Making a Difference in Health Care Patient Safety, a Global Issue with National and International...
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Making a Difference in Health Care
Patient Safety, a Global Issue with National and International Solutions
Holly Ann Burt
Affra S. Al Shamsi
http://nnlm.gov/training/patientsafety/global.html
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Patient Safety Objectives
Understand the historical movement and impact of patient safety
Describe definitions related to patient safety and recognize systems of potential error within and among institutions
Locate and be able to use resources available for administrators, researchers, health professionals, and patients and families
Formulate methods for the library to effectively participate in patient safety and related programs to improve the health care of our world
3
Patient Safety: Always an Issue
“I would give great praise to the physician whose mistakes are small, for perfect accuracy is seldom seen… .” Hippocrates, trans. by Francis Adams. On Ancient Medicine, Part 9; c. 400 BCE.
“All students or doctors who enter the wards for the purpose of making an examination must wash their hands thoroughly…”. Ignác Fülöp Semmelweis. 1847-1849.
Traditional Errors in Surgery. Levis RJ. Presidential Address, Medical Society of the State of Pennsylvania on June 6, 1888. JAMA. 1888 (Jun 23);10(25):790-791.
4
Patient Safety: 2000
To Err is Human: building a safer health system. Kohn LT, Corrigan JM, Donaldson MS. Washington, DC: National Academy Press; 2000. (Released in 1999.)
An Organisation with a Memory: report of an expert group on learning from adverse events in the NHS chaired by the chief medical officer. Department of Health Expert Group. London: The Stationery Office; 2000.
Iatrogenic Injury in Australia. Runciman WB, Moller J. Adelaide: Australian Patient Safety Foundation; 2001
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Studies
Adverse Events Studies– USA Occurrences in ICUs, 1980– Quality in Australian Health Care Study, 1995– USA Harvard Medical Practice Study, 1991– UK Bristol Royal Infirmary Inquiry, 2001– Danish Adverse Events Study, 2001– Adverse Events in New Zealand, 2002– Canadian Adverse Events Study, 2004
Other types of studies: Medication safety; Nosocomial infection; Patient satisfaction
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Setting the Stage: National
Agencies, Councils, Commissions– UK National Health Service, 1948– USA The Joint Commission, 1951– International Association for Healthcare Security and Safety
(IAHSS), 1968– Saudi Arabia, National Guard Health Affairs (NGHA) , 1983– Australian Patient Safety Foundation (APSF), 1988– USA Agency for Healthcare Research and Quality (AHRQ), 1989– National Centre For Monitoring Adverse Drugs Reaction (Oman),
1992 – USA: National Coordinating Council for Medication Error
Reporting and Prevention (NCC MERP), 1995
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Setting the Stage: International
Organizations– League of Nations, Health Organization, 1923– United Nations, World Health Organization, 1948– International Society for Quality in Health Care
(ISQua), 1984– International Conference on Harmonisation of
Technical Requirements for Registration of Pharmaceuticals for Human Use, 1990
– Critical Incident Reporting and Reacting Network (CIRRNET), 1996
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Concepts from Industry
Toyota Production System, 1950’s– Just in time production– Jidoka – stopping production
Alcoa Aluminum, 1987– Safety Culture
General Electric, 1995– Six Sigma: Define, Measure, Analyze, Improve,
Control (DMAIC)
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Concepts from Aviation
Federal Aviation Authority (FAA)– Aviation Safety Reporting System (ASRS), 1975 – Crew Resource Management (CRM), 1979 – Aviation Safety Action Program (ASAP), 2000 – Partnership for Safety Initiative (PFS), 2010
National Aeronautics and Space Administration (NASA)– NASA Safety Reporting System (NSRS), 1987
International Civil Aviation Organization (ICAO)– Global Aviation Safety Plan (GASP), 1997
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Concepts from Transportation
US National Transportation Safety Board (NTSB), 1966
UK Railway Industry– Confidential Incident Reporting & Analysis System
(CIRAS), 1996
Australian Transport Safety Bureau (ATSB) – Confidential Marine Reporting Scheme (REPCON), 2004
US Federal Railroad Administration (FRA)– Confidential Close Call Reporting System (C3RS), 2005
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Libraries Become Involved
UK Royal College of Physicians library, 1653 Pennsylvania Hospital, 1763
– opens first public medical library in a hospital
USA National Library of Medicine, 1836– Established as the Army Medical Library
International Federation of Library Associations (IFLA), 1926
Japan Medical Library Association, 1927
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Libraries Involvement Grows
First International Congress on Medical Librarianship. London, UK, 1953
Royal Hospital Medical Library, 1970 Arbeitsgemeinschaft für Medizinisches
Bibliothekswesen (AGMB), 1970 La Asociación de Bibliotecas Biomédicas
Argentinas, 1970 Association for Health Information and
Libraries in Africa (AHILA), 1984
13
Defining Patient Safety
Patient safety: Freedom from accidental injury; ensuring patient safety involves the establishment of operational systems and processes that minimize the likelihood of errors and maximize the likelihood of intercepting them when they occur. – To Err is Human 2000
Patient safety: Efforts to reduce risk, to address and reduce incidents and accidents that may negatively impact healthcare consumers. – NLM MeSH, 2012
14
Patient Safety: International
Patient safety: The reduction of risk of unnecessary harm associated with healthcare to an acceptable minimum.
An acceptable minimum refers to the collective notions of given current knowledge, resource available and the context in which care as delivered weighed against the risk of non-treatment or other treatment. – Conceptual Framework for the International Classification of Patient Safety, 2009
15
Defining Patient Safety Terms
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Patient Safety Terms Change
Reportable Events? It depends. Adapted from: MMS Committee on Quality of Medical Practice and Trinity Communications, Inc. Medical Errors and Perspectives on Patient Safety. Waltham, MA: Massachusetts Medical Society, 2007.
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Patient Safety Systems
Emergency Room
18
Patient Safety Systems (pt. 2)
19
Patient Safety Systems (pt. 3)
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Patient Safety Systems (pt. 4)
21
Sentinel Event
Jose Eric Martinez, died August 2, 1996 At least 17 errors contributed to the death of this infant:
− 4 physician events − 2 pharmacy events − 4 medication policy issues− 2 authority gradient issues– 2 response issues– 1 shift change/transfer issue– 1 mechanical issue– 1 violation (not following policy)
Turnbull JE. Systems approach to error reduction in health care. Japan Med Assoc J. 2001(Sep);44(9):392-403.
22
Types of Errors
System Errors (Latent) Communication Heavy workload/Fatigue Incomplete or unwritten
policies Inadequate training or
supervision Inadequate maintenance
of equipment/buildings
Human Mistakes (Active) Action slips or failures (e.g.
picking up the wrong syringe) Cognitive failures (e.g.
memory lapses, mistakes through misreading a situation)
Violations (i.e. deviation from standard procedures; e.g. work- arounds)
DeLisa JA. Physiatry: medical errors, patient safety, patient injury, and quality of care. Am J Phys Med Rehabil. 2004(Aug);83(8):575-583
23
Patient Safety Includes Quality
Quality
Evidenced-Based Medicine/Nursing
Guidelines
Training
Processes
Forms
Measurements / Benchmarking
24
Patient Safety Includes Safety
Safety
● Environment− Room arrangement
− Distractions/Noise
− Acuity/Census
● Equipment / Materials
− False alarms
− Bathroom floors/rails
− Electrical systems
25
Patient Safety Includes Management
Leadership Business case Response
to concerns Culture
Management
Policies/Processes– Disclosure– Hours– Reporting– Discipline– Participation (e.g.
on rounds)
26
Patient Safety Includes Culture
● Communication− Authority gradient
− Patient input
− Health literacy
Reporting− Sharing or silence
− Support or firing
− Change welcomed or not
Culture
27
Patient Safety at the Intersection
Quality
Safety
Culture
Management
28
Patient Safety is Comprehensive
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.
29
Librarians are Key
Dr. Robert Wachter:
So, a medical school librarian set off the modern patient safety movement?
Lucian Leape, MD:
Ergo, there we go.
Wachter R. In conversation with Lucian Leape, MD. WebM&M. 2006(Aug): Perspectives on Safety. http://webmm.ahrq.gov/perspective.aspx?perspectiveID=28
30
Patient Safety is Central
Quality Safety
Library and
Patient information
Safety services
Culture
Management
http://nnlm.gov/training/patientsafety/global.html