Patient Safety Resource Seminar: Librarians on the Front Lines: Patient Safety Resource Seminar: Librarians on the Front Lines Holly Ann Burt, MLIS, MDiv Ohio Health Sciences Library Association October 19, 2007


Patient Safety Resource Seminar: Patient Safety Resource Seminar Objectives Describe definitions related to patient safety and detect systems of potential error within institutions Identify patient safety issues and points of contact specific to individual institutions Locate resources available for administrators, health professionals, and patients and families Formulate methods for the library to effectively participate in improving patient safety


Patient Safety: Ongoing Problem: “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. 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. To Err is Human: Building a Safer Health System. Kohn LT, Corrigan JM, Donaldson MS. Washington, DC: National Academy Press; 2000. Patient Safety: Ongoing Problem


Sources of Patient Safety Concepts: Sources of Patient Safety Concepts Aviation Industry Federal Aviation Authority (FAA) Aviation Safety Reporting System (ASRS) – 1975 Aviation Safety Action Program (ASAP) – 2000 National Aeronautics and Space Administration (NASA) NASA Safety Reporting System (NSRS) – 1987 Department of Defense (DOD) Patient Safety Center (Armed Forces Institute Pathology) – 2001


Sources of Patient Safety Concepts: Sources of Patient Safety Concepts Transportation Industry 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 (CMRS) – 2004 Federal Railroad Administration (FRA) Confidential Close Call Reporting System (C3RS) – 2005


Sources of Patient Safety Concepts: Sources of Patient Safety Concepts Nuclear Energy Industry US Nuclear Regulatory Committee (NRC) – 1974 Computerized Accident Incident Reporting and Recordkeeping System (CAIRS) -1975 Manufacturing Industry Toyota Production System – 1977 Alcoa Aluminum: Safety Culture – 1987 General Electric: Six Sigma - 1995


Definition of Patient Safety: Definition of 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. Kohn LT, Corrigan JM, Donaldson MS. To err is human: building a safer health system. Washington, DC: National Academy Press; 2000:211.


Definitions in Patient Safety: Definitions in Patient Safety Error: failure of a planned action or use of a wrong plan


Definitions in Patient Safety: Sentinel Event / Critical Incident Definitions in Patient Safety Adverse Event / Clinical Event Preventable Adverse Event Adapted from: MMS Committee on Quality of Medical Practice and Trinity Communications, Inc. Medical Errors and Perspectives on Patient Safety. Massachusetts Medical Society, 2004. Error Reportable Events? It depends.


Patient Safety Systems: Emergency Room Patient Safety Systems Barrier/Defense Patient


Patient Safety Systems: Patient Safety Systems Adapted from: Reason J. Human error: models and management. BMJ 2000;320;768-770


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) Sentinel Event Turnbull JE. Systems approach to error reduction in health care. Japan Med Assoc J. 2001(Sep);44(9):392-403


Types of Errors: 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


Intersection of Patient Safety: Quality Intersection of Patient Safety Evidenced-Based Medicine/Nursing Guidelines Training Processes Forms Measurements / Benchmarking


Intersection of Patient Safety: Safety Intersection of Patient Safety Environment Room arrangement Distractions/Noise Acuity/Census Equipment / Materials False alarms Bathroom floors/rails Electrical systems


Intersection of Patient Safety: Management Intersection of Patient Safety Policies/Processes Disclosure Hours Reporting Discipline Participation (e.g. on rounds) Business case Response to concerns Culture Leadership


Intersection of Patient Safety: Culture Intersection of Patient Safety Communication Authority gradient Patient input Health literacy Reporting Sharing or silence Support or firing Change welcomed or not


Intersection of Patient Safety: Quality Safety Culture Management Intersection of Patient Safety


Exploring Patient Safety: Areas / Departments Family Practice Outpatient Emergency Room Radiology Surgery ICU / NICU / CCU Housekeeping Pathology Exploring Patient Safety IT/IS Admissions Pharmacy Laboratory Pediatrics Rehabilitation Hospice Care Palliative Care In-home service


Exploring Patient Safety: Processes Medication prescribing, preparation, point-of-care delivery Tests pre-analysis, analysis, post-analysis Surgery preparation, procedures, follow-up Patient transfers & hand-offs from care centers, during shift changes, across floors Exploring Patient Safety


Exploring Patient Safety: Events - using tools like RCA Near miss Adverse event / Clinical event Preventable adverse event Reportable event Sentinel event Exploring Patient Safety


Exploring Patient Safety: 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 Sharp End Examples: Medication adverse events Nosocomial Infections Blunt End Examples: Communication Culture Physical Environment Policies / Procedures Exploring Patient Safety 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.


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. Librarians are Key Wachter R. In conversation with Lucian Leape, MD. WebM&M. 2006(Aug): Perspectives on Safety. http://webmm.ahrq.gov/perspective.aspx?perspectiveID=28


Intersection of Patient Safety: Quality Safety Library and Patient information Safety services Culture Management Intersection of Patient Safety