Patient Safety You Can Make a Difference 2016

Patient Safety You Can Make a Difference 2016

Patient Safety is in the News HEADLINES … Blo g oks s l Bo s et l Doctor…cut off wrong leg Sponge left in woman’s body One in six NHS patients misdiagnosed Tw e l 2

Definitions in Patient Safety I Error: failure of a planned action or use of a wrong plan Near miss: event caught before harming a patient Adverse Event: commission or omission resulting in unintended harm to a patient Sentinel Event: event causing or risking serious injury or death 3

Layers of Patient Safety Sharp End Examples: Medication adverse events Nosocomial Infections Patient / Health Care Provider / Team / Task and Environmental Factors Contributing Factors Blunt End Examples: Communication Culture Physical Environment Policies / Procedures Sharp End: Immediate Cause(s) Management/ Organizational/ Regulatory Factors Blunt End: Root Cause(s) Adapted from the National Health Service. Department of Health. National Patient Safety Agency. Doing Less Harm: improving the safety and quality of care through reporting, analyzing and learning from adverse incidents involving NHS patients – key requirements for health care providers, August 2001. 4

Legislating Patient Safety Health Care Safety Net Act 2008 Consumer Product Safety Act 1972 Patient Safety and Quality Improvement Act 2005 Safe Medical Device Amendments 1990 Healthcare Research and Quality Act 1999 American Recovery and Reinvestment Act 2009 (HITECH) National Literacy Act 1991 HIPAA 1996 Affordable Care Act 2010 5

State Reporting Systems See: http: //www. nashp. org/patient-safety-toolkit/ and http: //www. qups. org 6

The Patient in Patient Safety l l The Agency for Healthcare Research and Quality (AHRQ) is one of several organizations with a section of their website focused on resources for patients and family members Patient advocates (often starting with their own experiences) have created advocacy organizations and written books to help others 7

What Each Patient Can Do l Individual Advocacy – In doctor & hospital visits – Share information l l – Get information l l – – Create a Personal Health Record or keep lists of health problems, previous operations, etc. List or bring all medications, supplements, and vitamins Ask questions about treatments, medications, etc. Research illnesses and treatments Bring an Advocate Know what to do before leaving l Ask about medications and future appointments 8

Support a Patient as an Advocate l Patient Advocate – For friends and family – – Go with the patient to appointments, be with them in the hospital and clinics Listen and take 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. 9

Represent the Patient Perspective l Patient Advocacy – In health care organizations – – – Learn about the broader issues of patient safety Work to improve safety at the organization and individual unit level Serve on committees and boards, ex. Patient Safety Advisory Committee Assist on rounds (still rare) Support staff and families Become a Patient Representative 10

Become Involved l Patient 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. Web. M&M. 2007(Mar): Perspectives on Safety. http: //webmm. ahrq. gov/perspective. aspx? perspective. ID=38 11

Patient Resources I l Questions To Ask Your Doctor [before, during and after your appointment] (AHRQ) http: //www. ahrq. gov/patients-consumers/patientinvolvement/ask-your-doctor/ l Speak Up Initiatives (and brochures) http: //www. jointcommission. org/speakup. aspx l Talking with your doctor: a guide for older people (NIA) https: //www. nia. nih. gov/health/publication/talking-your-doctor/ l We Care about Your Safety (video) http: //www. emmisafety. com/ashrm/Emmi. html 12

Patient Resources II l Become more familiar with the medicine you take (ISMP) http: //www. consumermedsafety. org/ l How to Create a Pill Card (AHRQ) http: //www. ahrq. gov/patients-consumers/diagnosistreatment/treatments/pillcard/ l Medicines and You: a guide for older adults (FDA) http: //www. fda. gov/Drugs/Resources. For. You/ucm 163959. htm l Personal Health Records (NLM) https: //www. nlm. nih. gov/medlineplus/personalhealthrecords. html 13

NLM Patient Resources II l l l l l Clinical. Trials. gov – http: //clinicaltrials. gov Drug Information Portal – http: //druginfo. nlm. nih. gov Genetics Home Reference – http: //ghr. nlm. nih. gov Household Products Database – http: //hpd. nlm. nih. gov Medline. Plus – http: //medlineplus. gov NIH Senior Health – http: //nihseniorhealth. gov Pillbox – http: //pillbox. nlm. nih. gov Pub. Med – http: //pubmed. gov Tox Town – http: //toxtown. nlm. nih. gov 14

Additional Resource Examples l Advocacy Organizations – l Conferences incorporating patient input – l MITSS, PULSE Research and Government Sites – l NPSF, Local coalitions Medical Error Support – l CAPS, Empowered patient, PULSE AHRQ, CDC, NLM Reporting Errors – FDA, ISMP 15

Intersection of Patient Safety Quality Patient Safety Patient and family involvement Culture Management 16

Keep the Patient in Patient Safety You will make a difference