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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 • Certification/Accreditation/Recognition • Research • Education/Communication • Support Agencies • Tools & Resources • Library Connections & Advocacy

  4. Federal & Provincial Legislation • Malpractice regulations • Adverse Reaction Reporting • MedEffect: drugs and health products • Mandatory and/or voluntary medical error reporting • SK, MB, ON, QC • BCAS - CIRS

  5. Federal & Provincial Legislation • Disclosure • Patient notification of adverse events • Position statements: CMA, CNA • Legislation: MB, QC • Guidelines/Policies: AB, BC, NF/LB, NS, ON, PE, SK • Liability protection for disclosure • British Columbia Evidence Act

  6. Federal & Provincial Legislation • Canadian Patient Safety Institute • Potential regulations • Nurse to patients staffing ratios • Mandatory overtime prohibited • Hours in a work-week

  7. Legislation Resources • Department of Justice • Justice Laws Web Site http://laws.justice.gc.ca/ • Health Law Institutes • Dalhousie University http://hli.law.dal.ca/ • University of Alberta http://www.law.ualberta.ca/centres/hli/

  8. Accreditation • Hospitals and Health Centers • CCHSA Patient Safety Goals & ROPs • Culture: One prospective analysis per year • Communication: Inform and educate patients/clients • Worklife/Workforce: Annual education/training to staff, support preventive maintenance program • Infection control: Guidelines • CCHSA 2007 Performance Measures • Patient Safety Education

  9. Certification • Health professionals: • recertification requirements to include patient safety topics • Students and residents: • Required to take patient safety courses • Topics included in residency programs • Maximum Duty Hours: • Less than than two or more consecutive periods of call for residents (Ontario)

  10. Recognition Programs • CRPNBC Awards of Excellence • MOHLTC Innovation Awards • CCHSE/CCDSS Awards Program • WRHA Leading Us to Excellence • OHA Innovation in Patient Safety Award • Individual conferences

  11. Research • Patient Safety Grants • Federal, Regional, Local • CHSRF/FCRSS • CIRH/IRSC • CPSI/ICSP • Health Sciences Centre Foundation • International • Robert Wood Johnson Foundation

  12. Research Resources • Health Services Research Projectsin Progress • HSRProj: http://www.nlm.nih.gov/hsrproj/ • Informational databases • MedEffects • JCAHO Sentinel Events • Journal Sources • PubMed.gov • PubMedCentral.gov

  13. Education Opportunities • Conferences/Seminars/Workshops • National & Regional, Medical associations • CPSI 2006 Patient Safety Studentship Program • Publications • Five journals, numerous newsletters and columns • Web-based modules and home study resources • In-house training • Created by library, brought in from outside

  14. Education Topics • Health literacy • Easy to read • Language appropriate • Legislation • Accreditation • CCHSA changes • Nursing issues & resources • EBM / EBM

  15. Communication Resources • Listservs • NPSF, JC-ICPS • Websites • Government, non-profit, professional, publicly owned, internal • Focused: health professionals, administration, patients & families • Alert services • MedEffects, ISMP, AORN, My NCBI (NLM PubMed), FDA,

  16. Support Agencies For those experiencing medical error • Patients and families • P.U.L.S.E. • Voice4Patients.com • Medical professionals • Medically Induced Trauma Support Services (MITSS) • Sorry Works! Coalition • Other leadership support agencies

  17. Patient Safety Tools • RCA – Root Cause Analysis • Examining events • Failure Modes and Effects Analysis (FMEA) • Examining processes • Six Sigma • Measurement studies • Probabilistic Risk Analysis (PRA) • Examining processes starting with outcomes

  18. Patient Safety Tools • Human Factors Engineering • Human abilities/characteristics affecting design/operation • Crew Resource Management (CRM) • Communication, team working • Situation-Background-Assessment-Recommendation (SBAR) • Communication, team working

  19. Tools Resources • Software • EMR, bar-coding, RCA • Consulting agencies • Concerning CCHSA/CCASS, focusing on processes, in-house training • Web-based information • Forms, tool-kits, articles

  20. NLM Resources • RCA / FMEA Support • PubMed search for similar events and/or processes • My NCBI Alerts tracked related events/processes • NIH Clinical Alerts & Advisories • My NCBI Collections save related citations for reference, publication, CCHSA/CCASS, etc.

  21. NLM Resources • RCA / FMEA Support (continued) • PubMed Clinical Queries identify related reviews • HSDB in TOXNET follow-up on toxicology issues in the Hazardous Substance Data Bank • HSRProj current projects on topics • Radiation Event Medical Management focusing on all aspects of radiation events

  22. NLM Resources • Evidenced - Based Medicine/Nursing • PubMed general citation search • PubMed Clinical Queries identify specific reviews • PubMed My NCBI for both alerts and citation collections

  23. NLM Resources • Patient & Family Concerns • MedlinePlus general searches, patient safety page • Household Products Database toxicology issues • ClinicalTrials.gov current and previous studies • ToxTown toxicology geared for school children

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

  25. Library Connections & Advocacy • In Training & Education • Student Curriculum • Pharmacy • Nurses • Assist with CME/CNE/CE requirements • Physicians, Residents, Nurses • Focus on computer skills, EMB, searching • Teach in Orientation classes • Prepare on-line tutorials and resources

  26. Library Connections & Advocacy • With Reference Services • Literature Searches • Stat for Emergency Room • Nursing Education Department • Monthly Infection Control Reports • Drug Use for Employees

  27. Library Connections & Advocacy • With Reference Services • Alerts • Recalls • Tables of Contents • Clinical Alerts • Drug Updates

  28. Library Connections & Advocacy • On the Website • Information Pages • For patients and families • For employees and health professionals • Celebrations • Good Catch • System changes due to FMEA • Current News • Evidence Based & Benchmarking information • Alerts

  29. Library Connections & Advocacy • Beyond the Library • In the hospital • Safety Fairs and programs • Visiting stations, departments & people • Serving on committees, councils & panels • Support accreditation requirements • In the community • Assist at community affairs department projects • Accept speaking engagements • Share your stories

  30. Library Connections & Advocacy In Summary: All of the roles of the library ultimately support Patient Safety - Michelle Eberle, 2007

  31. Patient Safety Resource Seminar: Librarians on the Front Lines Holly Ann Burt, MLIS, MDiv Available at: http://nnlm.gov/training/patientsafety/