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Patient Safety Resource Seminar. Part II - Resources. Goal of Patient Safety:. to identify and eliminate errors. Addressing Patient Safety. Legislation Research Recognition Patient Involvement Education Tools Library Connections & Advocacy. Legislation title slide. Legislation.

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goal of patient safety
Goal of Patient Safety:

to identify

and eliminate

errors

addressing patient safety
Addressing Patient Safety
  • Legislation
  • Research
  • Recognition
  • Patient Involvement
  • Education
  • Tools
  • Library Connections & Advocacy
state legislation i
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: http://www.nashp.org/pst-nashp , http://www.qups.org/ and http://www.sorryworks.net/

federal state legislation
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 - http://www.pso.ahrq.gov/
state legislation ii
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
federal legislation
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)
legislation resources i
Legislation Resources I
  • Library of Congress legislative informationhttp://thomas.loc.gov/
  • National Academy for State Health PolicyPatient Safety Toolbox http://www.nashp.org/pst-nashp
  • National Conference of State Legislatures http://www.ncsl.org/
  • QuPS.org – states’ public and private policy / initiatives
  • USA.gov – links to state legislatures
legislation resources ii
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
research
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, Grants.gov
    • Non-Profit/Private foundations: Commonwealth Fund, National Patient Safety Foundation, Robert Wood Johnson Foundation
    • Other agencies: Blue Cross/Blue Shield
research resources
Research Resources
  • Health Services Research Projectsin Progress
    • NLM HSRProj: http://www.nlm.nih.gov/hsrproj/
  • Informational databases
    • public: Joint Commission Sentinel Events, HHS Hospital Compare
    • member: Quantros/MedMarx, MedSun
    • private: HealthGrades
  • Article sources
    • PubMed.gov & PubMedCentral.gov
recognition accreditation
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

http://www.jointcommission.org/standards_information/npsgs.aspx

    • Sentinel Events
      • Support for required Root Cause Analysis’

http://www.jointcommission.org/sentinel_event.aspx

recognition certification
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
recognition degrees
Recognition: Degrees
  • Graduate Certificate
    • University of Wisconsin-Madisonhttp://www.engr.wisc.edu/ie/current/patientsafety/
  • Masters Degree
    • Thomas Jefferson Universityhttp://www.jefferson.edu/population_health/quality_safety/
    • University of Illinoishttp://www.uic.edu/orgs/online/patient-safety-leadership/
  • Additional Certificate Programs
    • ABQAURP http://www.abqaurp.org/certification.asp
    • Harvard Quality Colloquium http://www.qualitycolloquium.com/certificate.html
recognition awards
Recognition: Awards
  • NISTMalcolm Baldrige National Quality Programhttp://www.nist.gov/baldrige/
  • Joint CommissionJohn M. Eisenberg Award for Patient Safety and Qualityhttp://www.jointcommission.org/topics/eisenberg_award.aspx
  • ANCCMagnet Recognition Programhttp://www.nursecredentialing.org/Magnet.aspx
  • AHA-McKessonQuest for Quality Prizehttp://www.aha.org/about/awards/q4q/
  • ISMP Cheers Award http://www.ismp.org/Cheers/
  • AHTF-ACCEMarvin Shepherd Patient Safety Awardhttp://thehtf.org/shepherd.asp
patient involvement campaign
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 involvement personal
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
patient involvement advocate
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.
patient involvement representative
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
patient involvement activist
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. http://webmm.ahrq.gov/perspective.aspx?perspectiveID=38

patient involvement resources i
Patient Involvement Resources I
  • 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
patient involvement resources ii
Patient Involvement Resources II
  • 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
patient involvement resources iii
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
education teaching topics
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
education opportunities i
Education: Opportunities I
  • Conferences/Seminars/Workshops
    • NPSF, AHRQ, medical associations, coalitions
  • Books, Journals, Newsletters
    • Quality Chasm series http://www.nap.edu/
    • Patient Safety and Quality Healthcare http://www.psqh.com/
  • Podcasts and Videos
    • Drug Safety Podcasts (FDA) http://www.fda.gov/Drugs/DrugSafety/DrugSafetyPodcasts/
    • Healthcare 411 http://www.healthcare411.ahrq.gov/
education opportunities ii
Education: Opportunities II
  • Web-based education including CE/CME/CNE
  • Alert services ISMP, FDA, AORN, My NCBI, NIH, WHO
  • Email Discussions
    • NPSF Patientsafety-L http://www.npsf.org/psf/
    • American Society of Medication Safety Officers http://www.asmso.org/
  • Blogs and Wikis
    • Joint Commission WikiHealthCareTMhttp://wikihealthcare.jointcommission.org/
    • Blogs for Hospital Librarians http://mla-hls.wikispaces.com/Blogs
education connections
Education: Connections

For those experiencing medical error

  • Patients and families
    • P.U.L.S.E. http://www.pulseamerica.org/
    • Consumers Advancing Patient Safety (CAPS) http://www.patientsafety.org/
  • Medical professionals
    • Medically Induced Trauma Support Services (MITSS) http://www.mitss.org/
    • Sorry Works! Coalition http://sorryworks.net/
tools examining events i
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
tools examining events ii
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
tools resources
Tools: Resources
  • Web-based information (Forms, tool-kits, articles)
    • IHI SBAR tools www.IHI.org
    • NPSA RCA Toolkit www.npsa.nhs.uk
    • Pathways for Medication Safety www.medpathways.info
  • Software (EMR, bar-coding, RCA)
    • AHRQ Quality Indicators www.qualityindicators.ahrq.gov
  • Consulting agencies (Concerning Joint Commission, focusing on processes, in-house training)
    • Joint Commission Resources www.jcrinc.com
tools nlm resources i
Tools: NLM Resources I
  • RCA / FMEA Support, Evidenced-Based Medicine/Nursing
    • PubMedPubMed.gov

search for events and/or processes

    • PubMed Clinical Queries

identify related reviews

    • PubMed Topic-Specific Queries

additional subject filters

    • NIH Clinical Alerts & Advisories www.nlm.nih.gov/databases/alerts
tools nlm resources ii
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)toxnet.nlm.nih.gov research toxicology issues
    • Radiation Event Medical Management

remm.nlm.gov focus on radiation events

tools pubmed i
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)
tools pubmed ii
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
tools nlm patient resources i
Tools: NLM Patient Resources I
  • Patient and Family Concerns
    • 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
tools nlm patient resources ii
Tools: NLM Patient Resources II
  • Patient and Family Concerns (continued)
    • 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
library connections advocacy title slide
Library Connections & Advocacy title slide

Library Connections & Advocacy

advocacy librarian s critical role
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. http://webmm.ahrq.gov/perspective.aspx?perspectiveID=28

library connections advocacy
Library Connections & Advocacy

How is Your Library

Involved in Patient Safety

(or how will it be)?

advocacy start where you are
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
advocacy education
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
advocacy reach out
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
advocacy focused service i
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)
advocacy focused service ii
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
advocacy intra internet i
Advocacy: Intra-/Internet I
  • On the Website
    • Information Pages
      • On library contributions to patient safety
      • For patients and families
      • For advocates and liaisons
      • For health professionals and first responders
      • For students and researchers
      • For institutional leadership - executives, directors, managers, officers, and others
      • For those involved with legislation issues
advocacy intra internet ii
Advocacy: Intra-/Internet II
  • On the Website
    • Current News
      • Evidence Based & Benchmarking information
      • Alerts – Clinical, Drug, Consumer, etc.
      • How the Institution is involved in patient safety; Institutional progress in specific areas
      • Patient Safety Campaigns
      • Legislation affecting the institution
      • (Hospitals:) Good Catch
      • Librarians making a difference
advocacy outreach i
Advocacy: Outreach I
  • And MORE:
    • Health Fairs
      • Mishap Mansion/Room of Horrors
      • Patient Safety Awareness Week
    • In the community
      • Assist at community affairs department projects
      • Partner with other libraries
      • Serve as Community Liaison to professional advisory committees
library connections advocacy1
Library Connections & Advocacy

In Summary:

All of the roles of the library ultimately support Patient Safety

- Michelle Eberle, 2007

patient safety resource seminar librarians on the front lines

Patient Safety Resource Seminar: Librarians on the Front Lines

Holly Ann Burt, MLIS, MDiv

Available at:

http://nnlm.gov/training/patientsafety/