Patient Safety Resource Seminar: Librarians on the Front Lines

1. Patient Safety Resource Seminar: Librarians on the Front Lines Holly Ann Burt, MLIS, MDiv

2. Patient Safety Resource Seminar Objectives • Describe definitions related to patient safety and detect systems of potential error within institutions • Identify patient safety issues and points of contact specific to individual institutions • Locate resources available for administrators, health professionals, and patients and families • Formulate methods for the library to effectively participate in improving patient safety

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 I • Aviation Industry • Federal Aviation Authority (FAA) • Aviation Safety Reporting System (ASRS) – 1975 • Aviation Safety Action Program (ASAP) – 2000 • Voluntary Safety Reporting Programs (VSRP) - 2012 • National Aeronautics and Space Administration (NASA) • NASA Safety Reporting System (NSRS) – 1987 • Department of Defense (DOD) • Patient Safety Program – 2001

5. Sources of Patient Safety Concepts II • Transportation Industry • National Transportation Safety Board (NTSB) – 1966 • UK Railway Industry • Confidential Incident Reporting & Analysis System (CIRAS) – 1996 • Australian Transport Safety Bureau (ATSB) • Confidential Marine Reporting Scheme (REPCON) – 2004 • Federal Railroad Administration (FRA) • Confidential Close Call Reporting System (C3RS) – 2005

6. Sources of Patient Safety Concepts III • 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

7. 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.

8. 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 I Error: failure of a planned action or use of a wrong plan

9. Near miss / Close call Definitions in Patient Safety II Error Adverse Event / Clinical Event Preventable Adverse Event Sentinel Event / Critical Incident Reportable Events? It depends. Adapted from: MMS Committee on Quality of Medical Practice and Trinity Communications, Inc. Medical Errors and Perspectives onPatient Safety. Massachusetts Medical Society, 2004.

10. Patient Safety Systems I Barrier/Defense Error Patient Emergency Room

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

12. 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/transfer 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

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. Intersection of Patient Safety Quality Evidenced-Based Medicine/Nursing Guidelines Training Processes Forms Measurements / Benchmarking

15. Intersection of Patient Safety I Safety • Environment • Room arrangement • Distractions/Noise • Acuity/Census • Equipment / Materials • False alarms • Bathroom floors/rails • Electrical systems

16. Intersection of Patient Safety II Management Leadership • Policies/Processes • Disclosure • Hours • Reporting • Discipline • Participation (e.g. on rounds) • Business case • Response to concerns • Culture

17. Intersection of Patient Safety III Culture • Communication • Authority gradient • Patient input • Health literacy • Reporting • Sharing or silence • Support or firing • Change welcomed or not

18. Intersection of Patient Safety IV Quality Safety Culture Management

19. Exploring Patient Safety I Areas / Departments • Family Practice • Outpatient • Emergency Room • Radiology • Surgery • ICU / NICU / CCU • Housekeeping • Pathology • IT/IS • Admissions • Pharmacy • Laboratory • Pediatrics • Rehabilitation • Hospice Care • Palliative Care • In-home service

20. Exploring Patient Safety II Processes • Medication • prescribing, preparation, point-of-care delivery • Tests • pre-analysis, analysis, post-analysis • Surgery • preparation, procedures, follow-up • Patient transfers & hand-offs • from care centers, during shift changes, across floors • Communication • reporting, information sharing, encouragement/resistance

21. Exploring Patient Safety III Events - using tools like Root Case Analysis (RCA) • Near miss • Adverse event / Clinical event • Preventable adverse event • Reportable event • Sentinel event

22. Exploring Patient Safety IV Patient / Health Care Provider / Team / Task and Environmental Factors Sharp End Examples: Medication adverse events Nosocomial Infections Sharp End: Immediate Cause(s) Contributing Factors Blunt End Examples: Communication Culture Physical Environment Policies / Procedures Blunt End: Root Cause(s) Management/ Organizational/ Regulatory Factors Adapted from the National Health Service. Department of Health. National Patient Safety Agency. Doing Less Harm: improving the safety and quality of care through reporting, analyzing and learning from adverse incidents involving NHS patients – key requirements for health care providers, August 2001.

23. Librarians are Key • 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. http://webmm.ahrq.gov/perspective.aspx?perspectiveID=28

24. Patient Safety is Central QualitySafety Library and Patient information Safety services Culture Management