Patient Safety Resource Seminar

Part II - Resources

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Goal of Patient Safety:

to identify

and eliminate

errors

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Addressing Patient Safety

Legislation Research Recognition Patient Involvement Education Tools Library Connections & Advocacy

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Legislation title slide

Legislation

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State Legislation I

Malpractice regulations Mandatory and/or voluntary reporting

– Some form of reporting (adverse events, hospital acquired infections, etc.) in 43 states plus DC

Mandatory patient notification – 11 states require patients be notified of adverse events

Apologies permitted– 35 states plus DC have enacted apology laws

excluding expressions of sympathy as an admission of liability

Visit: http://www.nashp.org/pst-nashp , http://www.qups.org/ and http://www.sorryworks.net/

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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– Patient Safety 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

– 76 Patient Safety Organizations (PSOs) in 30 states and the District of Columbia - http://www.pso.ahrq.gov/

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State Legislation II

Staffing Issues– Nurse to patients staffing ratios: CA in 1999– Restricted/Regulated mandatory overtime for

nurses: 16 states

Pharmaceutical laws– 36 states and DC starting in MN in 1993– Safety topics include electronic prescription

requirements; regulations on forms, labels or packaging; legibility issues; internet sales; and reporting rules

– 41 state if reuse/recycling is included

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Federal Legislation

Electronic Prescription and Health Records Programs– Medicare Prescription Drug Act 2003– American Recovery & Reinvestment Act of 2009– The Patient Protection & Affordable Care Act of

2010 and Health Care & Education Reconciliation Act of 2010 (Affordable Care Act) o Health Information Technology for Economic and

Clinical Health Act (HITECH Act)

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Legislation Resources I

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

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Legislation Resources II

Health professional organizations Patient Safety Organizations Patient Safety Coalitions

– Local and state coalitions and organizations, plus specialized groups for patients and/or health professionals, are continuously forming

– 19 coalitions formed since 1997

State/Federal organizations with patient safety sections, components or initiatives

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Research

Research title slide

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Research

Patient Safety Grants– Government: Agency for Healthcare Research

and Quality (AHRQ), US HHS, National Institutes of Health, National Institute of Nursing Research, National Science Foundation, Grants.gov

– Non-Profit/Private foundations: Commonwealth Fund, National Patient Safety Foundation, Robert Wood Johnson Foundation

– Other agencies: Blue Cross/Blue Shield

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Research Resources

Health Services Research Projects in Progress – NLM HSRProj: http://www.nlm.nih.gov/hsrproj/

Informational databases– public: Joint Commission Sentinel Events, HHS

Hospital Compare– member: Quantros/MedMarx, MedSun– private: HealthGrades

Article sources– PubMed.gov & PubMedCentral.gov

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Recognition title slide

Recognition

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Recognition: Accreditation

Hospitals and Health Centers – Joint Commission Requirements

o Encourage patients’ active involvement in their own care as a patient safety strategy (Standards)

o The organization identifies safety risks inherent in its patient population (National Patient Safety Goal #15)

o Support information needs for other goals http://www.jointcommission.org/standards_information/npsgs.aspx

– Sentinel Eventso Support for required Root Cause Analysis’http://www.jointcommission.org/sentinel_event.aspx

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Recognition: Certification

Health professionals - recertification requirements include patient safety topics– Doctors in FL and PA – Pharmacists in FL, HI and NY

Students and residents - required to take patient safety courses– New York Medical College– Hospital residency programs

ACGME standard - 80-hour work week

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Recognition: Degrees

Graduate Certificate – University of Wisconsin-Madison

http://www.engr.wisc.edu/ie/current/patientsafety/

Masters Degree – Thomas Jefferson University

http://www.jefferson.edu/population_health/quality_safety/

– University of Illinois http://www.uic.edu/orgs/online/patient-safety-leadership/

Additional Certificate Programs– ABQAURP http://www.abqaurp.org/certification.asp

– Harvard Quality Colloquium http://www.qualitycolloquium.com/certificate.html

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Recognition: Awards

NIST Malcolm Baldrige National Quality Program http://www.nist.gov/baldrige/

Joint Commission John M. Eisenberg Award for Patient Safety and Quality http://www.jointcommission.org/topics/eisenberg_award.aspx

ANCC Magnet Recognition Program http://www.nursecredentialing.org/Magnet.aspx

AHA-McKesson Quest for Quality Prize http://www.aha.org/about/awards/q4q/

ISMP Cheers Award http://www.ismp.org/Cheers/

AHTF-ACCE Marvin Shepherd Patient Safety Award http://thehtf.org/shepherd.asp

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Patient Involvement title slide

Patient Involvement

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Patient Involvement: Campaign

AHRQ’s has created online videos and public service announcements for TV and radio

Use the “Build Your Question List” to prepare for medical appointments

www.ahrq.gov/questions/

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Patient Involvement: Personal

Individual Advocacy – In doctor & hospital visits

– Share information Create a Personal Health Record or keep 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

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Patient Involvement: Advocate

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.

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Patient Involvement: Representative

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

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Patient Involvement: Activist

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

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Patient Involvement Resources I

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

– Before Your Appointment http://www.ahrq.gov/questions/beforeappt.htm

– Speak Up Initiatives (and brochures) http://www.jointcommission.org/speakup.aspx

– We Care about Your Safety (video) http://www.emmisafety.com/ashrm/Emmi.html

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Patient Involvement Resources II

Online Information– Check Your Medicines: Tips for Using

Medicines Safely http://www.ahrq.gov/consumer/checkmeds.htm

– Personal Health Records http://www.nlm.nih.gov/medlineplus/personalhealthrecords.html

– Medicines and You: A Guide for Older Adults http://www.fda.gov/Drugs/ResourcesForYou/ucm163959.htm

– Where Medical Errors Occur and Steps You Can Take to Avoid Them http://www.ahrq.gov/consumer/cc/cc121807.htm

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Patient Involvement Resources III

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 title slide

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 I

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/Drugs/DrugSafety/DrugSafetyPodcasts/

– Healthcare 411 http://www.healthcare411.ahrq.gov/

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Education: Opportunities II

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

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Education: Connections

For those experiencing medical error

Patients and families─ P.U.L.S.E. http://www.pulseamerica.org/ ─ 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/

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Tools title slide

Tools

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Tools: Examining Events I

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

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Tools: Examining Events II

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

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Tools: Resources

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 Resources www.jcrinc.com

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Tools: NLM Resources I

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

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Tools: NLM Resources II

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

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Tools: PubMed I

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 Patient Safety (or the broader term Safety)

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Tools: PubMed II

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

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Tools: NLM Patient Resources I

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

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Tools: NLM Patient Resources II

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

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Library Connections & Advocacy title slide

Library Connections

& Advocacy

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Advocacy: Librarian’s Critical Role

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

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Library Connections & Advocacy

How is Your Library

Involved in Patient Safety

(or how will it be)?

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Advocacy: Start Where You Are

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

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Advocacy: Education

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

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Advocacy: Reach Out

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

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Advocacy: Focused Service I

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 Electronic Health Records (MedlinePlus Connect)

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Advocacy: Focused Service II

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

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Advocacy: Intra-/Internet I

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

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Advocacy: Intra-/Internet II

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

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Advocacy: Outreach I

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

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Advocacy: Outreach II

And ….

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Library Connections & Advocacy

In Summary:

All of the roles of the library ultimately support Patient Safety

- Michelle Eberle, 2007

Patient Safety Resource Seminar: Librarians on the Front Lines

Holly Ann Burt, MLIS, MDiv

Available at:

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