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/

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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

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Patient Involvement

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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

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Education

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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

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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/

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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

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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

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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

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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

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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

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Library Connections

& Advocacy

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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

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How is Your Library

Involved in Patient Safety

(or how will it be)?

Library Connections & Advocacy

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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

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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

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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

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And ….

Library Connections & Advocacy

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In Summary:

All of the roles of the library ultimately support Patient Safety

- Michelle Eberle, 2007

Library Connections & Advocacy

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Patient Safety Resource Seminar: Librarians on the Front Lines

Holly Ann Burt, MLIS, MDiv

Available at:

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