECRI's guidance to life. The recommendations are meant to help you get from being aware of an issue to assuring that your patients are safe.  Hear from our experts and guests on topics that affect your delivery of safe patient care.

Postincident Investigations

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