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					Patient Safety:
You Can Make a Difference




                   2009
Questions are the Answer
http://www.ahrq.gov/questionsaretheanswer/
                                             2
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.




                                                                         3
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


                                                                 4
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



                                                       5
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.


                                                                               6
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.
                                                                                                                                  8
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.

                                        9
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
                                                                                                             10
        Patient Safety Systems
                               Barrier/Defense

Error


                     Patient




                                                 11
      Patient Safety Systems

                                                                     Barrier/Defense
Errors
                                                                     Latent conditions/Active failures




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



                                                                                                         12
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
                                                                                                           13
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.




                                          14
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


                                                          15
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




                                            16
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.



                                                            17
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




                                                           18
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
                                                                                        19
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




                                            20
Be Aware of Resources

   Online Information
    –   5 Steps to Safer Health Care
        http://www.ahrq.gov/consumer/5steps.htm
    –   20 Tips to Prevent Medical Errors
        http://www.ahrq.gov/consumer/20tips.htm
    –   Be Prepared for Medical Appointments
        http://www.ahrq.gov/qual/beprepared.htm
    –   Speak Up Initiatives (and brochures)
        http://www.jointcommission.org/PatientSafety/SpeakUp/
    –   We Care about Your Safety (video)
        http://www.emmisafety.com/ashrm/Emmi.html

                                                                21
Be Aware of Resources

   Online Information
    –   Check Your Medicines: Tips for Using Medicines
        Safely http://www.ahrq.gov/consumer/checkmeds.htm
    –   Drug Information Portal
        http://druginfo.nlm.nih.gov/
    –   Medicines and You: A Guide for Older Adults
        http://www.fda.gov/Drugs/ResourcesForYou/ucm163959.htm
    –   Questions are the Answer (video)
        http://www.ahrq.gov/questionsaretheanswer/
    –   What You Can Do to Make Healthcare Safer
        http://www.npsf.org/download/WhatYouCanDo.pdf

                                                                 22
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/

                                                            23
Be Aware of Legislation Resources

   Library of Congress legislative information
    http://thomas.loc.gov/
   National Academy for State Health Policy
    Patient 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

                                                                 24
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.gov
    identify unknown pills by color, shape, etc.
   Dietary Supplements Labels Database -
    dietarysupplements.nlm.nih.gov including label ingredients
   NIH Senior Health - nihseniorhealth.gov
    information for seniors and their care givers
                                                                 25
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.gov
    toxicology geared for school children
   PubMed - pubmed.gov
    journal article citation database
                                                         26
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/


                                              27
Intersection of Patient Safety


 Quality                     Safety


                             Patient and
Patient                     family
Safety                      involvement

                           Culture
Management


                                       28

				
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