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Patient Safety Resource Seminar
Part II - Resources
to identify
and eliminate
errors
Goal of Patient Safety:
2
Addressing Patient Safety
Legislation Research Recognition Patient Involvement Education Tools Library Connections & Advocacy
3
Legislation
4
Federal & State Legislation
Malpractice regulations Mandatory and/or voluntary reporting
– Some form of reporting (adverse events, hospital acquired infections, etc.) in 42 states plus DC
Mandatory patient notification – 10 states require patients be notified of adverse
events
Apologies permitted– 35 states have enacted laws excluding expressions
of sympathy after accidents as proof of liability
Visit: http://www.nashp.org/pst-nashp , http://www.qups.org/ and http://www.sorryworks.net/
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– 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– 75 Patient Safety Organizations (PSOs) in 28 states
(January 2010) - http://www.pso.ahrq.gov/
Federal & State Legislation
Nurse to patients staffing ratios– Enacted in CA in 1999
Prohibiting mandatory overtime– 15 states (including CA)
Pharmaceutical laws– 32 states and DC starting in MN in 1993
Electronic prescription programs– Medicare Prescription Drug Act 2003– American Recovery and Reinvestment Act of
2009
Legislation Resources
Library of Congress legislative information http://thomas.loc.gov/
National Academy for State Health Policy Patient 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
Health professional organizations Patient Safety Coalitions/Organizations
– Local and state coalitions and organizations, plus specialized groups for patients and/or health professionals, are continuously forming
– http://www.pso.ahrq.gov/
State/Federal organizations with patient safety sections, components or initiatives
Research
10
Research
Patient Safety Grants– Government: Agency for Healthcare Research
and Quality (AHRQ), US DHHS, National Institutes of Health, National Institute of Nursing Research, National Science Foundation
– Non-Profit/Private foundations: Commonwealth Fund, National Patient Safety Foundation, Robert Wood Johnson Foundation
– Other agencies: Blue Cross/Blue Shield
11
Research Resources
Health Services Research Projects in Progress – NLM HSRProj: http://www.nlm.nih.gov/hsrproj/
Informational databases– public: Joint Commission Sentinel Events– member: USP MedMarx, MedSun– private: HealthGrades
Article sources– PubMed.gov – PubMedCentral.gov
Recognition
13
Recognition: Accreditation
Hospitals and Health Centers – National Patient Safety Goals
o Encourage patients’ active involvement in their own care as a patient safety strategy (#13)
o The organization identifies safety risks inherent in its patient population (#15)
o Support information needs for other goalshttp://www.jointcommission.org/PatientSafety/
NationalPatientSafetyGoals/
– Sentinel Eventso Support for required Root Cause Analysis’http://www.jointcommission.org/SentinelEvents/
14
Recognition: Certification
Health professionals - recertification requirements include patient safety topics– Doctors in FL and PA – Pharmacists in FL and NY
Students and residents - required to take patient safety courses– New York Medical College– Hospital residency programs
ACGME standard - 80-hour work week
15
Recognition: Degrees
Graduate Certificate – University of Wisconsin-Madison
http://www.engr.wisc.edu/ie/current/patientsafety/
Masters Degree – Northwestern University Institute for Healthcare Studies
http://www.medschool.northwestern.edu/ihs/
– University of Illinois http://global.uillinois.edu/patient-safety-leadership-programs/
Additional Certificate Programs– ABQAURP http://www.abqaurp.org/certification.asp
– Harvard Quality Colloquium http://www.qualitycolloquium.com/certificate.html
Recognition: Awards
NIST Malcolm Baldrige National Quality Program http://www.quality.nist.gov/
Joint Commission John M. Eisenberg Award for Patient Safety and Quality http://www.jointcommission.org/PatientSafety/EisenbergAward/
ANCC Magnet Recognition Program http://www.nursecredentialing.org/Magnet.aspx
AHA-McKesson Quest for Quality Prize http://www.aha.org/aha/news-center/awards/quest-for-quality/
ISMP Cheers Award http://www.ismp.org/Cheers/
AHTF-ACCE Marvin Shepherd Patient Safety Award http://www.acce-htf.org/shepherd.asp
17
Patient Involvement
18
Questions are the Answer http://www.ahrq.gov/questionsaretheanswer/ 19
Patient Involvement
Individual Advocacy – In doctor & hospital visits
– Share information Create 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
20
Patient Involvement
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.
21
Patient Involvement
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
22
Patient Involvement
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 23
Patient Involvement 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
24
Patient Involvement 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
Patient Involvement Resources
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
26
Education
27
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
28
Education: Opportunities
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/cder/drug/podcast/
– Healthcare 411 http://www.healthcare411.ahrq.gov/
29
Education: Opportunities
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 WikiHealthCareTM
http://wikihealthcare.jointcommission.org/ ─ Blogs for Hospital Librarians
http://mla-hls.wikispaces.com/Blogs 30
Education: Connections
For those experiencing medical error
Patients and families─ P.U.L.S.E. http://www.pulseamerica.org/ ─ Voice4Patients.com─ 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/31
Tools
32
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
33
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: Examining Events
34
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 www.jcrinc.com
Tools: Resources
35
RCA / FMEA Support, Evidenced-Based Medicine/Nursing
– PubMed PubMed.gov
search for events and/or processes
– PubMed Clinical Queriesidentify related reviews
– PubMed Topic-Specific Queriesadditional subject filters
– NIH Clinical Alerts & Advisories www.nlm.nih.gov/databases/alerts
Tools: NLM Resources
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: NLM Resources
37
PubMed Search Strategies– MeSH Terms related to patient safety issues
o Disease Transmission, Professional-to-Patiento Drug Administration Routeso Hospitalization (includes Length of Stay, Patient
Admission, Patient Discharge, and Patient Transfer)o Investigative Techniques (includes Equipment Safety) o Medical Errors (includes Diagnostic Errors, Medication
Errors and Observer Variation)o Patient Participationo Safety (includes Safety Management)
Tools: NLM Resources
PubMed Search Strategies (continued)– USE DETAILS to clean up a search E.g. searching for patient safety gives 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 Resources
39
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.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
Tools: NLM Resources
40
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.gov toxicology geared for school children
– PubMed - pubmed.gov journal article citation database
Tools: NLM Resources
41
Library Connections
& Advocacy
42
Dr. Robert Wachter:
So, a medical school librarian set off the modern patient safety movement?
Lucian Leape, MD:
Ergo, there we go.
Library Connections & Advocacy
Wachter R. In conversation with Lucian Leape, MD. WebM&M. 2006(Aug): Perspectives on Safety. http://webmm.ahrq.gov/perspective.aspx?perspectiveID=28
43
How is Your Library
Involved in Patient Safety
(or how will it be)?
Library Connections & Advocacy
44
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
Library Connections & Advocacy
45
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
Library Connections & Advocacy
46
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
Library Connections & Advocacy
47
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
Library Connections & Advocacy
48
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
Library Connections & Advocacy
49
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
Library Connections & Advocacy
50
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
Library Connections & Advocacy
51
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 & Advocacy
52
And ….
Library Connections & Advocacy
53
In Summary:
All of the roles of the library ultimately support Patient Safety
- Michelle Eberle, 2007
Library Connections & Advocacy
54
Patient Safety Resource Seminar: Librarians on the Front Lines
Holly Ann Burt, MLIS, MDiv
Available at:
http://nnlm.gov/training/patientsafety/