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Patient SafetyWorkforce Training
Susan Carr
EditorPatient Safety and Quality Healthcare
Primary researcher and writerTrain for Patient Safety
Quality Colloquium • August 21, 2005
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Patient Safety and Quality Healthcare
www.psqh.com A bi-monthly magazine published by
Lionheart Publishing. Feature articles, columns and news items
by and for all stakeholders.
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Train for Compliancewww.trainforcompliance.com
Train for Patient Safetywww.trainforpatientsafety.com
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ABQAURP www.abqaurp.org
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Train for Patient Safety
Basic Concepts in Patient Safety I & II Medication Safety Joint Commission and Medicare Safety
Initiatives Clinicians Non-clinicians Ambulatory Care Environment Patient Responsibility
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Comprehensive On-line Course
Course objectives and summary Approximately 30 lesson pages per
module In-text test questions Final multiple-choice test for certificate
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Where to Begin?
Problem of scale: global concepts and fine details, complex and simple
Definitions: What do we mean by error, mistake, systems, safety?
Where are we now? What approach will insure success?
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Culture of Patient Safety
Safety is the first priority Encourage reporting Learn from errors Transparency of information
Pervasive communication Migration of authority
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Systems Approach to Safety
“Individuals are responsible for the quality of their work, but focusing on systems rather than individuals will be more effective in reducing harm.”
Morath & Turnbull, To Do No Harm
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Systems Approach to Safety
Do not attempt to prevent all errors from occurring.
Prevent errors from causing harm to patients.
Support individuals by enhancing their performance.
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Systems Approach to Safety
“Systems approach substitutes
inquiry for blame and focuses on
circumstances rather than on
character.”
Morath & Turnbull
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The “New Look”
Network of theory and linked empirical findings from: Cognitive engineering Cognitive anthropology Social research on systems Management research Naturalistic decision making
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The “New Look”
“Two Years Before the Mast:Learning How to Learn About Patient Safety” by Richard Cook, MD
Published in the proceedings of meeting organized by the NPSF at the Annenberg Center for Health Sciences in California in 1998.
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Learning How to Learn — Cook
1. Learning about safety is not continuous but occurs at intervals.
Accidents, emergencies, changes in conditions,
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Learning How to Learn — Cook
2. Learning requires dissonance between belief and experiences.
Impossibilities, surprises,
“out of the box” experiences
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Learning How to Learn — Cook
3. Not everyone learns at the same time.
Based on need, experienceMay create dissonance
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Learning How to Learn — Cook
4. Learning is not always sequential.
Depends on where you begin: different roles, training, experience, trigger points
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Learning How to Learn — Cook
5. Learning does not necessarily produce appreciation for the consequences of what has been learned.
Hindsight is easy, and concepts such as Reason’s Swiss Cheese model are easier to understand than implement.
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Learning How to Learn — Cook
6. Learning about safety is not permanent.
Strive for continual experience-based learning
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Learning How to Learn — Cook
7. Learning about safety requires close contact with failure and also the distance needed for reflection.
Experience, analysis, and reflection are learning tools.
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Learning How to Learn — Cook
8. Learning recapitulates the sequence of research that comprises the New Look.
The value of earlier work in this field.
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Learning How to Learn — Cook
9. Learning inherently involves exploring the “second stories” that lie behind accidents and failure.
Dig deeply for details in the story. Complexity must be honored. Value the story.
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Learning How to Learn — Cook
10. Learning about safety exposes organizational stress.
Budgets, limited resources, hierarchies, priorities, change
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Learning How to Learn — Cook
11. Learning about safety begins with learning that people make safety.
Human performance is the “critical resource” in efforts to improve safety. Technology and processes should enhance, not constrain human performance.
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Cook & Woods’ Paradox
People are simultaneously the source of success and failure in safety.
Safety is a “chronic value under our feet that infuses all aspects of practice.”
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Basic Principles of Patient Safety I
I. The Origins of the Patient Safety Movement
II. Who Is Responsible for Patient Safety?
III. Terminology
IV. Factors that Contribute to Error and Injury
V. Leadership and Patient Safety
VI. Quality Improvement Programs and Management Practices for Patient Safety
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Basic Principles of Patient Safety II
I. Knowledge Management and Information Technology
II. Reporting Safety-Related Incidents
III. Investigation Systems for Patient Safety
IV. Organizations that Promote Patient Safety: Private Sector
V. Organizations that Promote Patient Safety: Public Sector
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Medication Safety
I. Scope of the Problem
II. Terminology
III. Data Collection and Error Reporting
IV. Opportunities for Medication Errors
V. Preventing Medication Errors
VI. Use of Technology
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Joint Commission and Medicare Safety Initiatives
Becoming Safer Moving Toward
Safety Safety Initiatives Patient
Identification Transferring
Information
Medication Safety Medical Equipment Reducing Infections Medication
Continuity Everyday Safety
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Patient Safety for Clinicians
I. The Patient Safety Imperative for Clinicians
II. The Concept and Culture of Safety
III. Definition of Error
IV. Liability, Disclosure, and Apology
V. Improving Patient Safety
VI. Clinical Information Technology (IT) Systems
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Patient Safety for Non-clinicians
I. The Non-clinician’s Role in Patient Safety
II. Executives and Senior Management
III. Patient Safety Officers, Risk Managers, and Quality Improvement Professionals
IV. Other Non-clinical Stakeholders
V. Safety Improvement Tools