• New Members
  
  • Welcome!  SPHCC is very pleased to welcome the nine state-operated mental health facilities of the Virginia Department of Behavioral Health & Developmental Services (DBHDS). They include:
    • Catawba Hospital
    • Central State Hospital
    • Commonwealth Center for Children & Adolescents
    • Eastern State Hospital
    • Northern Virginia Mental Health Institute
    • Piedmont Geriatric Hospital
    • Southern Virginia Mental Health Institute
    • Southwestern Virginia Mental Health Institute
    • Western State Hospital
  • SupporTips– New members are encouraged to take advantage of our archive of helpful suggestions for getting the most out of this newsletter and SPHCC website features.
    

• Article of the Month
  
  •  Human Factors Analysis in Patient Safety Systems[®] The Source, April 2015, Vol 13, #4, Pg 1 [Recommended for: LDR, PI] – Human factors are the #1 most frequently identified root cause of Sentinel Events. It follows then that if the ultimate goal is High Reliability/Zero Harm, that ultimately something must be done to improve reliability and decrease the risk of harm from human factors.  A critical first step in this direction is to better understand the nature of these factors and the manner in which they impact patient safety. This article provides insight into James Reason’s concepts of Active and Latent Failures for that purpose… and for greater appreciation of Just Culture. Thought Question: Is human error inevitable and if so does that make zero harm impossible? (See article B3 comment section for James Reason’s perspective)
    
  • Click here for our REVIEW(Mbr/Guest); the FULL TJC ARTICLE(Mbr); to share a COMMENT(Mbr/Guest).

**RECOMMENDED READING:

1. PR: Top Standards Compliance Issues for 2014  TJC (PDF/QV) [REF:IC, JCSC, PI, LDR]
   
2. PR: Sentinel Event Statistics for 2014  TJC (PDF/QV) [REF:JCSC, LDR, PI]
   
3. TS: Human Factors Analysis in Patient Safety Systems   TJC (PDF/QV) [REF: AOM, LDR, PI]
4. TS: Complying with RC.01.01.01 for BHC  TJC (PDF/QV) [REF: BHC, IM, JCSC]
5. EC: What to do when a patient turns violent  TJC (PDF/QV) [REF: EM, LDR, PI, RN, SFT]
6. EC: Compliance Checklist for EM.03.01.03  TJC (PDF/QV) [PEARL: EOC, JCSC, SFT]

**USEFUL UPDATES, LINKS & DOWNLOADS:

• TJC Tool: Compliance Checklist for EM.03.01.03
• Revised: Slightly reorganized Public Information Policy (PDF) [HTML]
  
• Merged: The Infection Prevention and Health Care–Associated Infection Portals
  
• NIOSH: Violence: Occupational Hazards in Hospitals
• Ref: TJC Patient Safety Systems Chapter (also in Accreditation Process Info section of E-dition)
• Latest TJC Blogs: Physician Leader Monthly – Leadership Blog
  

**SupporTips

• S-Tip/VC_RTN_How to access the full text of our newsletter summaries: 3-minute video clip explains 3 ways to access full text of the article summaries provided in our newsletter including the new 1-click access feature.