Patient Safety An Overview Patient Safety Patient Safety

Patient Safety An Overview

Patient Safety “Patient Safety is freedom from injury or illness resulting from the processes of healthcare” NQF 2001

Patient Safety “Healthcare Errors Are The Top Worry Of Patients” --The National Forum for Healthcare Quality

Driving Forces For Patient Safety The Institute Of Medicine’s Report: “To Err Is Human” n n n at least 44, 000 and perhaps as many as 98, 000 deaths per year related to medical errors the lowest estimate exceeds the number attributable to the 8 th leading cause of death medication errors account for 1 0 f 854 inpatient hospital deaths, and 1 of 131 outpatient deaths Source: http: //www 4. nationalacademies. org/iomhome. nsf

Driving Forces For Patient Safety • Leapfrog Groups-Large corporations/employers contracting for healthcare with patient safety incentives • Private/public entities-ISMP, NPSF, AHQR, NQF

Driving Forces for Patient Safety Regulatory bodies--HCFA, JCAHO • JCAHO – Sentinel Event Policy mid 1990’s – New Standards Effective July 1, 2001 – Patient Safety Goals, 2003/2004 • HCFA – New QA/PI Condition of Participation, March ‘ 03

Driving Forces for Patient Safety The New Consumer Well informed n Well Educated Has Quality Expectations n n

The Call to Action! “Healthcare is a decade or more behind other high-risk industries in its attention to ensuring basic safety. Aviation has focused on building safe systems …since WW II. Between 1990 and 1994, the U. S. Airline fatality rate was one-third the rate experienced in mid century. In 1998, there were no deaths in the U. S. in commercial Aviation. ” -- To Err Is Human (IOM)

Why do errors happen? n n Accidents are a form of information about a system. Health care services is a complex and technological industry prone to accidents When large systems fail, it is due to multiple faults that occur together Errors are due most often to the convergence of multiple contributing factors --To Err Is Human (IOM)

Healthcare Errors Most Likely to Occur When: n n n Many and varied interactions with technology Many individuals involved in care; multiple handoffs for care High acuity of illness or injury Environment prone to distraction Need for rapid decisions; time-pressured High volume, unpredictable patient flow --NQF

Creating a Culture of Safety n Acknowledge high-risk, error prone nature of modern healthcare Widespread shared acceptance of responsibility for risk reduction Encourage open communication about safety concerns in a nonpunitive environment, facilitating reporting of errors and safety concerns Learn from errors Embrace accountability for patient safety n Implement known “safe practices” n n --NQF 2001

Patient Safety What healthcare professionals can do: Report errors, ‘near-misses’ and unsafe practices Adopt and blend proven safe practices into your daily routines. Familiarize yourself with current topics in patient safety

Patient Safety Websites of interest: ISMP--Institute for Safe Medication Practices (ismp. org) NQF--National Forum for Healthcare Quality Measurement and Reporting (qualityforum. org) AHRQ--Agency for Healthcare Research and Quality (ashq. gov) NPSF--National Patient Safety Foundation (npsf. org)

Patient Safety Must Be Our # 1 Priority