Patient Safety Resource Seminar

Part II - Resources

to identify

and eliminate

errors

Goal of Patient Safety:

Addressing Patient Safety

LegislationCertification/Accreditation/RecognitionResearch Education/CommunicationSupport AgenciesTools & ResourcesLibrary Connections & Advocacy

Federal & Provincial Legislation

Malpractice regulationsAdverse Reaction Reporting

– MedEffect: drugs and health productsMandatory and/or voluntary medical

error reporting– SK, MB, ON, QC– BCAS - CIRS

Federal & Provincial Legislation

Disclosure– Patient notification of adverse events

o Position statements: CMA, CNAo Legislation: MB, QCo Guidelines/Policies: AB, BC, NF/LB, NS, ON,

PE, SK

– Liability protection for disclosureo British Columbia Evidence Act

Federal & Provincial Legislation

Canadian Patient Safety Institute Potential regulations

– Nurse to patients staffing ratios– Mandatory overtime prohibited– Hours in a work-week

Legislation Resources

Department of Justice – Justice Laws Web Site

http://laws.justice.gc.ca/

Health Law Institutes – Dalhousie University http://hli.law.dal.ca/

– University of Alberta http://www.law.ualberta.ca/centres/hli/

Accreditation

Hospitals and Health Centers– CCHSA Patient Safety Goals & ROPs

o Culture: One prospective analysis per year o Communication: Inform and educate

patients/clientso Worklife/Workforce: Annual education/training

to staff, support preventive maintenance programo Infection control: Guidelines

– CCHSA 2007 Performance Measureso Patient Safety Education

Certification

Health professionals: – recertification requirements to include

patient safety topicsStudents and residents:

– Required to take patient safety courses– Topics included in residency programs

Maximum Duty Hours: – Less than than two or more consecutive

periods of call for residents (Ontario)

Recognition Programs

CRPNBC Awards of ExcellenceMOHLTC Innovation Awards

CCHSE/CCDSS Awards Program WRHA Leading Us to Excellence OHA Innovation in Patient Safety Award

Individual conferences

Research

Patient Safety Grants– Federal, Regional, Local

o CHSRF/FCRSS o CIRH/IRSCo CPSI/ICSP o Health Sciences Centre Foundation

– Internationalo Robert Wood Johnson Foundation

Research Resources

Health Services Research Projects in Progress – HSRProj: http://www.nlm.nih.gov/hsrproj/

Informational databases– MedEffects– JCAHO Sentinel Events

Journal Sources– PubMed.gov – PubMedCentral.gov

Education Opportunities

Conferences/Seminars/Workshops– National & Regional, Medical associations– CPSI 2006 Patient Safety Studentship Program

Publications– Five journals, numerous newsletters and columns

Web-based modules and home study resources

In-house training– Created by library, brought in from outside

Education Topics

Health literacy– Easy to read– Language appropriate

LegislationAccreditation

– CCHSA changesNursing issues & resourcesEBM / EBM

Communication Resources

Listservs– NPSF, JC-ICPS

Websites – Government, non-profit, professional, publicly

owned, internal– Focused: health professionals,

administration, patients & families

Alert services– MedEffects, ISMP, AORN, My NCBI (NLM

PubMed), FDA,

Support Agencies

For those experiencing medical error

Patients and families─ P.U.L.S.E.─ Voice4Patients.com

Medical professionals─ Medically Induced Trauma Support Services

(MITSS)─ Sorry Works! Coalition

Other leadership support agencies

RCA – Root Cause Analysis – Examining events

Failure Modes and Effects Analysis (FMEA)

– Examining processes

Six Sigma– Measurement studies

Probabilistic Risk Analysis (PRA)– Examining processes starting with outcomes

Patient Safety Tools

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 Safety Tools

Software– EMR, bar-coding, RCA

Consulting agencies– Concerning CCHSA/CCASS, focusing

on processes, in-house training Web-based information

– Forms, tool-kits, articles

Tools Resources

RCA / FMEA Support– PubMed

search for similar events and/or processes

– My NCBI Alerts

tracked related events/processes

– NIH Clinical Alerts & Advisories– My NCBI Collections

save related citations for reference, publication, CCHSA/CCASS, etc.

NLM Resources

RCA / FMEA Support (continued)

– PubMed Clinical Queries

identify related reviews

– HSDB in TOXNET

follow-up on toxicology issues in the Hazardous Substance Data Bank

– HSRProj current projects on topics

– Radiation Event Medical Management focusing on all aspects of radiation events

NLM Resources

Evidenced - Based Medicine/Nursing– PubMed

general citation search

– PubMed Clinical Queries identify specific reviews

– PubMed My NCBI for both alerts and citation collections

NLM Resources

Patient & Family Concerns– MedlinePlus

general searches, patient safety page

– Household Products Database toxicology issues

– ClinicalTrials.gov current and previous studies

– ToxTown toxicology geared for school children

NLM Resources

How is Your Library

involved in Patient Safety

(or how will it be)?

Library Connections & Advocacy

In Training & Education– Student Curriculum

Pharmacy Nurses

– Assist with CME/CNE/CE requirements Physicians, Residents, Nurses

– Focus on computer skills, EMB, searching– Teach in Orientation classes– Prepare on-line tutorials and resources

Library Connections & Advocacy

With Reference Services– Literature Searches

Stat for Emergency Room Nursing Education Department Monthly Infection Control Reports Drug Use for Employees

Library Connections & Advocacy

With Reference Services– Alerts

Recalls Tables of Contents Clinical Alerts Drug Updates

Library Connections & Advocacy

On the Website– Information Pages

For patients and families For employees and health professionals

– Celebrations Good Catch System changes due to FMEA

– Current News Evidence Based & Benchmarking information Alerts

Library Connections & Advocacy

Beyond the Library– In the hospital

Safety Fairs and programs Visiting stations, departments & people Serving on committees, councils & panels Support accreditation requirements

– In the community Assist at community affairs department projects Accept speaking engagements

– Share your stories

Library Connections & Advocacy

In Summary:

All of the roles of the library ultimately support Patient Safety

- Michelle Eberle, 2007

Library Connections & Advocacy

Patient Safety Resource Seminar: Librarians on the Front Lines

Holly Ann Burt, MLIS, MDiv

Available at:

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