**Patient Safety: You Can Make a Difference**

<http://nnlm.gov/training/patientsafety/consumer.html>

**Instructors Guide**

**Agenda**

Introduction (10 minutes)

Optional: Show the AHRQ Video "Questions are the Answer" here
<http://www.ahrq.gov/questionsaretheanswer/>

Alternatively, show it just before the Patient Safety Solutions and/or
Making a Difference slides

Patient safety overview using the PowerPoint presentation (30 minutes)

Definition, system issues, safety culture, advocacy

Resources (10 minutes)

Materials review

Highlight the resources on the "Patient Safety Web References and
Resources" handout

Identify regional and local resources relevant to the attending patrons

Concluding Discussion (10 minutes)

Possible closing questions:

How do you see your role in patient safety?

How do you see the librarian\'s role in patient safety?

What is the first thing you will do when you leave here today?

**Course Preparation**

**Handouts:**

> Agenda
>
> PowerPoint Notes pages
>
> Bibliography
>
> Patient Safety Web References and Resources

**Also needed:**

Projector for PowerPoint presentation

Internet connection to show AHRQ video, relevant web resources, and any
local library pages

**Personalize:**

-   PowerPoint: Include your name, the date, and the organization to
    which you are presenting the program on the first side

-   NOTE: Slide 9 contains a great deal of information. If you print out
    the "Notes Pages" to use (rather than using the Script Notes), first
    duplicate slide 9. On slide 9, delete the Nurse and Patient/Family
    information and, on slide 10, delete everything before Nurse.
    (Remember not to save this version after printing.)

-   Include other handouts as desired

**Recommended reading before teaching:**

-   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>

-   Turnbull JE. Systems approach to error reduction in health care.
    *Japan Med Assoc J.* 2001(Sep); 44(9): 392-403.
    <http://www.med.or.jp/english/pdf/jmaj/v44no09.pdf>

-   Hendler GY, Napp ML. Practice-based learning and improvement morning
    report makes outpatients safer. *Focus Patient Safety.*
    2006;9(2):5-6. [http://npsf.org/paf/npsfp/fo/pdf/Focus Volume 9
    Issue 2\--
    final.pdf](http://npsf.org/paf/npsfp/fo/pdf/Focus Volume 9 Issue 2 -- final.pdf)

-   For a better understanding of the types of errors that may occur in
    hospitals, read:\
    Kalra J. Medical errors: impact on clinical laboratories and other
    critical areas. *Clin Biochem*. 2004(Dec);37(12):1052-1062.

-   For an understanding of how the environment plays a role in patient
    safety, read:\
    Ulrich R, Zimring C. *Role of the physical environment in the
    hospital of the 21st century: a once in a lifetime opportunity.*
    Princeton, NJ: Robert Wood Johnson Foundation; 2004.
    <http://www.rwjf.org/files/publications/other/RoleofthePhysicalEnvironment.pdf>

**SCRIPT NOTES**

(also on the slides)

**Introductory slides**

[Hippocrates]{.underline}

"Father of modern medicine" and the author of the phrase "Do no harm".
{Hippocrates}

[Traditional Errors in Surgery.]{.underline}

Dr. Richard J. Levis gave the Presidential Address to the Medical
Society of the State of Pennsylvania on June 6, 1888. {Levis}

\_\_\_\_\_\_

[To Err is Human]{.underline}

First of what became known as the *Quality Chasm Series* published by
the Institute of Medicine and available online through the National
Academies Press -- www.nap.edu {Kohn}

**Sources of Patient Safety Concepts**

Many concepts for use in the healthcare system have come from the
aviation and transportation industries, for example the need for
teamwork training for flight crews, error reporting systems, and how to
investigates accidents

Aviation Industry {Frankel (2004), Kao}:

> FAA - http://www.faa.gov/
>
> ASRS - http://asrs.arc.nasa.gov/
>
> NASA - http://www.nasa.gov/
>
> NSRS - http://www.hq.nasa.gov/office/codeq/nsrs/

Transportation {Spencer}:

> NTSB - http://www.ntsb.gov/

\_\_\_\_\_\_

Understanding safety cultures and the need for measuring processes come
for other industries.

Nuclear Industry {Webster}:

NRC - http://www.nrc.gov/

CAIRS - http://hss.energy.gov/csa/analysis/cairs/

Manufacturing Industry{Spencer}:

Toyota {Furman} - http://www.toyota.co.jp/en/vision/production_system/

Alcoa -
http://www.alcoa.com/global/en/about_alcoa/sustainability/health_safe_approach.asp

GE {James} - http://www.ge.com/annual97/sixsigma/

**Definitions slides**

Important especially where consumers want to research this issue.

[Patient safety]{.underline} {Kohn}

This is a working definition. Different institutions may have different
definitions.

\_\_\_\_\_\_

[Error]{.underline}: An error is the failure of a planned action to be
completed as intended (i.e., error of execution) or the use of a wrong
plan to achieve an aim (i.e., error of planning). An error may be act of
commission or an act of omission.

(*Patient safety: achieving a new standard for care.* pg. 30)
{Committee}

[Adverse event]{.underline}: An adverse event results in unintended harm
to the patient by an act of commission or omission rather than by the
underlying disease or condition of the patient. (This definition makes
it clear that the potentially avoidable results of an underlying disease
or condition, for example, a recurrent myocardial infarction in a
patient who was not given a beta-blocker (an error of omission), should
be considered an adverse event.) (Ibid. pg 32) {Committee}

[Near miss]{.underline}: A near miss is an act of commission or omission
that could have harmed the patient but did not cause harm as a result of
chance, prevention, or mitigation. (Ibid. pg 34) {Committee}

[Sentinel event]{.underline}: A sentinel event is an unexpected
occurrence involving death or serious physical or psychological injury,
or the risk thereof. Serious injury specifically includes loss of limb
or function. The phrase, \"or the risk thereof\" includes any process
variation for which a recurrence would carry a significant chance of a
serious adverse outcome. {Joint Commission (2008)}

\_\_\_\_\_\_

[Adverse Event]{.underline}: an injury caused by medical management. An
injury is harm caused by an external force or action. An adverse event
may or may not be preventable. {MMS}

In this case, this does NOT refer to malpractice or deliberate errors.
Adverse or Clinical events are, for example, an unpredictable reaction
to a drug.

[Preventable adverse event]{.underline}: an adverse event caused by
error. {MMS}

[Reportable events]{.underline} depend on institution and state
requirements. This may be why events an individual has experienced was
not reported.

**Sentinel Event Slide**

[Jose Eric Martinez, died August 2, 1996]{.underline}

**Why haven't we "solved patient safety" after five years?**

17 errors in Root Cause Analysis {Turnbull}

Bad Apple analogy - fire nurse, however -- even with the new nurse there
is the possibility for the same error to occur (and it has, but
references are few)

(For reference only - if someone asks)

[Physician]{.underline}:

wrong medication amount written on order,

verification by second doctor missed decimal point,

recalculation by third doctor missed wrong decimal point,

physician dismissed nurses' concern

[Pharmacy]{.underline}:

no follow-up on questioned order

no cross-check of filled order with questioned order

[Medication policy]{.underline}:

no clear policy on questioning orders,

handwritten form,

use of zeros,

infant weight not required

[Authority gradient]{.underline}:

pharmacist to nurse,

nurse to physician

[Response issues]{.underline}:

resident to pharmacist,

nurse to pharmacist

[Shift change]{.underline}:

resident gave verbal information to next shift

[Mechanical issue]{.underline}:

beeper turned off

[Violation]{.underline}:

faxed order to pharmacy followed by hard copy

**Patient Safety System's slides** (References provided for additional
details)

Many mistakes are caught before they reach the patient

[Near Miss]{.underline}

Missed diagnosis by physician -- caught after shift change {Cosby}

Nurse brings up issue -- Physician responds to problem {Turnbull}

Prescription error by resident -- caught by presiding {Turnbull}

Barriers include not only individuals, but policies and procedures of in
department

\_\_\_\_\_\_

You could ask the consumers which types of errors/mistakes/problems they
may know about in each area. The goal is to highlight the fact there may
be problems at every level and that, as patients or patient advocates,
they need to be aware of potential problems at every level.

[Emergency Room]{.underline}

Latent: Overcrowding leading to fatal treatment delay {Trzeciak}

Active: 10% of all pediatric emergency patients experienced prescribing
errors {Kozer, Lesar}

Latent: 7% of errors were due to equipment failures {Thomas}

[Admissions]{.underline}

Barcodes were switched on two patients leading to a potentially fatal
near-miss {McDonald}

2% of wristbands contained errors {Renner}

[Laboratory]{.underline}

3% of test orders not completed {Matlow}

> Specimens mislabeled {Sazama, Bonini}

[Transfers]{.underline} - Transfers/handoffs between persons, shifts,
floors, departments, buildings, institutions

> Verbal information from day resident to night did not match
> information on written orders {Turnbull}
>
> Recent study showed 43% of communication breakdowns occurred with
> handoffs. Of all the communication errors in this study, 3% were
> across institutions, 19% between departments and 78% within one
> department {Greenberg}

[Physician]{.underline}

> Latent error: Long hours, studies show after 24 hours 20% more
> mistakes and took 14% longer to complete tasks. {Taffinder}
>
> Active error: Interruptions/Fatigue/Assumptions leading to missed
> diagnosis - Brain cramp {Yee}

[Pharmacy]{.underline} -- medication errors most completely studied of
all errors

> Similar packaging/Sound-alike names - "Celebrex -- Cerebyx -- Celexa"
> {Joint Commission (2006)}
>
> Can't get a hold of physician {Turnbull}

[Nurse]{.underline} - Considered the front line of defense and expected
to catch every error. However, there are a number of conditions for
nurses that may lead to mistakes being made.

> Understaffed {Savill}
>
> Transfusion given to patient in same room or to patient with same last
> name {McDonald, Sazama}
>
> Didn't expect adult doses in children's drawer {Wilson}

[Patient / Family]{.underline} - Can help prevent errors from reaching a
patient.

> Communication, language {Shapiro}
>
> Not giving full history of illness or homeopathic medicines {Shapiro}
>
> Patient warning of \[transfusion\] problem ignored {Sazama}

Error winds its way through the system, patient injured or killed,
sentinel event {Reason}

**Types of Errors Slide**

Examples of latent and active errors {DeLisa, Kalra}

**Making A Difference**

[Individual Advocacy]{.underline} {Gibson}

If possible, show the Video:
<http://www.ahrq.gov/questionsaretheanswer/>

[Patient Advocacy]{.underline} {NPSF}

[Patient Representative]{.underline} {Frankel (2003)}

More and more hospitals are including patient representatives on
committees, boards and even rounds.

Some hospitals include patient families in their studies of events (e.g.
root cause analysis) {Munch}

[Patient Participant/Activist]{.underline} {Gibson}

Being aware of legislation, being on listservs, participating in groups
such as

Consumers Advancing Patient Safety - www.patientsafety.org

Josie King Foundation - josieking.org

Medically Induced Trauma Support Services - mitss.org

Pulse America - pulseamerica.org

**Be Aware of Potential Problems / Resources**

Even environment can play a part in the problems {Ulrich}

**NLM Resources**

http://www.nlm.nih.gov/

AIDSinfo -- Current information on drugs, vaccines, research, and
clinical trials: http://www.aidsinfo.nih.gov/

ClinicalTrials.gov: Information on federally and privately supported
clinical research - clinicaltrials.gov

DailyMed -- Information about marketed drugs including FDA approved
labels: http://dailymed.nlm.nih.gov/

Dietary Supplements Labels Database: dietarysupplements.nlm.nih.gov

Dirline -- Directory of Health Organizations, includes Health Hotlines
http://dirline.nlm.nih.gov/

Drug Information Portal: druginfo.nlm.nih.gov

Genetics Home Reference -- Genetic conditions and the genes responsible:
http://ghr.nlm.nih.gov/

Household Products Database -- Health and safety information on
household products: http://householdproducts.nlm.nih.gov/

HSRProj (Health Services Research Projects in Progress):
www.nlm.nih.gov/hsrproj/

MedlinePlus -- Health information for patients, families and health care
providers: http://medlineplus.gov/

MedlinePlus Go Local:
http://www.nlm.nih.gov/medlineplus/golocal/topicmap_616.html

NIH Clinical Alerts & Advisories:
http://www.nlm.nih.gov/databases/alerts/clinical_alerts.html

PubMed -- Citation references including abstracts from thousands of
biomedical journal, includes My NCBI Alerts, My NCBI Collections,
Clinical Queries: http://www.pubmed.gov

Radiation Event Medical Management - REMM: remm.nlm.gov

NIH Clinical Alerts and Advisories: www.nlm.nih.gov/databases/alerts/

NIH Senior Health.gov: nihseniorhealth.gov

TOXMAP -- Environmental Health E-Maps based on EPA reported toxic
releases: http://toxmap.nlm.nih.gov/

TOXNET -- especially HSDB (Hazardous Substance Data Bank), Household
Products Database, and LactMed: http://toxnet.nlm.nih.gov/

Tox Town: Toxicologytoxtown.nlm.nih.gov

WISER - Wireless Information System for Emergency Responders:
wiser.nlm.nih.gov

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