Patient Safety by yurtgc548


									Patient Safety:
You Can Make a Difference

Questions are the Answer
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.

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) –
    –   UK Railway Industry: Confidential Incident Reporting &
        Analysis System (CIRAS) – 1996

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

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.

Definitions in Patient Safety

      Error: failure of a planned action or
      use of a wrong plan
                        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            7
Definitions in Patient Safety

                    Error                                                                  Adverse
                                                  Preventable                              Event /
          Near miss /                             Adverse Event                            Clinical
          Close call                                                                       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 on
 Patient Safety. Massachusetts Medical Society, 2004.
Patient Safety Systems

          No health professional
             begins their day
    with the goal of making a mistake
        and harming their patient.

    there are problems in the system
         that can lead to errors.

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
        Patient Safety Systems



      Patient Safety Systems

                                                                     Latent conditions/Active failures

   Emergency Room
                                               Physicians                                     Adverse or
                                                        Pharmacy                               Sentinel
                                                                     Patient / Family           Event
           Adapted from: Reason J. Human error: models and management. BMJ 2000;320;768-770

Types of Errors

System Errors (Latent) Human Mistakes (Active)
   Communication Heavy                                      Action slips or failures (e.g.
    workload/Fatigue                                          picking up the wrong syringe)
   Incomplete or unwritten                                  Cognitive failures (e.g.
    policies                                                  memory lapses, mistakes
   Inadequate training or                                    through misreading a situation)
    supervision                                              Violations (i.e. deviation from
   Inadequate maintenance                                    standard procedures; e.g work-
    of equipment/buildings                                    arounds)

DeLisa JA. Physiatry: medical errors, patient safety, patient injury, and quality of care. Am J Phys Med
Rehabil. 2004(Aug);83(8):575-583
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.

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
    –   Get information
          Ask questions about treatments, medications, etc.
          Research illnesses and treatments

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

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.

Making A Difference

   Patient Representative – In health care
     – 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

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

Gibson, Rosemary. Role of the patient in improving patient safety. WebM&M. 2007(Mar):
Perspectives on Safety.
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

Be Aware of Resources

   Online Information
    –   5 Steps to Safer Health Care
    –   20 Tips to Prevent Medical Errors
    –   Be Prepared for Medical Appointments
    –   Speak Up Initiatives (and brochures)
    –   We Care about Your Safety (video)

Be Aware of Resources

   Online Information
    –   Check Your Medicines: Tips for Using Medicines
    –   Drug Information Portal
    –   Medicines and You: A Guide for Older Adults
    –   Questions are the Answer (video)
    –   What You Can Do to Make Healthcare Safer

Be Aware of Resources

   Conferences/Seminars/Workshops
    –   NPSF, AHRQ, coalitions, medical associations
   Books, Journals, Newsletters
    –   Quality Chasm series
    –   Patient Safety and Quality Healthcare
   Podcasts and Videos
    –   Healthcare 411
    –   Drug Safety Podcasts (FDA):

Be Aware of Legislation Resources

   Library of Congress legislative information
   National Academy for State Health Policy
    Patient Safety Toolbox for States
   National Conference of State Legislatures
 – states’ public and private policy / initiatives
 – links to state legislatures

NLM Resources

   MedlinePlus -
    general searches, patient safety page
   Drug Information Portal -
    searches across NLM, NIH and FDA databases
   Pillbox -
    identify unknown pills by color, shape, etc.
   Dietary Supplements Labels Database - including label ingredients
   NIH Senior Health -
    information for seniors and their care givers
NLM Resources

   Genetics Home Reference -
    study genetic conditions and the responsible genes
 -
    current and previous studies
   Household Products Database -
    health and safety information
   Tox Town -
    toxicology geared for school children
   PubMed -
    journal article citation database

For those experiencing medical error
   P.U.L.S.E.
   Consumers Advancing Patient Safety
   Medically Induced Trauma Support
    Services (MITSS)

Intersection of Patient Safety

 Quality                     Safety

                             Patient and
Patient                     family
Safety                      involvement



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