Our APSS outline actionable steps healthcare organizations should take to successfully implement and sustain behavior change for high reliability, shared understanding, thorough communication, and meaningful person-centered care across the organization.
Actionable steps include:
Executive Summary Checklist
Leadership checklist guide to determine whether current evidence-based guidelines are being followed in your organization
Performance improvement plan to follow if improvements are necessary
Clinical workflow for preoccupation with workflow for areas of improvement
How to educate patients and family members about the significance of their role throughout the continuum
Each APSS is developed by a multidisciplinary workgroup comprised of patient safety experts, healthcare technology professionals, hospital leaders, and patient advocates. The Foundation is proud to connect as many stakeholders as possible to focus on how these challenges can best be addressed.
We believe that progress cannot be achieved by sitting on the sidelines; we must take ACTION together. Like-minded individuals are the driving force that makes our mission to reach ZERO preventable deaths not just conceivable, but achievable.
On October 7th, 2021, my sister Gladys was forced, against her wishes, to the hospital by her dialysis nurse for anxiety. Instead of being sent to the neighboring hospital that day, she was sent to a hospital that was significantly further for reasons unknown.
My sister Gladys has never had any prior heart or health issues besides renal failure. She was in hospital care for a few hours before her heart stopped. The hospital claims that she had a heart attack. At the age of 23 with no prior cardiovascular health issues, this was difficult to believe.
For the next two months, the hospital neglected my sister and never bothered to engage with our family to shed clarity on what occurred that day. We have filed multiple reports of neglect to administration, yet it seems as if everyone looked the other way. Shortly after, Gladys was transferred to a nearby nursing home where she only lasted six days before being admitted back into the hospital. It was discovered by family that her body was covered in bruises and marks of neglect following her stay at the nursing home.
As of now, my sister Gladys is still a patient at the hospital, where we are very concerned for her safety due to previous experiences. Recently, an electroencephalogram was conducted and results showed that there was evidence of past brain damage that had occurred in her previous care facilities and now new brain damage was occurring. The hospital has recommended that Gladys be discharged to a nursing home, but with previous negative experiences, we are very hesitant and worried about her health and safety. We want a fighting change for Gladys and to provide her proper care. To return to the nursing home makes our family feel as though the hospital has requested that we disconnect her.
In addition, there has been a lot of inconsistency between hospital staff on my sister’s mental state due to the brain damage found. I am sharing my Sister’s story in hopes that instances of neglect similar to Gladys’ story do not go unnoticed and to shed light on the lack of transparency in our current healthcare system.
My name is Joe Power, and my father, Michael Power, died in the hospital last March. The circumstances around my father’s death left a giant question mark in our lives due to the lack of answers we received from the hospital during the original review. I wanted to share his story
My father was admitted to the hospital March 5th, 2021 due to a severe chest infection, which significantly worsened over the next few days. As a result of the pandemic, our family was barely able to visit my father and unable to see the care provided by the hospital first hand. The serious events arise on Saturday, March 13th, 2021, the day my father passed away.
Our family was advised to come to the hospital around 10:30 AM, during which we were not told over the phone that He had already passed. Upon arrival, there was a large, fist-sized, bruise on the side of his head. This bruise was dismissed and given zero explanation by staff when asked about. Later it was discovered that my Father had a series of bruises, consistent with those of a defensive fall, down his right hand side. This necessitated an autopsy, which was especially hard on our family as it further delayed the funeral.
Although the autopsy did not link the bruises to his death, the hospital took no serious action to explain the bruises. A review was opened by the hospital and it was verified by CCTV footage that my Father did fall, at least once, before his passing. However, this was not reported anywhere in his medical chart, not passed on to the medical team, nor reported to the family. It was only after the CCTV footage proved His fall, and ultimately the medical staff’s negligence of care, did the hospital accept their fault and apologize.
The hospital review concluded with reported findings that pointed to staff failure and the recommendation of staff retraining on a number of skills. The hospital ruled the bruising due to an “assisted fall,” although the bruising found was entirely incompatible with this type of fall.
We have filed a formal complaint with the hospital, which has not received an official response within the 9 months, and counting, of it being filed. I am sharing my Father’s story in hopes of his memory not being dismissed as another patient safety statistic.