The Patient Safety Authority (PSA) is pleased to announce its next virtual Engagement Roundtable discussion. In lieu of regional in-person events, this virtual series is open statewide via Microsoft Teams.

It's more critical than ever to stay connected with other patient safety professionals. This session will provide a forum to exchange information and ask questions in a collaborative environment across a range of patient safety topics.

Join Shawn Kepner, MS, data analyst for the PSA and data editor for its journal, Patient Safety, as he discusses how PSA analyzes event reports submitted to PA-PSRS. Following the data pipeline from beginning to end, Shawn will discuss insights gleaned from the nation’s largest database. Areas of focus will include free-response text data from event details and the use of natural language processing.

After you register you will receive a confirmation email that includes the link to join the meeting via Microsoft Teams. Please copy and paste the link provided in the confirmation email into a new calendar appointment.
 
In addition to the confirmation email, the instructions on how to join will also be included in the course materials email that is sent out prior to the registered event.

Join Brenna Simcoe, PharmD, clinical program director for the medicine service line at WellSpan Health, and Angie Mays, RN, clinical coordinator for the central monitoring services at WellSpan Health, they will describe a highly reliable model of sepsis care that successfully integrates remote surveillance, real-time clinical decision support, and the expertise of the bedside team, understand how to utilize any or all components of the care model to support early sepsis recognition and treatment, and recognize barriers and challenges to implementation and maintenance.

1.0 continuing education hours will be awarded for completion of this webinar. Continuing education credits apply to Pennsylvania registered nurses only.

Steve Mrozowksi, MHA, senior director, safety and high reliability at the Cleveland Clinic, will describe the inter-play between error-proofing tactics, culture, and health I.T. in medical error reduction, provide examples of low- and high-impact error reduction strategies, and describe at least two strategies to identify and reduce weight documentation errors in healthcare.

1.0 continuing education hours will be awarded for completion of this webinar. Continuing education credits apply to Pennsylvania registered nurses only.

JoAnn Adkins, BSN, RN, senior infection preventionist at the Patient Safety Authority, will discuss the importance of vaccinations for everyone, describe the role vaccination plays in developing immunity, discuss how community immunity helps prevent the spread of disease, and the three vaccinations important to healthcare workers.

To view the webinar recording, please visit the Patient Safety Authority's YouTube channel at: https://www.youtube.com/watch?v=6RzQf2KsrUo.

Holly Shadle, DNP, CRNP, nurse practitioner in the dermatology department at UPMC - North Central PA and adjunct faculty for the nursing department at the Pennsylvania College of Technology, will:

• Explain the negative implications of catheter-associated urinary tract infections (CAUTI) and why reduction is so important,
• Identify the most effective evidence-based intervention strategies for CAUTI reduction,
• Describe two practice-based interventions used for the initiative,
• Identify the three educational components necessary for achieving successful CAUTI reduction, and
• Describe how this initiative could be implemented and sustained in larger acute care settings and could be adapted to reduce other healthcare-associated infections.

To view the webinar recording, please visit the Patient Safety Authority's YouTube channel at: https://www.youtube.com/watch?v=t9XB8q8dDwI.

At Geisinger, the multidisciplinary Committee to Improve Clinical Diagnosis and the Safer Dx Learning Lab (a collaboration with Baylor College of Medicine) are taking a systematic approach to learn how health care systems can enhance the safety and accuracy of the diagnostic process. As a result of the work, potential diagnostic opportunities are reviewed, shared with departments, and learning opportunities are identified. Constructive feedback is completed when appropriate and any system issues that may impact diagnostic safety are identified. Lessons learned are shared broadly in an open, transparent, and constructive fashion.

Join Divvy Upadhyay, MD, MPH, program lead and scientist in the division of quality, safety and patient experience at Geisinger to understand how this “learning health system” approach is being implemented to improve diagnostic safety across the health system.

To view the webinar recording, please visit the Patient Safety Authority's YouTube channel at: https://www.youtube.com/watch?v=6mmlpZlxDRY.

Members of the lesbian, gay, bisexual, transgender, and queer (LGBTQ) community have long described experiencing stigma and lack awareness and education about their needs in healthcare environments. Delay or lack of treatment for medical and psychiatric symptoms is a patient safety issue that can lead to poor patient outcomes. In honor of Pride month, we have invited Dr. Sarah Noble, DO, psychiatrist and medical director of Outpatient Behavioral Health at Einstein Healthcare Network, to speak about some of the unique needs of the LGBTQ community in accessing and receiving behavioral health care. Dr. Noble will share insight on how facilities can provide a safe environment and share resources for LGBTQ behavioral health.

To view the webinar recording, please visit the Patient Safety Authority's YouTube channel at: https://www.youtube.com/watch?v=m5HXI1tJQgw

COVID-19 has been incredibly stressful—personally and professionally—and has profoundly affected everyone in healthcare, including those of us in patient safety, quality, and risk management.
 
Grab a cup of coffee or tea and join this virtual round table to decompress and share your experiences. Some of your colleagues have offered to discuss their coping strategies, and please feel free to do the same. We will also be providing resources from professionals trained to handle stress.

After you register you will receive a confirmation email that includes the link to join the meeting via Microsoft Teams. Please copy and paste the link provided in the confirmation email into a new calendar appointment.
 
In addition to the confirmation email, the instructions on how to join will also be included in the course materials email that is sent out prior to the registered event.

Situations involving an active shooter in a healthcare setting can have a devastating impact, including long-term organizational effects. Employee situational awareness and vigilance are imperative in today's workplace environment.

Join Bruce Veseth, training and investigation coordinator at WellSpan Security Services, where he describes how to:
 
• Respond to an active shooter
• Discern between an active shooter and a hostage situation
• Develop an active shooter threat assessment checklist
• Recognize potential workplace violence threats
• Protect yourself in public areas
• And more!

To view the webinar recording, please visit the Patient Safety Authority's YouTube channel at: https://www.youtube.com/watch?v=72gdV3qTCp4.

Join Angela R. Coladonato, DNP, RN, NEA-BC, senior vice president and chief nursing officer at Chester County Hospital (CCH) Penn Medicine, where she defines the concept of emotional intelligence, summarizes the four domains of emotional intelligence, identifies a few tips for leading with emotional intelligence, and discusses a few ways to increase your emotional intelligence.

To view the webinar recording, please visit the Patient Safety Authority's YouTube channel at: https://www.youtube.com/watch?v=gHHvdgzQQIc.

This course is ideal for the new Patient Safety Officer (PSO) and anyone who wants to brush up on the basic principles of event reporting in Pennsylvania. The education program will be offered in four one-hour modules that will discuss the historical context of the Medical Care Availability and Reduction of Error (MCARE) Act (Act 13), define the key elements of MCARE, explain the role and responsibility of the PSO, discuss the Final Guidance for Reporting Requirements and apply reporting guidelines to event scenarios.

Please note that this course is a repeat of the educational program that was offered on January 21, 2021 and is being offered as single one-hour sessions for those patient safety professionals who are unable to attend a 4-hour course or who registered to attend January 21, 2021 but were unable to attend all the modules on that date.

1.0 continuing education hours will be awarded for completion of this module. Continuing education credits apply to Pennsylvania registered nurses.

This course is ideal for the new Patient Safety Officer (PSO) and anyone who wants to brush up on the basic principles of event reporting in Pennsylvania. The education program will be offered in four one-hour modules that will discuss the historical context of the Medical Care Availability and Reduction of Error (MCARE) Act (Act 13), define the key elements of MCARE, explain the role and responsibility of the PSO, discuss the Final Guidance for Reporting Requirements and apply reporting guidelines to event scenarios.

Please note that this course is a repeat of the educational program that was offered on January 21, 2021 and is being offered as single one-hour sessions for those patient safety professionals who are unable to attend a 4-hour course or who registered to attend January 21, 2021 but were unable to attend all the modules on that date.

1.0 continuing education hours will be awarded for completion of this module. Continuing education credits apply to Pennsylvania registered nurses.

This course is ideal for the new Patient Safety Officer (PSO) and anyone who wants to brush up on the basic principles of event reporting in Pennsylvania. The education program will be offered in four one-hour modules that will discuss the historical context of the Medical Care Availability and Reduction of Error (MCARE) Act (Act 13), define the key elements of MCARE, explain the role and responsibility of the PSO, discuss the Final Guidance for Reporting Requirements and apply reporting guidelines to event scenarios.

Please note that this course is a repeat of the educational program that was offered on January 21, 2021 and is being offered as single one-hour sessions for those patient safety professionals who are unable to attend a 4-hour course or who registered to attend January 21, 2021 but were unable to attend all the modules on that date.

1.0 continuing education hours will be awarded for completion of this module. Continuing education credits apply to Pennsylvania registered nurses.

This course is ideal for the new Patient Safety Officer (PSO) and anyone who wants to brush up on the basic principles of event reporting in Pennsylvania. The education program will be offered in four one-hour modules that will discuss the historical context of the Medical Care Availability and Reduction of Error (MCARE) Act (Act 13), define the key elements of MCARE, explain the role and responsibility of the PSO, discuss the Final Guidance for Reporting Requirements and apply reporting guidelines to event scenarios.
 
Please note that this course is a repeat of the educational program that was offered on January 21, 2021 and is being offered as single one-hour sessions for those patient safety professionals who are unable to attend a 4-hour course or who registered to attend January 21, 2021 but were unable to attend all the modules on that date.

1.0 continuing education hours will be awarded for completion of this module. Continuing education credits apply to Pennsylvania registered nurses.

The U.S. Department of Labor, Occupational Safety and Health Administration's (USDOL-OSHA) core mission is to assure that every working man and woman has a safe and healthy workplace. To do that, OSHA is setting and enforcing standards and providing training, outreach, education, and assistance.

Join Isabel DeOliveira, MS, regional compliance assistance specialist at the USDOL-OSHA, where she describes the most common OSHA citations, compares all industry citations to healthcare citations, describes how COVID-19 has influenced changes in OSHA citations, and identifies resources available to ensure compliance with the regulation.

To view the webinar recording, please visit the Patient Safety Authority's YouTube channel at: https://www.youtube.com/watch?v=NgLX-sxLzA0.

The Patient Safety Authority (PSA) would like to introduce you to our upcoming, 18-month collaboration for Pennsylvania healthcare facilities to implement Communication and Optimal Resolution (CANDOR). We will host 2 webinars at the beginning of February 2021 to provide an introduction. The webinars will address the following:

•             Define the CANDOR process and provide insight to value and benefit

•             Outline the PSA collaboration process, including expectations and timeline

Interested facilities should include:

•             Acute care hospitals

•             Critical access hospitals

•             Ambulatory surgery centers

•             Rehab hospitals

•             Behavioral Health hospitals

The target audience of the "PSA Introduction to a CANDOR Collaboration for Insurers and Legal Representatives" webinar should include:

•             Risk Retention Groups

•             Liability insurers

•             Facility legal Representative

•             Risk Managers

To view the webinar recording, please visit the Patient Safety Authority's YouTube channel at: https://www.youtube.com/watch?v=kTGv5Pyzk6M

The Patient Safety Authority (PSA) would like to introduce you to our upcoming, 18-month collaboration for Pennsylvania healthcare facilities to implement Communication and Optimal Resolution (CANDOR). We will host 2 webinars at the beginning of February 2021 to provide an introduction. The webinars will address the following:

•             Define the CANDOR process and provide insight to value and benefit

•             Outline the PSA collaboration process, including expectations and timeline

Interested facilities should include:

•             Acute care hospitals

•             Critical access hospitals

•             Ambulatory surgery centers

•             Rehab hospitals

•             Behavioral Health hospitals

The target audience for the "PSA Introduction to a CANDOR Collaboration for Pennsylvania Healthcare Facilities" webinar should include:

•             Patient Safety Officer

•             Risk Management

•             CEO/President/Medical Affairs

To view the webinar recording, please visit the Patient Safety Authority's YouTube channel at: https://www.youtube.com/watch?v=jd4QrH3LpNI

Join Matthew Keris, Esq., as he defines artificial intelligence; describes how it is being used in healthcare; outlines the risks associated with computer-assisted diagnosis and remote monitoring; and provides potential mitigation strategies. 

To view the webinar recording, please visit the Patient Safety Authority's YouTube channel at: https://www.youtube.com/watch?v=Ftd6YoDcWwY

Join Dr. Tanya Uritsky, clinical pharmacy specialist in pain stewardship at the Hospital of the University of Pennsylvania, where she will identify risk factors for opioid-induced respiratory depression in hospitalized surgical patients, define opioid tolerance, recognize other CNS depressants that can potentiate opioid-induced sedation and respiratory depression, and recommend an appropriate opioid starting dose for an opioid naïve perioperative patient.

Opioid stewardship is the appropriate use of opioids and is an important part of patient safety. The highest risk for the development of opioid-induced respiratory depression is during the first 24 hours post-operatively. Knowing the best practices for pain management in the perioperative period, including how to identify a patient at increased risk for opioid-related adverse events, can help to improve patient safety. This session will provide insights into patient-related risk factors and considerations for pain management in the perioperative period. 

To view the webinar recording, please visit the Patient Safety Authority's YouTube channel at: https://www.youtube.com/watch?v=CcFYMgtLh7w

Accreditation Statement:

In support of improving patient care, this activity has been planned and implemented by Amedco LLC and PSHP. Amedco LLC is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Pharmacists and Pharmacy Technicians (ACPE):

Amedco LLC designates this activity for a maximum of 1.00 knowledge-based CPE contact hours comprised of the following topic designator: 08 – Pain Management.

As we continue to adjust to a new way of conducting business and with your safety in mind, the Patient Safety Authority would like to take the opportunity to continue our series of roundtable discussions to facilitate engagement between PA healthcare facilities.

Instead of regional in-person events, the Engagement Roundtable series will be conducted virtually, with participation open statewide via Microsoft Teams. The Patient Safety Authority believes that in the age of social distancing, finding ways to stay connected with other patient safety professionals is more important than ever. The primary goal of these events is to facilitate the sharing and discussion of information in a collaborative environment for a range of patient safety topics.

This session is intended to give hospitals and ambulatory surgery facilities an opportunity to discuss current topics of interest and issues of concern submitted by facilities. This session will lead off with a discussion of how facilities prepare for potential disasters in the OR and lessons learned from actual events, followed by a general discussion.

November 19, 2020 is World Wide Pressure Injury Prevention Day. Are you up on the latest in pressure injury prevention? Have you seen the recent guidance on medical device-related pressure injuries (MDRPI) and COVID skin/wound care?

Join Dr. Diane Krasner, wound and skin care consultant; fellow, the American Academy of Nursing; co-chair, Why Wound Care?; co-editor, Chronic Wound Care: The Essentials; and adjunct clinical faculty, HACC York Campus-Nursing. Topics covered will include:

•             New and notable terminology, guidelines, consensus documents and position papers

•             Medical device-related pressure injuries

•             COVID pressure injuries and wound care

•             End-of-life pressure injuries

•             Pressure injury litigation in Pennsylvania

This up-to-date information will help you and your facility to care for patients/residents with pressure injuries confidently.

Attendees will also receive a complimentary PDF copy of the eBook "Chronic Wound Care: The Essentials”.

To view the webinar recording, please visit the Patient Safety Authority's YouTube channel at: https://www.youtube.com/watch?v=JCDY73zr4cs

Join Ursula Nawab, MD, senior medical director of patient safety at the Children’s Hospital of Philadelphia, associate professor of clinical pediatrics in the division of neonatology, department of pediatrics at the University of Pennsylvania’s Perelman School of Medicine; Avram H. Mack, MD, associate chair for quality and safety within the Children’s Hospital of Philadelphia department of psychiatry, full professor at the University of Pennsylvania Perlman School of Medicine; and Andrea Colfer, MSN, senior patient safety process manager at the Children’s Hospital of Philadelphia; where they will share one institution’s journey to overcome the cognitive biases that may contribute to diagnostic error.

Attendees will be able to formulate ideas on how to tackle missed opportunities in diagnosis in their institution, discuss the formation and history of a Cognitive Bias Think Tank, understand the working objectives of the Cognitive Bias Think Tank, explore a quality improvement initiative and other initiatives of the Cognitive Bias Think Tank, and apply this institution’s learnings and next steps to help inform future work.

To view the webinar recording, please visit the Patient Safety Authority's YouTube channel at: https://www.youtube.com/watch?v=dvsTqn6oxKE

The Pennsylvania Opioid Surgical Stewardship Enterprise (POSSE) engages hospitals throughout Pennsylvania to prevent chronic opioid use among surgical patients. POSSE’s patient-centered domain engages patients in developing patient-friendly and easy-to-understand materials that raise awareness about the management of surgical pain and the prevention of opioid use disorder. Join Susan Cosgrove, MPA, director of health literacy at the Health Care Improvement Foundation (HCIF) as she discusses the basic principles of health literacy and how they apply to the development and dissemination of education materials for surgical patients and families.

To view the webinar recording, please visit the Patient Safety Authority's YouTube channel at: https://www.youtube.com/watch?v=ZISpeSshsLg

As we all adjust to a new way of conducting business and with your safety in mind, the Patient Safety Authority would like to take the opportunity to launch a new series of virtual events to facilitate engagement between PA healthcare facilities.

Instead of regional in-person events, the Engagement Roundtable series will be conducted virtually, with participation open statewide via Microsoft Teams. The Patient Safety Authority believes that in the age of social distancing, finding ways to stay connected with other patient safety professionals is more important than ever. The primary goal of these events is to facilitate the sharing and discussion of information in a collaborative environment for a range of patient safety topics.

This roundtable event is intended to give acute care facilities an opportunity to discuss the current COVID-19 pandemic with each other, and how they are screening patients undergoing elective and non-elective procedures.

After you register you will receive a confirmation email that includes the link to join the meeting via Microsoft Teams.

In addition to the confirmation email, the instructions on how to join will also be included in the course materials email that is sent out prior to the registered event.

Penny Hoover, BSN, RN, nurse paralegal and Continue Service Readiness (CSR) nurse consultant for Joint Commission Resources will describe how the lack of care coordination during handoff increases surgical patient safety events, help healthcare providers recognize areas in the surgical department where a lack of care coordination poses the greatest threat, and discuss how to standardize care coordination during handoff with an evidence-based communication tool.

To view the webinar recording, please visit the Patient Safety Authority's YouTube channel at: https://www.youtube.com/watch?v=6diKWFm2Df4

Jeffrey Bomba, MBA, Intensive Care Unit (ICU) patient care manager, AHN Jefferson, and Irma D’Antonio, MSN, manager of nursing quality and patient experience, AHN Jefferson, share their experience treating the first COVID-19-positive patient in Western Pennsylvania.

As the world was still beginning to grapple with the new virus, the Jefferson Hospital ICU team dynamically shifted operations to overcome the pandemic-induced care gaps, including leveraging telemedicine to ensure consistent around-the-clock intensivist coverage. The team also incorporated strategies learned by other facilities treating COVID-19 patients.

These interventions decreased length of stay and improved patient outcomes. In addition, their innovative use of mobile device technology allowed patients and families to connect safely, and a dedicated team of nurses provided comfort and support through the unprecedented times.
 
To view the webinar recording, please visit the Patient Safety Authority's YouTube channel at: https://www.youtube.com/watch?v=u-EoKwOv2zE

Elliott K. Main, MD, medical director, California Maternal Quality Care Collaborative, clinical professor of obstetrics and gynecology, Stanford University School of Medicine, and Robert Ferguson, MPH, chief policy officer, Jewish Healthcare Foundation, will identify Pennsylvania trends and themes related to maternal morbidity and mortality as reported through PA-PSRS, describe the strategies implemented by California to decrease maternal mortality rates and how to work toward sustainability, and discuss the initiatives being implemented by the Pennsylvania Perinatal Quality Collaborative (PAPQC) and identify value of participation in the collaboration.

To view the webinar recording, please visit the Patient Safety Authority's YouTube channel at: https://www.youtube.com/watch?v=gOhRPxH0xbU

Tony Salvatore, MA, director of suicide prevention at Montgomery County Emergency Service (MCES), will describe incidence and rates of suicide among elders in PA, describe risk and protective factors for elder suicide, describe current concepts of suicide as applied to elders, and describe measures for reducing suicide risk of elders in health care settings. (Presentation originally planned for P2S2)

To view the webinar recording, please visit the Patient Safety Authority's YouTube channel at: https://www.youtube.com/watch?v=hjo6nqTy44A

Ann E. Miller, MSN, RN, senior patient safety specialist at UPMC Presbyterian Shadyside, will describe the value a Culture of Safety Survey brings to a healthcare organization, discuss three successful initiatives that enhance the safety culture, and identify an initiative that you can implement in your area to improve the safety culture. (Presentation originally planned for P2S2)

To view the webinar recording, please visit the Patient Safety Authority's YouTube channel at: https://www.youtube.com/watch?v=1mD-yV6D0b8

Improving quality and patient safety is hard work. In fact, at times the work can seem like drudgery or like we are pushing the boulder up a steep hill. The personal toll for those who are the “helpers” of healthcare (à la Fred Rogers) can be overwhelming, tiring and depressing. You are a person first -before you are a health professional. Join Diane C. Frndak, PhD, MBA and Holly Hampe, DSc, MHA, assistant professors of health services administration leadership at Robert Morris University, as this session will focus on the science of flourishing as a heart-centered journey creating a real-time community of like-minded people. The facilitators will help participants learn about Positivity-Engagement-Relationships-Meaning-Achievement-Vitality (PERMA-V) and get a booster shot of HAPPY (Healthcare Applied Positive Psychology Yearnings). This session will practice skills in a fun and supportive learning environment. Key positive psychology skills for creating greater happiness and well-being will be introduced, such as: mindfulness, gratitude, strengths, flow, humor, positivity, stress management and resilience. The session will be interactive and engaging while introducing evidence-based science of flourishing exercises. The session will be a breath of fresh air and an act of self-care for the self-identified FRAZZLED. A created HAPPY infographic will be available with some other resources to continue the learning after the session. (Presentation originally planned for P2S2)

To view the webinar recording, please visit the Patient Safety Authority's YouTube channel at: https://www.youtube.com/watch?v=XOqD4rZLxpw

In 2017, a patient died after receiving vecuronium instead of midazolam. Join Matthew Keris, Esq., as he discusses the facts of the event, system and individual failures that contributed to the outcome, and risk reduction strategies that could prevent similar situations in your healthcare facility. 

 
To view the webinar recording, please visit the Patient Safety Authority's YouTube channel at: https://www.youtube.com/watch?v=JJlJfCd62ag

Jeffrey Bomboy, BS, RN, senior patient safety liaison, and JoAnn Adkins, BSN, RN, senior infection preventionist at the Patient Safety Authority, will describe everyday preventative actions staff can take to help prevent the spread of COVID-19, outline three methods of screening children for symptoms, and discuss the importance of hand hygiene and methods for optimal safety.

To view the webinar recording, please visit the Patient Safety Authority's YouTube channel at: https://www.youtube.com/watch?v=scC-U-oe2-8

Feel like your 30-hour days have somehow doubled? Feel like you have more questions than answers lately? While our infection preventionists are always available to answer your individual questions, leverage collective power and tune in for a brief webinar on April 7 and April 28 from 12:30-1:00 p.m. If you have a question, there’s a good chance that someone else has the same one. Likewise, someone else may raise an issue you haven’t had time to think of yet. Submit your questions ahead of time to Terri Lee Roberts (terroberts@pa.gov) or JoAnn Adkins (joaadkins@pa.gov).

To view the webinar recording, please visit the Patient Safety Authority's YouTube channel at: https://www.youtube.com/watch?v=3p-gL2ZH4Po

• PA-DOH Life Safety Code Updates (presented by Charlie Schlegel, director, Department of Health, Division of Safety Inspection)
• What’s New in ASC Quality (presented by Julie Volz, project coordinator for Quality Insights Quality Innovation Network)
• Infection Prevention Surveillance Strategies for ASFs (presented by the Patient Safety Authority infection preventionists)
• Human Factors Strategies That Can Be Used to Improve Processes in ASF Settings (presented by the Patient Safety Authority patient safety liaisons)

Continuing education hours will be awarded for completion of this course. Continuing education credits apply to Pennsylvania registered nurses only.

• Enhancing your CMS Emergency Preparedness program using specific examples for continued compliance (presented by Emergency Educators LLC)
• Understanding changes to the CMS quality reporting requirements that reduce data collection and promotes patient-centered care (presented by Quality Insights of Pennsylvania)
• Discussion of unrecognized medication safety problems in ASFs and the use of risk reduction strategies to ensure safe medication practices (presented by the Institute of Safe Medication Practices)
• Recognizing how the design of medical devices, equipment, and instruments can provide ideal spaces for bioburden accumulation and subsequent development of surface biofilms, and combat bioburden prevalence with quality improvement initiatives (presented by the Patient Safety Authority)

• Pennsylvania Patient Safety Reporting System (PA-PSRS): Understanding and Applying Criteria, Case Studies, and Analytics
• Bullying in Healthcare
• Pneumococcal Vaccines
• Norovirus
• Scabies

• Pennsylvania Patient Safety Reporting System (PA-PSRS): Understanding and Applying Criteria, Case Studies, and Analytics
• Bullying in Healthcare
• Pneumococcal Vaccines
• Norovirus
• Scabies

• Pennsylvania Patient Safety Reporting System (PA-PSRS): Understanding and Applying Criteria, Case Studies, and Analytics
• Bullying in Healthcare
• Pneumococcal Vaccines
• Norovirus
• Scabies

• Pennsylvania Patient Safety Reporting System (PA-PSRS): Understanding and Applying Criteria, Case Studies, and Analytics
• Bullying in Healthcare
• Pneumococcal Vaccines
• Norovirus
• Scabies

• Pennsylvania Patient Safety Reporting System (PA-PSRS): Understanding and Applying Criteria, Case Studies, and Analytics
• Bullying in Healthcare
• Pneumococcal Vaccines
• Norovirus
• Scabies

Over 93 million Americans are at risk of not understanding their health plan of care due to low health literacy. Improving health literacy and patient engagement will improve shared decision making and improve patient and staff satisfaction. Leaders can assist with improving health literacy through implementation of strategies to improve health literacy and becoming a health literate organization.

•  Responding to Error: Dr. Princy Thottathil will present: “When was the last time you were a Second Victim?... Not a question of IF, but WHEN...” She will discuss the concept of “second victim” and how to manage this experience.

• Medication Safety: Dr. Rachel Levine, Dr. Vitaly Gordin, and Jennifer Hubbell will present information on the Prescription opioid and heroin crisis and how to manage opioid related adverse drug events.

• Improving Diagnosis: Dr. Sarah Tilstra and Dr. Deborah DiNardo present, “How Doctors Think: Understanding and Combatting Errors in Clinical Reasoning”. Which will describe how clinicians think, how to identify errors, and how to implement strategies to prevent these errors.

• Infection Prevention: Dr. David Nace and Dr. Jeffrey Miller will discuss antibiotic stewardship: why it is important, challenges, opportunities, and strategies for implementing a program.

• Responding to Error: Mark Atlee will lead a panel discussion about disclosure, including misconceptions and strategies to improve how facilities address this difficult topic.

• Medication Safety: Kathryn Shradley and Joy Trout discuss the impact health literacy has on medication management and patient outcomes along with evidence based organizational strategies to improve medication safety.

• Improving Diagnosis: Dr. Michael Bruno and Dr. Timothy Mosher review diagnostic error and discuss radiology related events and strategies.

• Infection Prevention: Emily Shears will discuss strategies for engaging leadership and how to create strategic goals for your infection prevention program.

Final Guidance for Acute Health Care Facility Determinations of Reporting Requirements for Pressure Injuries under the Medical Care Availability and Reduction of Error (MCARE) Act went into effect on January 1, 2018. This webinar will highlight two Pennsylvania facility perspectives and the processes they are using to identify, treat, monitor, and report pressure injuries in their facilities. This webinar will also provide a review of baseline Pennsylvania Patient Safety Reporting System (PA-PSRS) pressure injury reporting data collected since the reporting criteria has changed, an overview of the reporting principles, decision tree tool and online education available.

• Highlight the new reporting requirements 
• Inform attendees of the modifications necessary to the PA-PSRS data interface to support implementation of the new reporting standards

The Pennsylvania Patient Safety Authority would like to invite you to attend the first annual Long-Term Care Infection Prevention Symposium.  This session will include topics specifically focused on long-term care and presented by experts.