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Patient Safety: You Can Make a Difference

Patient Safety: You Can Make a Difference . 2012. 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 www.ahrq.gov/questions/. Patient Safety: Ongoing Problem.

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Patient Safety: You Can Make a Difference

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  1. Patient Safety: You Can Make a Difference 2012

  2. 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 • www.ahrq.gov/questions/

  3. Patient Safety: Ongoing Problem • “I would give great praise to the physician whose mistakes are small, for perfect accuracy is seldom seen… .”Hippocrates, trans. by Francis Adams. On Ancient Medicine, Part 9; c. 400 BCE. • Traditional Errors in Surgery. Levis RJ. Presidential Address, Medical Society of the State of Pennsylvania on June 6, 1888. JAMA. 1888 (Jun 23);10(25):790-791. • To Err is Human: Building a Safer Health System.Kohn LT, Corrigan JM, Donaldson MS. Washington, DC: National Academy Press; 2000.

  4. Sources of Patient Safety Concepts • Aviation Industry • Federal Aviation Authority (FAA): Aviation Safety Reporting System (ASRS) – 1975 • National Aeronautics and Space Administration (NASA) : NASA Safety Reporting System (NSRS) – 1987 • Transportation Industry • National Transportation Safety Board (NTSB) – 1966 • UK Railway Industry: Confidential Incident Reporting & Analysis System (CIRAS) – 1996

  5. Sources of Patient Safety Concepts • Nuclear Energy Industry • US Nuclear Regulatory Committee (NRC) – 1974 • Computerized Accident Incident Reporting and Recordkeeping System (CAIRS) -1975 • Manufacturing Industry • Toyota Production System – 1977 • Alcoa Aluminum: Safety Culture – 1987 • General Electric: Six Sigma - 1995

  6. Definition of Patient Safety Patient safety: Freedom from accidental injury; ensuring patient safety involves the establishment of operational systems and processes that minimize the likelihood of errors and maximize the likelihood of intercepting them when they occur. Kohn LT, Corrigan JM, Donaldson MS. To err is human: building a safer health system. Washington, DC: National Academy Press; 2000:211.

  7. Near miss – event caught before harming a patient Adverse Event – commission or omission resulting in unintended harm to a patient Sentinel Event – event causing or risking serious injury or death Definitions in Patient Safety Error: failure of a planned action or use of a wrong plan

  8. Near miss / Close call Definitions in Patient Safety Error Adverse Event / Clinical Event Preventable Adverse Event Sentinel Event Not all events must be reported. Adapted from: MMS Committee on Quality of Medical Practice and Trinity Communications, Inc. Medical Errors and Perspectives onPatient Safety. Massachusetts Medical Society, 2004.

  9. Patient Safety Systems No health professional begins their day with the goal of making a mistake and harming their patient. However, there are problems in the system that can lead to errors.

  10. Sentinel Event • Jose Eric Martinez, died August 2, 1996 At least 17 errors contributed to the death of this infant: • 4 physician events • 2 pharmacy events • 4 medication policy issues • 2 authority gradient issues • 2 response issues • 1 shift change issue • 1 mechanical issue • 1 violation (not following policy) Turnbull JE. Systems approach to error reduction in health care. Japan Med Assoc J. 2001(Sep);44(9):392-403

  11. Error Patient Safety Systems Barrier/Defense Patient

  12. Barrier/Defense Latent conditions/Active failures Errors Adverse or Sentinel Event Admissions Laboratory Physicians Patient / Family Transfers Emergency Room Nurses Pharmacy Patient Safety Systems Adapted from: Reason J. Human error: models and management. BMJ 2000;320;768-770

  13. System Errors (Latent) Communication Heavy workload/Fatigue Incomplete or unwritten policies Inadequate training or supervision Inadequate maintenance of equipment/buildings Human Mistakes (Active) Action slips or failures (e.g. picking up the wrong syringe) Cognitive failures (e.g. memory lapses, mistakes through misreading a situation) Violations (i.e. deviation from standard procedures; e.g work- arounds) Types of Errors DeLisa JA. Physiatry: medical errors, patient safety, patient injury, and quality of care. Am J Phys Med Rehabil. 2004(Aug);83(8):575-583

  14. Be Aware of Potential Problems Understanding systems and processes leads to asking the right questions to find answers to what has occurred and what might happen again.

  15. Making A Difference • Individual Advocacy – In doctor & hospital visits • Share information • Create and bring 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

  16. Making A Difference • Individual Advocacy (continued) • Bring an Advocate • To appointments • At the bedside in the hospital • Know what to do before leaving • Ask about medications • Ask about future appointments

  17. Making A Difference • Patient Advocate – For friends and family • Go with the patient to appointments, be with them in the hospital • Listen and take 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.

  18. Making A Difference • Patient Representative – In health care organizations • Working to improve safety at the organization and individual unit level • Serving on committees and boards • Assisting on rounds (still rare) • Supporting staff and families related to patient safety events

  19. Making A Difference • 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. http://webmm.ahrq.gov/perspective.aspx?perspectiveID=38

  20. Patient Safety Solutions When a near miss or a preventable or unpreventable adverse event occurs a variety of resources are available on the web and in the hospital

  21. Be Aware of Resources • Online Information • 5 Steps to Safer Health Carehttp://www.ahrq.gov/consumer/5steps.htm • 20 Tips to Prevent Medical Errorshttp://www.ahrq.gov/consumer/20tips.htm • Before Your Appointment http://www.ahrq.gov/questions/beforeappt.htm • Speak Up Initiatives(and brochures) http://www.jointcommission.org/speakup.aspx • We Care about Your Safety (video)http://www.emmisafety.com/ashrm/Emmi.html

  22. Be Aware of Resources • Online Information • Check Your Medicines: Tips for Using Medicines Safely http://www.ahrq.gov/consumer/checkmeds.htm • Personal Health Recordshttp://www.nlm.nih.gov/medlineplus/personalhealthrecords.html • Medicines and You: A Guide for Older Adults http://www.fda.gov/Drugs/ResourcesForYou/ucm163959.htm • Where Medical Errors Occur and Steps You Can Take to Avoid Them http://www.ahrq.gov/consumer/cc/cc121807.htm

  23. Be Aware of Resources • Conferences/Seminars/Workshops • NPSF, AHRQ, coalitions, medical associations • Books, Journals, Newsletters • Quality Chasm series http://www.nap.edu/ • Patient Safety and Quality Healthcare http://www.psqh.com/ • Podcasts and Videos • Healthcare 411 http://www.healthcare411.ahrq.gov/ • Drug Safety Podcasts (FDA): http://www.fda.gov/cder/drug/podcast/

  24. Be Aware of Legislation Resources • Library of Congress legislative informationhttp://thomas.loc.gov/ • National Academy for State Health PolicyPatient Safety Toolbox for States http://www.pstoolbox.org/ • National Conference of State Legislatures http://www.ncsl.org/ • QuPS.org – states’ public and private policy / initiatives http://www.qups.org/ • USA.gov – links to state legislatures

  25. NLM Resources • MedlinePlus- medlineplus.gov general searches, patient safety page • Drug Information Portal- druginfo.nlm.nih.gov 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 - nihseniorhealth.gov information for seniors and their care givers

  26. NLM Resources • Genetics Home Reference - ghr.nlm.nih.gov study genetic conditions and the responsible genes • ClinicalTrials.gov- clinicaltrials.gov current and previous studies • Household Products Database - hpd.nlm.nih.gov health and safety information • Tox Town - toxtown.nlm.nih.govtoxicology geared for school children • PubMed - pubmed.gov journal article citation database

  27. Connections For those experiencing medical error • P.U.L.S.E. http://www.pulseamerica.org/ • Voice4Patients.com • Consumers Advancing Patient Safety (CAPS) http://www.patientsafety.org/ • Medically Induced Trauma Support Services (MITSS) http://www.mitss.org/

  28. Intersection of Patient Safety QualitySafety Patient and Patient family Safety involvement Culture Management

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