Patient Safety You Can Make a Difference 2016 Patient Safety is in the News HEADLINES Doctorcut off wrong l eg Sponge left in womans body One in six NHS patients misdiagnosed Blogs Tweets ID: 766808
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Patient Safety You Can Make a Difference 2016
Patient Safety is in the News HEADLINES … Doctor…cut off wrong legSponge left in woman’s bodyOne in six NHS patients misdiagnosed Blogs Tweets Books
Definitions in Patient Safety I Error: failure of a planned action or use of a wrong plan Adverse Event: commission or omission resulting in unintended harm to a patient Near miss: event caught before harming a patient Sentinel Event: event causing or risking serious injury or death
Layers of Patient Safety Sharp End Examples: Medication adverse events Nosocomial Infections Blunt End Examples: Communication Culture Physical Environment Policies / Procedures Sharp End: Immediate Cause(s) Blunt End: Root Cause(s) Contributing Factors Patient / Health Care Provider / Team / Task and Environmental Factors Management/ Organizational/ Regulatory Factors 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.
Legislating Patient Safety
State Reporting Systems See: http://www.nashp.org/patient-safety-toolkit/ and http://www.qups.org
The Patient in Patient Safety 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 membersPatient advocates (often starting with their own experiences) have created advocacy organizations and written books to help others
What Each Patient Can Do Individual Advocacy – In doctor & hospital visitsShare information Create a Personal Health Record or keep lists of health problems, previous operations, etc. List or bring all medications, supplements, and vitaminsGet informationAsk questions about treatments, medications, etc. Research illnesses and treatments Bring an AdvocateKnow what to do before leavingAsk about medications and future appointments
Support a Patient as an Advocate Patient Advocate – For friends and familyGo with the patient to appointments, be with them in the hospital and clinicsListen 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.
Represent the Patient Perspective Patient Advocacy – In health care organizations Learn about the broader issues of patient safetyWork to improve safety at the organization and individual unit level Serve on committees and boards, ex. Patient Safety Advisory CommitteeAssist on rounds (still rare)Support staff and families Become a Patient Representative
Become Involved 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. WebM&M . 2007(Mar): Perspectives on Safety. http://webmm.ahrq.gov/perspective.aspx?perspectiveID=38
Patient Resources I Questions To Ask Your Doctor [before, during and after your appointment] (AHRQ) http://www.ahrq.gov/patients-consumers/patient-involvement/ask-your-doctor/ Speak Up Initiatives (and brochures) http://www.jointcommission.org/speakup.aspxTalking with your doctor: a guide for older people (NIA) https://www.nia.nih.gov/health/publication/talking-your-doctor/ We Care about Your Safety (video) http://www.emmisafety.com/ashrm/Emmi.html
Patient Resources II Become more familiar with the medicine you take (ISMP) http://www.consumermedsafety.org/ How to Create a Pill Card (AHRQ)http:// www.ahrq.gov/patients-consumers/diagnosis-treatment/treatments/pillcard/Medicines and You: a guide for older adults (FDA) http://www.fda.gov/Drugs/ResourcesForYou/ucm163959.htm Personal Health Records (NLM) https://www.nlm.nih.gov/medlineplus/personalhealthrecords.html
NLM Patient Resources II ClinicalTrials.gov – http://clinicaltrials.gov Drug Information Portal – http://druginfo.nlm.nih.gov Genetics Home Reference – http://ghr.nlm.nih.govHousehold Products Database – http://hpd.nlm.nih.govMedlinePlus – http://medlineplus.gov NIH Senior Health – http://nihseniorhealth.govPillbox – http://pillbox.nlm.nih.gov PubMed – http://pubmed.gov Tox Town – http://toxtown.nlm.nih.gov
Additional Resource Examples Advocacy Organizations CAPS, Empowered patient, PULSE Conferences incorporating patient inputNPSF, Local coalitionsMedical Error Support MITSS, PULSE Research and Government SitesAHRQ, CDC, NLMReporting Errors FDA, ISMP
Quality Safety Patient and Patient family Safety involvement Culture Management Intersection of Patient Safety
You will make a difference Keep the Patient in Patient Safety