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Patient Safety Resource Seminar

Patient Safety Resource Seminar

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Patient Safety Resource Seminar

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  1. Patient Safety Resource Seminar Part II - Resources

  2. Goal of Patient Safety: to identify and eliminate errors

  3. Addressing Patient Safety • Legislation • Research • Recognition • Patient Involvement • Education • Tools • Library Connections & Advocacy

  4. Legislation title slide Legislation

  5. State Legislation I • Malpractice regulations • Mandatory and/or voluntary reporting • Some form of reporting (adverse events, hospital acquired infections, etc.) in 43 states plus DC • Mandatory patient notification • 11 states require patients be notified of adverse events • Apologies permitted • 35 states plus DC have enacted apology laws excluding expressions of sympathy as an admission of liability Visit: , and

  6. Federal & State Legislation • Patient Safety Officers mandated • Point of contact in the hospital, report events, and coordinate activities to provide safety to patients • 5 states require this position, 1 for a voluntary program • Patient Safety Officers are found in most states and several countries • Reporting Agencies established • Federal Patient Safety and Quality Improvement Act of 2005 • Departments of Health began collecting reporting information and/or providing educational materials • 76 Patient Safety Organizations (PSOs) in 30 states and the District of Columbia -

  7. State Legislation II • Staffing Issues • Nurse to patients staffing ratios: CA in 1999 • Restricted/Regulated mandatory overtime for nurses: 16 states • Pharmaceutical laws • 36 states and DC starting in MN in 1993 • Safety topics include electronic prescription requirements; regulations on forms, labels or packaging; legibility issues; internet sales; and reporting rules • 41 state if reuse/recycling is included

  8. Federal Legislation • Electronic Prescription and Health Records Programs • Medicare Prescription Drug Act 2003 • American Recovery & Reinvestment Act of 2009 • The Patient Protection & Affordable Care Act of 2010 and Health Care & Education Reconciliation Act of 2010 (Affordable Care Act) • Health Information Technology for Economic and Clinical Health Act (HITECH Act)

  9. Legislation Resources I • Library of Congress legislative information • National Academy for State Health PolicyPatient Safety Toolbox • National Conference of State Legislatures • – states’ public and private policy / initiatives • – links to state legislatures

  10. Legislation Resources II • Health professional organizations • Patient Safety Organizations • Patient Safety Coalitions • Local and state coalitions and organizations, plus specialized groups for patients and/or health professionals, are continuously forming • 19 coalitions formed since 1997 • State/Federal organizations with patient safety sections, components or initiatives

  11. Research title slide Research

  12. Research • Patient Safety Grants • Government: Agency for Healthcare Research and Quality (AHRQ), US HHS, National Institutes of Health, National Institute of Nursing Research, National Science Foundation, • Non-Profit/Private foundations: Commonwealth Fund, National Patient Safety Foundation, Robert Wood Johnson Foundation • Other agencies: Blue Cross/Blue Shield

  13. Research Resources • Health Services Research Projectsin Progress • NLM HSRProj: • Informational databases • public: Joint Commission Sentinel Events, HHS Hospital Compare • member: Quantros/MedMarx, MedSun • private: HealthGrades • Article sources • &

  14. Recognition title slide Recognition

  15. Recognition: Accreditation • Hospitals and Health Centers • Joint Commission Requirements • Encourage patients’ active involvement in their own care as a patient safety strategy (Standards) • The organization identifies safety risks inherent in its patient population (National Patient Safety Goal #15) • Support information needs for other goals • Sentinel Events • Support for required Root Cause Analysis’

  16. Recognition: Certification • Health professionals - recertificationrequirements include patient safety topics • Doctors in FL and PA • Pharmacists in FL, HI and NY • Students and residents - required to take patient safety courses • New York Medical College • Hospital residency programs • ACGME standard - 80-hour work week

  17. Recognition: Degrees • Graduate Certificate • University of Wisconsin-Madison • Masters Degree • Thomas Jefferson University • University of Illinois • Additional Certificate Programs • ABQAURP • Harvard Quality Colloquium

  18. Recognition: Awards • NISTMalcolm Baldrige National Quality Program • Joint CommissionJohn M. Eisenberg Award for Patient Safety and Quality • ANCCMagnet Recognition Program • AHA-McKessonQuest for Quality Prize • ISMP Cheers Award • AHTF-ACCEMarvin Shepherd Patient Safety Award

  19. Patient Involvement title slide Patient Involvement

  20. Patient Involvement: Campaign • AHRQ’s has created online videos and public service announcements for TV and radio • Use the “Build Your Question List” to prepare for medical appointments •

  21. Patient Involvement: Personal • Individual Advocacy – In doctor & hospital visits • Share information • Create a Personal Health Record or keep lists of health problems, previous operations, etc. • List or bring all medications, supplements, and vitamins • Get information • Ask questions about treatments, medications, etc. • Research illnesses and treatments • Bring an Advocate • Know what to do before leaving • Ask about medications and future appointments

  22. Patient Involvement: Advocate • Patient Advocate – For friends and family • Willingness to go with the patient to appointments, be with them in the hospital and clinics • Listening and taking notes • Speak up when necessary to clarify an issue and to ask a question • Question when something does not seem right in the hospital, nursing homes, clinics, etc.

  23. Patient Involvement: Representative • Patient Representative – In health care organizations • Work to improve safety at the organization and individual unit level • Serve on committees and boards • Assist on rounds (still rare) • Support staff and families

  24. Patient Involvement: Activist • Patient Participant/Activist • Participate on state and regional coalitions and organizations and/or • Serve nationally • Advocate for public reporting and accountability of hospital and health system performance • Volunteer, make donations, work with fund-raising • Be aware of state and national legislation, contact legislators Gibson, Rosemary. Role of the patient in improving patient safety. WebM&M. 2007(Mar): Perspectives on Safety.

  25. Patient Involvement Resources I • Online Information • 5 Steps to Safer Health Care • 20 Tips to Prevent Medical Errors • Before Your Appointment • Speak Up Initiatives(and brochures) • We Care about Your Safety (video)

  26. Patient Involvement Resources II • Online Information • Check Your Medicines: Tips for Using Medicines Safely • Personal Health Records • Medicines and You: A Guide for Older Adults • Where Medical Errors Occur and Steps You Can Take to Avoid Them

  27. Patient Involvement Resources III • More Information • Websites: AHRQ, NLM, etc. • Alerts: My NCBI, etc. • Organizations: staff, committees, leaders, etc. • Conferences: NPSF, etc. • Advocacy • Websites: CAPS, PULSE, NPSF, etc. • Legislation resources • Medical Error Support • Websites: MITSS, PULSE, Voice4Patients

  28. Education title slide Education

  29. Education: Teaching Topics • Health literacy • Easy to read, Language appropriate • Legislation • Accreditation/Certification requirements • Joint Commission changes • Evidence Based Medicine/Nursing, Research Based Practice • Consumer resources & advocacy

  30. Education: Opportunities I • Conferences/Seminars/Workshops • NPSF, AHRQ, medical associations, coalitions • Books, Journals, Newsletters • Quality Chasm series • Patient Safety and Quality Healthcare • Podcasts and Videos • Drug Safety Podcasts (FDA) • Healthcare 411

  31. Education: Opportunities II • Web-based education including CE/CME/CNE • Alert services ISMP, FDA, AORN, My NCBI, NIH, WHO • Email Discussions • NPSF Patientsafety-L • American Society of Medication Safety Officers • Blogs and Wikis • Joint Commission WikiHealthCareTM • Blogs for Hospital Librarians

  32. Education: Connections For those experiencing medical error • Patients and families • P.U.L.S.E. • Consumers Advancing Patient Safety (CAPS) • Medical professionals • Medically Induced Trauma Support Services (MITSS) • Sorry Works! Coalition

  33. Tools title slide Tools

  34. Tools: Examining Events I • Root Cause Analysis (RCA) • Examining events • Incident Decision Tree • Examining events • Failure Modes and Effects Analysis (FMEA) • Examining processes • Probabilistic Risk Analysis (PRA) • Examining processes starting with outcomes • Six Sigma • Measurement studies

  35. Tools: Examining Events II • Human Factors Engineering • Human abilities/characteristics affecting design/operation • Crew Resource Management (CRM) • Communication, team working • Situation-Background-Assessment-Recommendation (SBAR) • Communication, team working • Patient/Problem, Assessment/Actions, Continuing/Changes, Evaluation (PACE) • Communication

  36. Tools: Resources • Web-based information (Forms, tool-kits, articles) • IHI SBAR tools • NPSA RCA Toolkit • Pathways for Medication Safety • Software (EMR, bar-coding, RCA) • AHRQ Quality Indicators • Consulting agencies (Concerning Joint Commission, focusing on processes, in-house training) • Joint Commission Resources

  37. Tools: NLM Resources I • RCA / FMEA Support, Evidenced-Based Medicine/Nursing • search for events and/or processes • PubMed Clinical Queries identify related reviews • PubMed Topic-Specific Queries additional subject filters • NIH Clinical Alerts & Advisories

  38. Tools: NLM Resources II • RCA / FMEA Support, Evidenced-Based Medicine/Nursing (continued) • PubMed My NCBI Alerts track events/processes, keep current on research • PubMed My NCBI Collections save related and critical citations • Hazardous Substance Data Bank (HSDB) research toxicology issues • Radiation Event Medical Management focus on radiation events

  39. Tools: PubMed I • PubMed Search Strategies • MeSH Terms related to patient safety issues • Disease Transmission, Professional-to-Patient • Drug Administration Routes • Hospitalization (includes Length of Stay, Patient Admission, Patient Discharge, and Patient Transfer) • Investigative Techniques (includes Equipment Safety) • Medical Errors (includes Diagnostic Errors, Medication Errors and Observer Variation) • Patient Participation • Patient Safety (or the broader term Safety)

  40. Tools: PubMed II • PubMed Search Strategies (continued) • USE DETAILS to clean up a search E.g. searching for patient safetygives the result: ("patients"[MeSH Terms] OR "patients"[All Fields] OR "patient"[All Fields]) AND ("safety"[MeSH Terms] OR "safety"[All Fields]) • Health Literacy – find search term under the Topic-Specific Queries link • “Patient Safety” – using the phrase with quotes will turn off automatic term mapping, only articles using this specific phrase will be found

  41. Tools: NLM Patient Resources I • Patient and Family Concerns • MedlinePlus- general searches, patient safety page • Drug Information Portal- searches across NLM, NIH and FDA databases • Pillbox - pillbox.nlm.nih.govidentify unknown pills by color, shape, etc. • Dietary Supplements Labels Database -dietarysupplements.nlm.nih.govincluding label ingredients • NIH Senior Health - information for seniors and their care givers

  42. Tools: NLM Patient Resources II • Patient and Family Concerns (continued) • Genetics Home Reference - study genetic conditions and the responsible genes • current and previous studies • Household Products Database - health and safety information • Tox Town - toxtown.nlm.nih.govtoxicology geared for school children • PubMed - journal article citation database

  43. Library Connections & Advocacy title slide Library Connections & Advocacy

  44. Advocacy: Librarian’s Critical Role • Dr. Robert Wachter: So, a medical school librarian set off the modern patient safety movement? • Lucian Leape, MD: Ergo, there we go. Wachter R. In conversation with Lucian Leape, MD. WebM&M. 2006(Aug): Perspectives on Safety.

  45. Library Connections & Advocacy How is Your Library Involved in Patient Safety (or how will it be)?

  46. Advocacy: Start Where You Are • With Literature Searches • Stat for Emergency Room • Nursing Education Department • Monthly Infection Control Reports • Drug Use and Clinical Adverse Events • Patient/Family Questions • Specifics Adverse Events, FMEAs, RCAs • Research Studies

  47. Advocacy: Education • In Training & Education • Student Curriculum development • CME/CNE/CE requirements assistance • Including patient safety when focusing on computer skills, EMB, searching, etc. • During orientation classes and introductions • On-line tutorials and resources preparation • In reference services, e.g. with patients and families, health professionals

  48. Advocacy: Reach Out • Participation • On Patient Safety committees, teams and boards • Attending related M&Ms, councils, committees and meetings • (Hospitals:) On Rounds, providing RCA support • Connect and Educate • Safety Officers, Advocates and Directors • Executives: CEO, CNO, CME and others • Institutional leaders: Directors, Lawyers, Liaisons

  49. Advocacy: Focused Service I • Creating & Sharing Information • Through Alert Services • Recalls, Tables of Contents, Clinical Alerts, Drug Updates, Diseases and Treatments • Supporting Institutional Resources and Needs • Balanced Score Card, Indicators, Legislation • Magnet Status, Joint Commission preparations • Policies, Procedures, Employee Handbooks • Electronic Health Records (MedlinePlus Connect)

  50. Advocacy: Focused Service II • Creating & Sharing Information • For Patient Education • Brochures, Flyers, Surveys • Supporting nurses and patient educators • In Telling Stories • Of library involvement, institutional successes, individual joys or concerns • In Newsletters, on Blogs, with Articles, through the Intra- or Internet