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ICPL Patient Safety by y486F4V

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									Patient Safety Workshop

        April 16,2009
   Iowa City Public Library
    Iowa City, Iowa



                    www.lib.uiowa.edu/hardin/ppeca
                  Collaborators

University of Iowa Academic Medical Center
• Hardin Library for the Health Sciences
• University of Iowa Hospitals and Clinics
  – Patients’ Library
  – Clinical Quality Safety & Performance Improvement
• College of Public Health
  – Institute for Quality Healthcare
• Zipperer Project Management
• Consumers Advancing Patient Safety
                                   www.lib.uiowa.edu/hardin/ppeca
             Local Partners

A very special thank you to:
           Iowa City Public Library
                       &
  The National Network of Libraries of
  Medicine Greater Midwest Region for
  funding this project.


                         www.lib.uiowa.edu/hardin/ppeca
         Program Presentation

• Module #1 / Roxanne Goeltz
  [Recorded May 2005 / Skokie, IL]
• Module #2 / Mary K Brooks, RN
  University of Iowa Health Center (UIHC)
• Module #3 / Chris Childs
  UI Hardin Library for the Health Sciences

                             www.lib.uiowa.edu/hardin/ppeca
Patient Safety- What You
     Need to Know
     Mary Kay Brooks, RN


                www.lib.uiowa.edu/hardin/ppeca
      Healthcare Can Be Unsafe
• The patient safety movement began in the
  mid-1990s
• Institute of Healthcare Improvement (IHI)
  estimates that 15 million instances of medical
  harm occur in the US each year – a rate of
  over 40,000 per day
• No one wants to be the 1% of hospital
  patients who suffer harm
                              www.lib.uiowa.edu/hardin/ppeca
          Be Confident, Yet Prepared
• Healthcare-acquired infections, adverse drug
  events, surgical errors, pressure sores, and other
  complications are commonplace.
• Most patient injuries are caused by a combination
  of mistakes.
• They are not any one person’s fault. This is what
  experts call “systems failure.”
• Systems failure can happen in the best hospitals
  and doctors offices.       www.lib.uiowa.edu/hardin/ppeca
         Humans Make Mistakes

• Doing the               • Add bleach to the
  wrong thing               color load
• Not doing the           • Speeding
  right thing
• Doing the right         • Wash hands, but
  thing but incorrectly     not long enough to
  or incompletely           kill germs
                            – Tip: sing Happy Birthday
                              twice while washing!
                             www.lib.uiowa.edu/hardin/ppeca
       Errors vs “Bad” Medicine

• Most injuries in health care are not caused
  by a bad person
• The healthcare community has made
  patient safety a priority and is doing a lot:
  – Local hospital projects
  – National stories
  – Coalition building
                              www.lib.uiowa.edu/hardin/ppeca
           The Science of Safety

• Hindsight bias       • “How could I have
                         been so careless?”

• Human factors        • Driving and talking
                         on a cell phone


• Swiss cheese model
                         SWISS
                         CHEESE????
                          www.lib.uiowa.edu/hardin/ppeca
              How Systems Fail

   Some holes due
    to known risks

                                             Hazards




 Harm                      Other holes due to
                              hidden risks

Protection against
                        www.lib.uiowa.edu/hardin/ppeca
hazards = one slice
of cheese
      What Should You Do?
• Be a team member and take an active
  role by:
  – Speaking up and asking questions
  – Be willing to politely challenge things you
    don’t understand
  – Know the basics of your health and history
    • You should be able to give:
       – Name and dose of medications, herbals, vitamins
         you are taking
       – Past health history of you are your family
       – Why you are visiting the doctor
                                   www.lib.uiowa.edu/hardin/ppeca
       Having a Safe Surgery

• Stop Infections
  – Antibiotics before surgery
  – Washing skin where surgery will be with a special
    soap
  – Don’t shave surgical site with razors
• Safe Surgery
  – Provider will mark your surgical site
  – Take a “time out” to make sure they have the right
    patient and surgery
  – Be truthful with your anesthesiologist
     • Show them your medical history and med card!
                                   www.lib.uiowa.edu/hardin/ppeca
               Medication Safety

• Go to one pharmacy
• Keep a medication card (vitamins, herbals,
  supplements)
• Avoid grapefruit juice 8 hours before or
  after pills
• Fill your prescriptions and take all the pills
• Keep pills in their original bottles
• Don’t take other people’s pills
                             www.lib.uiowa.edu/hardin/ppeca
• Make sure your name is on the label
   – Look for right drug and dose
      Medication Safety (Cont’d)

• Keep your pills separate from your pets pills
• Throw away expired pills
• Use a timer or pillbox to help you remember to
  take your pills
• If flying on a plane, carry on your pills
• If you are in the hospital, have the provider
  check your name band before giving medication
• Don’t store pills in bathroom medicine cabinet
                             www.lib.uiowa.edu/hardin/ppeca
       Stopping Infections in Hospitals

• Most powerful germs live in the hospital!
• Pay attention to handwashing and cleanliness
• Tell providers to wash their hands before they
  touch you
• Make sure you wash your hands
   – especially before bed
   – Wash palms, backs, and between fingers
• Sneeze into your sleeve not your hand
• Don’t ask for flowers or wear jewelry
                            www.lib.uiowa.edu/hardin/ppeca
• Don’t touch your IV or surgery site
      Questions are the Answer!

• Don’t be afraid to Speak Up
• There are other people in the hospital to
  talk to
  – Patient Relations
  – Quality Department
  – Librarian
  – Social Workers
  – Pastors                www.lib.uiowa.edu/hardin/ppeca

• Ask your QUESTIONS!
    Next Speaker



The Librarian Can Help




              www.lib.uiowa.edu/hardin/ppeca
 Prepared with Information:
The role information can play
     in the safety of care
          Chris Childs


                  www.lib.uiowa.edu/hardin/ppeca
         Information and Safety

Better informed patients:
• Play a greater role in their health care
• Participate more in decision making
• Follow agreed treatment regimens
• Have less anxiety
• Have more realistic expectations
                            www.lib.uiowa.edu/hardin/ppeca
          Information Anxiety

• Gathering information can be
  overwhelming
• Others can help you with the task so you
  have what you need
  – Librarians
  – Healthcare Professionals
  – Family & Friends
                               www.lib.uiowa.edu/hardin/ppeca
   Good Health Information Exists

• Talk to healthcare professionals
  – Patient education flyers
• Consult a librarian for quality resources
  – Books, articles, videos
• Search the Internet
  – Evaluate for quality

                               www.lib.uiowa.edu/hardin/ppeca
     How to Evaluate Information

• What makes information reliable?
  – Credibility of source
  – Date published/updated
  – Supported with data
• Reasons to be cautious of “bad”
  information
  – Can lead to wrong treatment decision
  – Confusing               www.lib.uiowa.edu/hardin/ppeca
               MedlinePlus
              www.medlineplus.gov


Consumer Health Website
Contains Authoritative Information from
• National Library of Medicine
• National Institute of Heath
• Other Government Agencies
• Health Related Organizations
                            www.lib.uiowa.edu/hardin/ppeca
                   MedlinePlus

• Website Includes
  – Information on over 750 health topics
  – Extensive information about drugs
  – Illustrated Medical Encyclopedia
  – Interactive Patient Tutorials
  – Medical Dictionary
  – Directories
  – Latest health news         www.lib.uiowa.edu/hardin/ppeca
               NIH Senior Health
                 http://nihseniorhealth.gov/

           Features                   User Friendly
•   Linked to MedlinePlus      • Adjust Contrast
•   Health & Wellness          • Change the size of the
    Information for Older        text on any page
    Adults                     • Automated voice option
•   Health Topics                available that will read all
•   Exercise Stories             of the displayed text
•   Health Videos


                                   www.lib.uiowa.edu/hardin/ppeca
               MedlinePlus

       Important Facts to Remember
• Free to the public
• Information is available in both English
  and Spanish
• Only requirement is that the consumer
  has access to the Internet
  – www.medlineplus.gov
                           www.lib.uiowa.edu/hardin/ppeca
    Talking to Healthcare Providers

• Review articles and web information with
  your physician
• Become familiar with terminology
• Be organized
  – Prepare a list of questions based on what you
    read prior to your visit
  – Bring only the articles you need to discuss

                             www.lib.uiowa.edu/hardin/ppeca
              A Success Story

• A patient thought his condition contained the
  words “clavicle” and “steel” in it.
• Working with a librarian, he found a book that
  revealed the name to be “Subclavian steal
  syndrome.”
• Searching in Medline produced a definition of
  the condition and two full text review articles.

                                www.lib.uiowa.edu/hardin/ppeca

								
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