Presentation on theme: "Making a Difference in Health Care Patient Safety, a Global Issue with National and International Solutions Holly Ann Burt Affra S. Al Shamsi"— Presentation transcript:
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
2 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
5 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
6 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
7 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
8 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)
9 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
10 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 (C 3 RS), 2005
11 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
12 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
16 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.
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
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