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
Guidance on how to measure outcomes
To gain access to a PDF of the APSS for download, please login/register below.
APSS are revised annually and available free of charge on our website for download.
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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.
I’m a registered nurse, and have worked in healthcare for almost 30 years. In 2011, my husband had a bout of diverticulitis. Subsequently, the surgeon recommended an elective laparoscopic colon resection. So, in 2012, he went in for this simple procedure.
When he arrived at the floor, I was told that for the most part it went well. Although, he did have lap surgery, they also decided to give him a temporary ileostomy. However, when I arrived to see him around 4pm post-operative, he was sweating, pale, very little urine output in his foley and his abdomen looked like he was nine months pregnant. I called his nurse into the room, who also was a friend of mine. She agreed that something was wrong. She called the doctor and started a second IV. The doctor came and said he was dehydrated. I argued that he looked like he was internally bleeding. He said he was fine, but agreed to order labs.
I asked also for an X-ray or CT scan and was told that was unnecessary. Labs demonstrated that there was a blood loss, and his potassium was elevated to about 7. (Elevated potassium can be a symptom of internal bleeding). The MD came back, and ordered a type and cross and transfusion of two units, plus a bolus, because his blood pressure was under 90 systolic. He still refused an X-ray. He just said well maybe he is having some sepsis, and I don’t believe he is bleeding, “I believe it’s just blood loss from the surgery”. He said he believed the potassium was in error, it wasn’t and he was give d50 and insulin to bring it down.
The hours ticked by, and my husband continued to deteriorate, and around 11pm, they transferred him to ICU. I went home, because he was in the hands of the ICU intensivist, and we 5 kids, four of whom were still in school. Around 1am, I got an urgent call from the ICU intensivist that he had ordered a CAT scan. My husband’s belly had an estimated 2 liters of blood in it, and they were calling in a trauma surgeon. His hemoglobin was about 5 and mass transfusion protocol was initiated. When they opened him, my husband was full of blood. The trauma surgeon was able Patient Safety Movement Foundation | patientsafetymovement.org to stop the bleeding, but unable to close his belly. He was brought back to the ICU intubated, and belly packed. He went back to the OR after the internal swelling went down, and was closed. It was a year-long recovery. This was due to failure to rescue. If I had as a family member called a rapid response at 5pm, this could have been avoided. My husband took a long time to recover. My husband almost died.
I’m thankful that he is alive, but his long recovery could have been avoided if he had had the proper interventions early in the evening. After the event, people couldn’t believe that this could happen to a nurse’s husband. IF this could happen to my husband, it could happen to anyone.