Massachusetts Coalition for the Prevention of Medical Errors

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Initiatives

Elimination Of Hospital-Acquired Infections In Acute Care Hospitals

Overview

Presentations From The October 5 2009 ICU Safe Care/CUSP Initiative

Infection Prevention: Highlights From Massachusetts Hospitals, June 2009

Presentations From The June 2009 Infection Prevention Summit

Hand Hygiene Resources

Ontario Hand Hygiene Program
This website will provide easy access to information and materials as well as a discussion forum where hospitals can share success stories and lessons learned.

A practical step-by-step implementation guide.
Train-the-trainer sessions for up to three people from every hospital in Ontario.
Tools and materials, such as online training modules, a hand care program, posters, and visual reminders.
Support and guidance from ministry staff during program implementation.
An audit process and tool to evaluate program impact and measure hand hygiene compliance rates (observation tool)
A methodology for selecting and placing appropriate hand hygiene products ( placement tool)
A multifaceted approach to successful improvements in hand hygiene: Beyond Posters and Reminders

Joint Commission: Measuring Hand Hygiene Compliance: Overcoming the Challenges

Joint Commission review and recommendations for monitoring hand hygiene compliance.

Institute for Healthcare Improvement

Key Lessons from MGH hand hygiene program

Hospital hand hygiene policies

General Resources for Hand Hygiene

Sample Posters From Hospitals

Patient and Family Advisory Councils

Effective October 1, 2010, all acute, chronic, and long term care hospitals in Massachusetts are required to establish a Patient and Family Advisory Council (PFAC). The purpose of these Councils is for patient and family members to advise the hospital on matters including, but not limited to, patient and provider relationships, institutional review boards, quality improvement initiatives, and patient education on safety and quality matters to the extent allowed by state and federal law.

Patient and Family Advisory Councils serve as the "patient voice" and the institutional infrastructure for including the patient and family member perspective in hospital organizational decision-making. Councils are typically comprised of patients, family members, executive leadership, and staff, working in partnership to assure the delivery of the highest standard of comprehensive and compassionate care is delivered at each hospital. All acute, chronic, and long term care hospitals are required to have a written plan by September 30, 2009 for the establishment of a Patient and Family Advisory Council (PFAC) by October 1, 2010. Information about programs supporting hospitals to meet these requirements is available here.

Reducing Medication Errors – Anticoagulation Medication Safety

Overview

Safely Managing Patients on Warfarin

Treatment and Prophylaxis of DVT (Deep Vein Thrombosis) and VTE (Venous Thromboembolism)

For more information, contact Effie Pappas Brickman at the MA Coalition, 781-262-6082 or email ebrickman@macoalition.org.

Reducing Medication Errors in Ambulatory Settings – Medication List

Patient Medication List
The Coalition is making available a patient medication list to you, your family, and providers of health care. Taking an active role in your care has many advantages. This list will:

Assist you in getting ready to visit your doctor;
Provide more complete and accurate information to health care providers;
Help you track your medications, herbal, and supplement use; and
Help your doctor provide a high level of quality care to help you achieve your best possible health.

Overview

Pilot Test Results of Med List

Patient Medication Safety - Actions to Help Protect Yourself

Patient Med List – (The Med List is a two-page Word document. You can print it out, or save it to your own computer so you can complete and update your own medication list.)

Actions for Prescribers – IOM

Actions for Pharmacists - IOM

Comments on the Patient Med List are welcome. Email Effie Brickman at ebrickman@macoalition.org.

Reducing Medication Errors in Acute Care Facilities – Reconciling Medications

Overview

Background

Implementation Guide for Safe Practices (A Resource Book of Materials)
View Table of Contents
To Purchase this click here for an Order Form

Safe Practice Recommendations

Getting Started

Implementing Reconciling Process

Measurement Strategy

Toolkit

References

Reducing Medication Errors in Acute Care Facilities – Inpatient and Consumer Medication Safety

Overview and Resources

Best Practice Recommendations for Reducing Medication Errors in Acute Hospitals

Safety First Alerts, tips for clinicians:

Reducing Medication Errors in Long Term Care Facilities – Best Practices

Overview and Safe Practices Workbook Project

Best Practices from DPH

Reducing Medical Errors in Healthcare Facilities – Communicating Critical Test Results

Background

Overview

Implementation Guide for Safe Practices (A Resource Book of Materials)
View Table of Contents
To Purchase this click here for an Order Form

Communicating Critical Test Results: Safe Practice Recommendations

Editorial: Doing Better with Critical Test Results

Starter Set

Getting Started

Implementing the Communicating Critical Test Results Recommendations

Measurement Strategy

Toolkit

References

Defining Accountability in Patient Safety

Project Background

Literature Review 2003 - Accountability for Patient Safety: A Review of Cases, Concepts, and Practices

Final Report of The Accountability Project May 2007

Current Context of Accountability Project

Reducing Restraint & Seclusion Use

Project Background and Overview

Principles, Best Practices, References, and Definitions

Best Practice Recommendations to Reduce Restaint & Seclusion Use - Definitions Included

Improvement Workbook: includes articles, tools and other resources; available for purchase by contacting us at 781-262-6080 or macoalition@macoalition.org

Reporting Requirements

Reporting Requirements Across Agencies

The Coalition conducted an inventory of hospital reporting requirements across health care agencies. For each agency, the document identifies reportable incidents, incident specifics required when reporting, disclosable information, as well as confidentiality issues. The agencies presented include: Massachusetts Board of Registration in Medicine, Massachusetts Department of Public Health, Massachusetts Department of Mental Health, Massachusetts Office of the Chief Medical Examiner, JCAHO, CMS/LTC, and the FDA.
This document was last revised April 2004 and does not include changes based on any regulations after this date. If you have comments or updates, contact Effie Brickman at 781-262-6082 or ebrickman@macoalition.org.