Making a Difference in Health Care

Patient Safety, a Global Issue with National and International Solutions

Holly Ann Burt

Affra S. Al Shamsi

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

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Patient Safety Objectives

Understand the historical movement and impact of patient safety

Describe definitions related to patient safety and recognize systems of potential error within and among institutions

Locate and be able to use resources available for administrators, researchers, health professionals, and patients and families

Formulate methods for the library to effectively participate in patient safety and related programs to improve the health care of our world

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Patient Safety: Always an Issue

“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.

“All students or doctors who enter the wards for the purpose of making an examination must wash their hands thoroughly…”. Ignác Fülöp Semmelweis. 1847-1849.

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.

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Patient Safety: 2000

To Err is Human: building a safer health system. Kohn LT, Corrigan JM, Donaldson MS. Washington, DC: National Academy Press; 2000. (Released in 1999.)

An Organisation with a Memory: report of an expert group on learning from adverse events in the NHS chaired by the chief medical officer. Department of Health Expert Group. London: The Stationery Office; 2000.

Iatrogenic Injury in Australia. Runciman WB, Moller J. Adelaide: Australian Patient Safety Foundation; 2001

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Studies

Adverse Events Studies– USA Occurrences in ICUs, 1980– Quality in Australian Health Care Study, 1995– USA Harvard Medical Practice Study, 1991– UK Bristol Royal Infirmary Inquiry, 2001– Danish Adverse Events Study, 2001– Adverse Events in New Zealand, 2002– Canadian Adverse Events Study, 2004

Other types of studies: Medication safety; Nosocomial infection; Patient satisfaction

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Setting the Stage: National

Agencies, Councils, Commissions– UK National Health Service, 1948– USA The Joint Commission, 1951– International Association for Healthcare Security and Safety

(IAHSS), 1968– Saudi Arabia, National Guard Health Affairs (NGHA) , 1983– Australian Patient Safety Foundation (APSF), 1988– USA Agency for Healthcare Research and Quality (AHRQ), 1989– National Centre For Monitoring Adverse Drugs Reaction (Oman),

1992 – USA: National Coordinating Council for Medication Error

Reporting and Prevention (NCC MERP), 1995

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Setting the Stage: International

Organizations– League of Nations, Health Organization, 1923– United Nations, World Health Organization, 1948– International Society for Quality in Health Care

(ISQua), 1984– International Conference on Harmonisation of

Technical Requirements for Registration of Pharmaceuticals for Human Use, 1990

– Critical Incident Reporting and Reacting Network (CIRRNET), 1996

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Concepts from Industry

Toyota Production System, 1950’s– Just in time production– Jidoka – stopping production

Alcoa Aluminum, 1987– Safety Culture

General Electric, 1995– Six Sigma: Define, Measure, Analyze, Improve,

Control (DMAIC)

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Concepts from Aviation

Federal Aviation Authority (FAA)– Aviation Safety Reporting System (ASRS), 1975 – Crew Resource Management (CRM), 1979 – Aviation Safety Action Program (ASAP), 2000 – Partnership for Safety Initiative (PFS), 2010

National Aeronautics and Space Administration (NASA)– NASA Safety Reporting System (NSRS), 1987

International Civil Aviation Organization (ICAO)– Global Aviation Safety Plan (GASP), 1997

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Concepts from Transportation

US National Transportation Safety Board (NTSB), 1966

UK Railway Industry– Confidential Incident Reporting & Analysis System

(CIRAS), 1996

Australian Transport Safety Bureau (ATSB) – Confidential Marine Reporting Scheme (REPCON), 2004

US Federal Railroad Administration (FRA)– Confidential Close Call Reporting System (C3RS), 2005

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Libraries Become Involved

UK Royal College of Physicians library, 1653 Pennsylvania Hospital, 1763

– opens first public medical library in a hospital

USA National Library of Medicine, 1836– Established as the Army Medical Library

International Federation of Library Associations (IFLA), 1926

Japan Medical Library Association, 1927

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Libraries Involvement Grows

First International Congress on Medical Librarianship. London, UK, 1953

Royal Hospital Medical Library, 1970 Arbeitsgemeinschaft für Medizinisches

Bibliothekswesen (AGMB), 1970 La Asociación de Bibliotecas Biomédicas

Argentinas, 1970 Association for Health Information and

Libraries in Africa (AHILA), 1984

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Defining 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. – To Err is Human 2000

Patient safety: Efforts to reduce risk, to address and reduce incidents and accidents that may negatively impact healthcare consumers. – NLM MeSH, 2012

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Patient Safety: International

Patient safety: The reduction of risk of unnecessary harm associated with healthcare to an acceptable minimum.

An acceptable minimum refers to the collective notions of given current knowledge, resource available and the context in which care as delivered weighed against the risk of non-treatment or other treatment. – Conceptual Framework for the International Classification of Patient Safety, 2009

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Defining Patient Safety Terms

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Patient Safety Terms Change

Reportable Events? It depends. Adapted from: MMS Committee on Quality of Medical Practice and Trinity Communications, Inc. Medical Errors and Perspectives on Patient Safety. Waltham, MA: Massachusetts Medical Society, 2007.

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Patient Safety Systems

Emergency Room

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Patient Safety Systems (pt. 2)

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Patient Safety Systems (pt. 3)

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Patient Safety Systems (pt. 4)

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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/transfer 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.

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Types of Errors

System Errors (Latent) Communication Heavy workload/Fatigue Incomplete or unwritten

policies Inadequate training or

supervision Inadequate maintenance

of equipment/buildings

Human Mistakes (Active) Action slips or failures (e.g.

picking up the wrong syringe) Cognitive failures (e.g.

memory lapses, mistakes through misreading a situation)

Violations (i.e. deviation from standard procedures; e.g. work- 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

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Patient Safety Includes Quality

Quality

Evidenced-Based Medicine/Nursing

Guidelines

Training

Processes

Forms

Measurements / Benchmarking

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Patient Safety Includes Safety

Safety

● Environment− Room arrangement

− Distractions/Noise

− Acuity/Census

● Equipment / Materials

− False alarms

− Bathroom floors/rails

− Electrical systems

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Patient Safety Includes Management

Leadership Business case Response

to concerns Culture

Management

Policies/Processes– Disclosure– Hours– Reporting– Discipline– Participation (e.g.

on rounds)

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Patient Safety Includes Culture

● Communication− Authority gradient

− Patient input

− Health literacy

Reporting− Sharing or silence

− Support or firing

− Change welcomed or not

Culture

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Patient Safety at the Intersection

Quality

Safety

Culture

Management

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Patient Safety is Comprehensive

Adapted from the National Health Service. Department of Health. National Patient Safety Agency. Doing Less Harm: improving the safety and quality of care through reporting, analyzing and learning from adverse incidents involving NHS patients – key requirements

for health care providers, August 2001.

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Librarians are Key

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

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Patient Safety is Central

Quality Safety

Library and

Patient information

Safety services

Culture

Management

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