**Patient Safety Resource Seminar: Librarians on the Front Lines**

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

**Instructors Guide (4.0 MLA CE)**

**AGENDA**

Introduction (15 minutes)

Patient safety overview (1 hour)

PowerPoint: Definition, system issues, safety culture

Patient safety at your institution (15 minutes)

Discussion: where to connect (break out - 5 minutes)

> For those not in hospital settings, ask where they would expect to
> find this information -- either in a hospital or in their own
> settings.

Group summary (10 minutes)

Handout out the "First Break-Out Composite"

> NOTE: Send any new/not-included-on-handout information to the GMR

Break (15 minutes)

Addressing Patient Safety (1 hour)

PowerPoint: Resources Review

> **NOTE: It is not necessary to spend much time on any slide in this
> section*! ****Highlight information and resources that may be
> important to those you will be teaching and breeze past those that are
> of less interest. You may also want to point out specific links and
> sections on the Resources handout as you go.*

Providing resources (30 minutes)

Group Discussion: materials we can provide (20 minutes)

> Elicit discussion of the types of materials available to each group
> and write on a sheet, especially stress WHEN/WHAT -- so they are not
> just regurgitating the slides -- and what they may have provided in
> the past
>
> Print answers on appropriate poster sheet labeled: Health
> Professionals, Hospital Staff, Patients and Families
>
> Ask about "after an event" and apply to appropriate sheet
>
> NOTE: Send any new/not-included-on-handout information to the GMR

Materials review (10 minutes)

Handout "Group Discussion Composite -- Resources Medical Librarians Can
Offer"

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

Advocacy Discussion (30 minutes)

Discussion: Patient Safety Event (break out - 10 minutes)

> Highlight "Patient Safety Advocacy Suggestions" and ask what other
> possibilities folks may have accomplished (20 minutes)
>
> NOTE: Send any new/not-included-on-handout information/anecdotes to
> the GMR

Conclusion (15 minutes)

Summary and Evaluation

**Patient Safety Resource Seminar: Librarians on the Front Lines**

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

**Instructors Guide (2.5 MLA CE)**

**AGENDA**

Introduction (5 minutes)

Patient safety overview (45 minutes)

PowerPoint: Definition, system issues, safety culture

Patient safety at your institution (15 minutes)

Discussion: where to connect (break out - 5 minutes)

> For those not in hospital settings, ask where they would expect to
> find this information -- either in a hospital or in their own
> settings.

Group summary (10 minutes)

Handout out the "First Break-Out Composite"

> NOTE: Send any new/not-included-on-handout information to the GMR

Addressing Patient Safety (30 minutes)

PowerPoint: Resources Review

> **NOTE: It is not necessary to spend much time on any slide in this
> section*! ****Highlight information and resources that may be
> important to those you will be teaching and breeze past those that are
> of less interest. You may also want to point out specific links and
> sections on the Resources handout as you go.*

Providing resources (25 minutes)

Group Discussion: materials we can provide (15 minutes)

> Elicit discussion of the types of materials available to each group
> and write on a sheet, especially stress WHEN/WHAT -- so they are not
> just regurgitating the slides -- and what they may have provided in
> the past
>
> Print answers on appropriate poster sheet labeled: Health
> Professionals, Hospital Staff, Patients and Families
>
> Ask about "after an event" and apply to appropriate sheet
>
> NOTE: Send any new/not-included-on-handout information to the GMR

Materials review (10 minutes)

Handout "Group Discussion Composite -- Resources Medical Librarians Can
Offer"

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

Advocacy Discussion (20 minutes)

Discussion: Patient Safety Event (break out - 10 minutes)

> Highlight "Patient Safety Advocacy Suggestions" and ask what other
> possibilities folks may have accomplished (10 minutes)
>
> NOTE: Send any new/not-included-on-handout information/anecdotes to
> the GMR

Conclusion (10 minutes)

Summary and Evaluation

**Course Preparation**

**Handout ahead of time:**

> Agenda
>
> Blank Card for names
>
> First Break Out: Patient safety at your institution: where to connect
>
> Group Discussion: What Can the Library Provide? (could be on the back)
>
> Second Break Out: Patient Safety Advocacy
>
> Patient Safety Advocacy Suggestions (could be on the back)
>
> PowerPoint Notes pages
>
> Bibliography
>
> Patient Safety Web References and Resources
>
> Evaluation Questions
>
> MLA CE Evaluation

**Handouts during class/after discussions:**

> First Break-Out Composite: Patient safety at your institution: where
> to connect
>
> Group Discussion Composite: Resources Medical Librarians Can Offer
> (could be on the back)

**Also needed:**

> Projector for PowerPoint
>
> Poster sheets for writing -- used in Group Discussion
>
> Instructors notes

**Personalize:**

PowerPoint

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

-   Part II -- Include your name on the final slide

Other handouts may be included as desired

**Recommend reading includes:**

-   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>

-   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%20Volume%209%20Issue%202%20\--%20final.pdf](http://npsf.org/paf/npsfp/fo/pdf/Focus Volume 9 Issue 2 -- final.pdf)

-   Thomas EJ, Peterson LP. Measuring Errors and Adverse Events in
    Health Care. *J Gen Intern Med.* 2003(Jan);18(1): 61-67.
    <http://www.qualitycolloquium.com/documents/Measuring_Errors_and_Adverse_Events.pdf>

-   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>

-   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 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**

[Aviation]{.underline}

Many concepts for use in the healthcare system have come from aviation,
for example the need for teamwork training for flight crews and in the
operating room and human and machine interactions called human factors.
Many of the current reporting systems are based on in part on the
Aviation Safety Reporting System. {Frankel (2004)}{Kao}

FAA - http://www.faa.gov/

ASAP -
http://www.faa.gov/safety/programs_initiatives/aircraft_aviation/asap/

ASRS - http://asrs.arc.nasa.gov/

ASHDI - http://www.ashdi.com/

DOD - http://www.defenselink.mil/

http://www.afip.org/PSC/

NASA - http://www.nasa.gov/

NSRS - http://www.hq.nasa.gov/office/codeq/nsrs/

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

[Transportation]{.underline}

The National Transportation Safety Board (NTSB) investigates accidents
in the areas of Aviation, Highways, Marine and Pipeline & Hazardous
Materials, and Railroads. Some today argue for the creation of a
National Patient Safety Board along the same lines as the NTSB. Recent
studies in fatigue in the railroad industry are making their way into
the patient safety arena.

{Dorrian}{Spencer}

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

FRA - http://www.fra.dot.gov/

C3RS - http://www.closecallsrail.org/

CIRAS - http://www.ciras.org.uk/

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

[Nuclear/Manufacturing]{.underline}

Additional studies on human and machine interactions, the need for a
safety culture and measuring process come from the nuclear energy and
the manufacturing industries.

Applications for patient safety come from a variety of sources.

Nuclear {Webster}:

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

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

Manufacturing {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**

[Patient safety]{.underline} {Kohn}

*This is a working definition. It is important to know what the
definition is in your institution*

(*To Err is Human*){Kohn}

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

[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 (Sentinel Events) 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}

*NOT malpractice or deliberate errors*

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

[Reportable events]{.underline} *depend on institution and state
requirements.*

**Patient Safety System's slides** (References provided for additional
detail on events)

[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*

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

[Emergency Room]{.underline}

Latent: Overcrowding leading to fatal treatment delay {Trzeciak}

Latent: Patient assessment omitted in 35.6% of critical incidents in
this study {Thomas}

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

*Ask which:* 7% of errors were due to equipment failures {Thomas}
*\[latent\]*

[Admissions]{.underline}

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

2% of wristbands contained errors {Renner}

Patient medication information incorrect or missing {Gleason}

[Laboratory]{.underline} - Complex process -- pre-analysis, analysis,
post-analysis {Kalra}

> 3% of test orders not completed {Matlow}
>
> Specimens mislabeled {Sazama}{Bonini}
>
> Unrecognized discrepancies in tests {Matlow}

[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}
>
> Latent error -- the authority gradient: Resident/junior doctor not
> responding to or contacting attending physician with questions or
> concerns {Cosby}

*Request participants to suggest additional errors \[find both latent
and active\]*

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

> Similar packaging/Sound-alike names - "Celebrex -- Cerebyx -- Celexa"
> {Joint Commission (2006)}
>
> Inconsistent process for handling questioned orders {Turnbull}
>
> Can't get a hold of physician {Turnbull}
>
> Study of interventions by clinical pharmacist on cardiology wards
> rounds at Duke University Hospital -- averaged nearly 300
> interventions each month, 90 of which were medication errors
> {LaPointe}

[Nurse]{.underline} - front line of defense, sharp end

> Understaffed {Savill}
>
> No policies or checklists to follow {Sazama}
>
> 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}

> Communication, language {Shapiro}
>
> Not giving full history of illness or homeopathic medicines {Shapiro}
>
> Sharing when there is a concern {Shapiro} OR
>
> Patient warning of \[transfusion\] problem ignored {Sazama}

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

**Sentinel Event Slide**

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

*Why haven't we "solved it" after eight 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)*

*Those who read the Turnbull article: which events on this slide can you
name?*

[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

**Types of Errors Slide**

*Examples of latent and active errors* {DeLisa}{Kalra}

**Patient Safety Systems (intersection) slides**

**[Quality]{.underline}**

"Increasing the likelihood of desired health outcomes consistent with
current professional knowledge" {Burde}

> Evidence-based medicine/Evidence-based nursing/Research-based practice
>
> Guidelines: Surgical, handoffs -- transfer protocols
>
> Training: knowledge deficits
>
> Processes: written/unwritten rules, diffusion of responsibility
>
> Forms: handwritten/computer
>
> Standards: related to accreditation {Joint Commission (Standards)
> 2008}
>
> Measurements: AHRQ patient safety indicators, NQF performance measures

**[Safety]{.underline}**

"Safety \[science\] is not just about making unsafe things safe. It is
about better design, more extensive consideration of how things interact
with people and environment, and about better management and control of
things that are dangerous." {UNSW}

*Environment*

> Workflow, distractions {Ulrich}
>
> Staffing of floors, time of day {Welton}

*Equipment*

> Locations of machines/wiring/outlets {Chawla}
>
> Unnoticed demo mode on pump -- Human Factors Engineering {Gosbee}
>
> Health professionals increasingly involved in design phase {Malhotr}

**[Management]{.underline}**

> Leadership critical {Meyer}
>
> Business case -- costs from adverse events, litigation, increased
> insurance costs, to patients {Hwang}
>
> Policies and procedures {Turnbull}
>
> All on rounds/FMEA/RCA, including patients {Pronovost}{Scarsi}{Frankel
> (2005)}

**[Culture]{.underline}**

> Safety culture {ECRI}
>
> Communication, Chain of command for questioning orders
> {Cosby}{Turnbull}
>
> Patient Input {Munch}

**Exploring Patient Safety** (final slide)

> Diagram published in the *Canadian Root Cause Analysis Framework*
> {Hoffman}
>
> Sharp end: refers to the personnel or parts of the health care system
> in direct contact with patients. Personnel operating at the sharp end
> may literally be holding a scalpel (e.g., an orthopedist who operates
> on the wrong leg) or figuratively be administering any kind of therapy
> (e.g., a nurse programming an intravenous pump) or performing any
> aspect of care.
>
> Blunt end: refers to the many layers of the health care system that
> affect the scalpels, pills, and medical devices, or the personnel
> wielding, administering, and operating them.
>
> Thus, an error in programming an intravenous pump would represent a
> problem at the sharp end, while the institution's decision to use
> multiple types of infusion pumps (making programming errors more
> likely) would represent a problem at the blunt end. {AHRQ}

**Librarians are Key**

> From "In conversation with Lucian Leape", father of the modern patient
> safety movement. {Wachter}

**Dr. Robert Wachter, Editor, AHRQ WebM&M:** As you were in the middle
of that study, what was your sense of its potential?

**Dr. Lucian Leape:** We always were convinced it was an important
study, if nothing else, because of its magnitude. Looking at 30,000
patients gives you some clout. None of us had really thought much about
the preventability issue, and nobody knew anything about systems, of
course. We weren\'t completely surprised by our results, because
[earlier work](http://psnet.ahrq.gov/resource.aspx?resourceID=1586) had
shown similar findings. But we were, shall we say, dismayed to find that
4% of patients had adverse events. The surprise for me was that two
thirds of them were caused by errors. I\'ll never forget---I went to the
library one day and did a literature search on what was known about
preventing errors, and I didn\'t find anything. And I went to the
librarian and said, \"I\'m interested in how you prevent medical errors,
and I\'ve found papers about complications, but nothing much about
errors.\" And I asked her to look over my search strategy because I was
not finding anything. She looked at it and she said, \"Well, your
strategy looks all right. Have you looked in the humanities
literature?\" And I sort of looked at her and said, \"The what?\" I know
what humanities are, mind you. But it really never occurred to me. So
she tried the same search strategy in the humanities literature, and
boom, out came 200 papers. I started to read them and discovered [James
Reason](http://psnet.ahrq.gov/resource.aspx?resourceID=1592) and [Jens
Rasmussen](http://psnet.ahrq.gov/resource.aspx?resourceID=1491) and all
those people. A year later, I came up for air and realized that we in
health care could use this. If I didn\'t know how errors happen, most
other people wouldn\'t know it either. So I decided to write a paper.

**RW:** So, a medical school librarian set off the modern patient safety
movement?

**LL:** Ergo, there we go.

**PART II**

**NOTE: It is not necessary to spend much time on any slide in this
section*! ****Highlight information and resources that may be important
to those you will be teaching and breeze past those that are of less
interest. You may also want to point out specific links and sections on
the Resources handout as you go.*

**Legislation - Federal/State/Local**

[Reporting, Mandatory/Voluntary]{.underline}

{NASHP} - http://www.pstoolbox.org/

Patients want disclosure, to know what happened, how consequences will
be mitigated, how reoccurrences will be prevented {Gallagher}

> As of December 2006, 27 states passed adverse event reporting rules
> and statutes legislation: MA (1986), KS (1986), FL (1995-v/m), NY
> (1998), OH (1999), WA (1999), UT (2001), CO (2002), NV (2002/2005), PA
> (2002/2004), RI (2002), SC (2002), SD (2002), TN (2002), CA
> (2003/2006), GA (2003), ME (2003), MN (2003), OR (2003/2005), TX
> (2003), CT (2004), MD (2004), NJ (2004), IL (2005), IN (2005), WY
> (2005), VT (2006)
>
> CA, CO, CT, FL, GA, IL, IN, KS, MA, MD, ME, MN, NV, NJ, NY, OH, (OR),
> PA, RI, SC, SD, TN, TX, UT, VT, WA, WY

[States with Mandatory Notification of Adverse Events to
Patients]{.underline}

{ASHRM} - http://www.ashrm.org/ashrm/resources/disclosurelaws.html

> FL (2004), NV (2004), PA (2004), NJ (2005), WA (2005), VT (2006) - FL,
> NV, NJ, PA, VT, WA

[Apology]{.underline}

{ASHRM} - http://www.ashrm.org/ashrm/resources/disclosurelaws.html

Six states \... have enacted laws excluding expressions of sympathy
(e.g., "I'm sorry that you are hurt") after accidents as proof of
liability. {Cohen}

> 35 states MA (1986), TX (1999), CA (2000), FL (2001), WA (2002), TN
> (2003), CO (2003), OR (2003), MD (2004), NC(2007), OH (2004), OK
> (2004), WY (2004), AZ (2005), CT (2005), GA (2005), IL (2005), LA
> (2005), ME (2005), MO (2005), MT (2005), NC (2005), NH (2005), SD
> (2005), VA (2005), WV (2005), DE (2006), HI (2006), IA(2006), ID
> (2006), IN(2006), SC (2006), VT (2006), NB(2007), ND(2007)
>
> AZ, CA, CO, CT, DE, FL, GA, HI, ID, IL, IN, IA, LA, ME, MD, MA, MO,
> MT, NB, NH, NC, ND, OH, OK, OR, SC, SD, TN, TX, UT, VT, VI, WA, WV, WY

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

[P.S. Officer]{.underline} (from various websites)

> 4 states - PA (2002), FL (2003), NV (2003), WY (2005)

[Reporting agencies established]{.underline} (from various websites)

Act {GPO}

> "Patient safety centers: approximately 7 states have enacted
> legislation to create state patient safety centers, which are mostly
> public/private partnerships were formed to improve, ensure, and
> promote patient safety through education of providers about best
> practices, fostering a culture of safety, developing collaborative
> relationships among stakeholders, and educating consumers. {Rosenthal}
>
> 7 states -- NY (2000), FL (2002), PA (2002 - Patient Safety
> Authority), OR (2003 - Patient Safety Commission), MD (2004), MA
> (2004 - Betsy Lehman Center for Patient Safety and Medical Error
> Prevention), MI (2006) - FL, MA, MI, MD, NY, OR, PA

Many DoHs are taking on the responsibility originally given to patient
safety organizations

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

[Other laws addressing patient safety issues]{.underline}

> Staffing levels: CA (1999) "Safe Staffing Law" {Moore}{Welton};
> "Patient Safety Act" {MNA}
>
> Overtime: CA (1999-local), ME (2000), NJ (2001), OR (2001), MD (2002),
> MN (2002), WA (2002), CT (2004), WA (2004), WV (2004) {SEIU}
>
> Marketing Laws: MN (1993), WA (2000), WV (2001), ID (2002), VT (2002,
> 2007), CO (2003), DC (2003), FL (2003, 2006), ME (2003, 2005, 2007),
> CA (2004, 2005, 2006), IL (2004), MD (2004), DE (2005), MI (2005), MT
> (2005), TN (2004), NH (2006), SC (2006), AZ (2007), LA (2007), MA
> (2007), SD (2007), TX (2007) - AZ, CA, CO, DC, DE, FL, ID, IL, LA, MD,
> MA, ME, MI, MN, MT, NH, SC, SD, TN, TX, VT, WA, WV "In response to the
> IOM report, NCSL reports that, beginning five years ago, at least 15
> states have passed laws aimed at reducing prescription drug errors...
> They address improved legibility, clearer or \"common sense\" labeling
> of bottles, regulating telepharmacy and electronic
> records." {NCSL}{Hanson}{Moore}
>
> Electronic prescription programs: Medicare Prescription Drug,
> Improvement and Modernization Act (MMA) of 2003. Provides for the
> development of an Electronic Prescription Program and leading to
> Electronic Health Records {Brinckerhoff}{GPO}

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

> [State P.S. Coalitions]{.underline} (from various websites -- see
> resource list)
>
> Original dedicated agencies in CO, DC, IL, MA, MI, MN, NV, NY, PA, TX,
> VA, WA, WI
>
> Specialized organizations may include health care agencies, insurers,
> manufacturers, patient representatives and other stakeholders
>
> [Health professional organizations]{.underline} (from various
> websites)
>
> AMA: http://www.ama-assn.org/
>
> Massachusetts Nurses Association: http://www.massnurses.org/
>
> [State Organizations]{.underline} (from various websites)
>
> With PS sections - CA, KY, FL, UT, etc.

**Research**

Millions of dollars in grants have been offered to individuals and to
organizations on the topic of patient safety

[Grants]{.underline} {Omnicell}

Collected from:
http://www.omnicell.com/about_omnicell/patient_safety/grants.asp

*Government:*

> AHRQ: http://www.ahrq.gov/fund/
>
> US Department of Health and Human Services: http://www.hhs.gov/grants/
>
> National Institutes of Health: http://grants.nih.gov/
>
> National Institute of Nursing Research:
> http://ninr.nih.gov/ninr/research.html
>
> National Science Foundation: http://www.nsf.gov/funding/

*Non-Profit/Private foundations:*

> Commonwealth Fund: http://www.cmwf.org/programsgrants/
>
> National Patient Safety Foundation: http://www.npsf.org/r/
>
> Robert Wood Johnson Foundation: http://www.rwjf.org/applications/

*Other agencies*

> BC/BS Insurance Company offered \$35,000 to 4 hospitals in MA 2005
> {Broadkin}

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

[HSRProj]{.underline}:

Lists nearly 450 patient safety projects and 250 on Medical errors
(probably some overlap), includes funder, PI and project information -
(11/1/08).

[Databases]{.underline}

> public: Joint Commission:
> http://www.jointcommission.org/SentinelEvents/Statistics/
>
> member:
>
> USP MedMarx (US Pharmacopeial Convention, med errors) -
> http://www.usp.org/patientSafety/medmarx/
>
> MedSun (Med Prod Surveill Network, devices) - http://www.medsun.net
>
> private - HealthGrades (hospital reports) -
> http://www.healthgrades.com

**Recognition**

> [NPSG:]{.underline} {Joint Commission (2008)}
>
> [Sentinel Events:]{.underline} {Joint Commission (2008)}

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

[Health Professionals]{.underline}

Doctors: every 2 yr - FL 2 hrs, PA 12 hrs {AMA}

Pharmacists: FL 2 hrs/2 yrs, NY 3 hrs/3yrs {NABP}

[Students/Residents]{.underline}

Medical Schools -- NY Med College {Halbach}

Residency program -- Johns Hopkins, MD {Young}

[Residency requirements]{.underline} - ACGME (2003) {ACGME}

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

Potential degrees and certificate programs include (see also resource
list):

> Health Care Quality Management - Certificate (ABQAURP):
> <http://www.abqaurp.org/certification.asp>
>
> Healthcare Quality and Patient Safety - Certificate (Institute for
> Healthcare Studies, Northwestern University):
> <http://www.medschool.northwestern.edu/ihs/education/certificate/>
>
> Healthcare Quality and Patient Safety - MS Degree (Institute for
> Healthcare Studies, Northwestern University):
> <http://www.medschool.northwestern.edu/ihs/education/master/>
>
> Patient Safety Certificate Program (Harvard Quality Colloquium):
> <http://www.qualitycolloquium.com/certificate.html>
>
> Patient Safety - Graduate Certificate (Systems Engineering Initiative
> for Patient Safety (SEIPS), University of Wisconsin-Madison):
> <http://www2.fpm.wisc.edu/seips/Courses/pscertificateprog.html>
>
> Patient Safety, Error Science and Full Disclosure - Graduate
> Certificate; Patient Safety Leadership - MS degree: Patient Safety
> Organizations - Graduate Certificate (UI Global Campus):
> <http://global.uillinois.edu/programs/patient-safety/>

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

Representative list of awards includes:

> NIST - http://www.quality.nist.gov/ - Institutions
>
> JCAHO - http://www.jointcommission.org/PatientSafety/EisenbergAward/ -
> major achievements of individuals and organizations in improving
> patient safety and quality
>
> ANCC - http://www.nursecredentialing.org/magnet/ - health care
> organizations that provide nursing excellence {Sherwill-Navarro}
>
> AHA McKesson -
> http://www.aha.org/aha/news-center/awards/quest-for-quality/ -
> organizations
>
> ISMP - http://www.ismp.org/Cheers/ - individuals, organizations,
> companies, and agencies that have, through their actions during the
> previous year, set a superlative standard of excellence for others to
> follow in the prevention of medication errors and other adverse events
>
> AHTF-ACCE - http://www.acce-htf.org/shepherd.asp - inventor, incident
> investigator, author, educator, technology manager, and a promoter of
> safe use of technology in healthcare and/or other person with similar
> recognized patient safety accomplishments.

**Patient Involvement**

Individual {Gibson}

If possible, show the video *Questions are the Answer*:
http://www.ahrq.gov/questionsaretheanswer/

\_\_\_

Advocate {NPSF} -- going with patient to doctor/ hospital, being willing
to speak up.

Representative {Frankel} - More and more hospitals are including patient
representatives on committees, boards and even rounds.

\_\_\_

National {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

\_\_\_

Patient Involvement Resources: These are all included in the "Patient
Safety Web References and Resources" handouts, but we wanted to
highlight the different kinds of available resources.

**Education**

Opportunities for everyone to learn more about patient safety

[Conferences/Seminars]{.underline}

> The first major conference was by NPSF in 1996 at Annenberg. Many
> other groups now include patient safety modules in their meetings
>
> [Publications]{.underline}
>
> Five journals with a main focus on Patient Safety: International
> Journal for Quality in Health Care, Quality & Safety in Health Care
> (2002), Joint Commission on Journal on Quality and Safety (2003),
> Patient Safety & Quality Healthcare (2004 - online), Journal of
> Patient Safety (2005)
>
> Newsletters: TIPS, ISMP, CAPSlink, Focus
>
> Columns: AORN J, MCN
>
> [Web-based modules]{.underline}
>
> Some are free, other cost -- see the Resources list

\_\_\_

Medically Induced Trauma Support Services (MITSS) also has information
for patient and families

\_\_\_

Note: formerly the Patient Safety Officers Section (PSOS) through the
American Institute for Healthcare Quality (AIHQ) of the American Board
of Quality Assurance and Utilization Review Physicians (ABQAURP)

\_\_\_

NPSF is the oldest and probably the most active email discussion list
with over 2,500 members. However, a variety of other lists, blogs, and
wikis are springing up. Even the Joint Commission has gotten into the
act with their new WikiHealthCare.

Additional resources and links are on the handout (and may be
highlighted at this time).

**Tools**

> [RCA]{.underline} - Jose Eric Martinez {Turnbull}
>
> [IDT]{.underline} -
> http://www.npsa.nhs.uk/health/resources/incident_decision_tree
>
> [FMEA]{.underline} - patient identification, medication processed,
> blood sampling {Akpon}
>
> [PRA]{.underline} -- or ST-PRA (sociotechnical PRA) {Marx}
>
> [Six Sigma]{.underline} - DMAIC (Define, Measure, Analyze, Improve,
> Control) methodology {ASQ}

\_\_\_

> [HFE]{.underline} - {Gosbee}
>
> [CRM]{.underline} -- {Salas}
>
> [SBAR]{.underline} -- {Haig}
>
> [PACE]{.underline} - {Schroeder}

\_\_\_

[Resources]{.underline}

Examples of available 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 PSI www.qualityindicators.ahrq.gov
>
> Consulting agencies (Concerning Joint Commission, focusing on
> processes, in-house training)
>
> Joint Commission www.jcrinc.com/27746/

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

NLM Resources - www.nlm.nih.gov

> ClinicalTrials.gov: clinicaltrials.gov
>
> Dietary Supplements Labels Database: dietarysupplements.nlm.nih.gov
>
> Drug Information Portal: druginfo.nlm.nih.gov
>
> Drugs and Lactation Database (LactMed):
> http://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT
>
> Genetics Home Reference: ghr.nlm.nih.gov
>
> Hazardous Substance Data Bank - HSDB:
> http://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?HSDB
>
> Household Products Database: hpd.nlm.nih.gov
>
> HSRProj (Health Services Research Projects in Progress):
> www.nlm.nih.gov/hsrproj/
>
> MedlinePlus: http://www.nlm.nih.gov/medlineplus/patientsafety.html
>
> MedlinePlus Go Local:
> http://www.nlm.nih.gov/medlineplus/golocal/topicmap_616.html
>
> PubMed (including My NCBI Alerts, My NCBI Collections, Clinical
> Queries, Special Queries): 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
>
> TOXNET: toxnet.nlm.nih.gov
>
> ToxSeek (includes searches of international toxicology databases):
> toxseek.nlm.nih.gov
>
> Tox Town: toxtown.nlm.nih.gov
>
> WISER - Wireless Information System for Emergency Responders:
> wiser.nlm.nih.gov

Things to look for in doing research {Thomas}

**Library Connections & Advocacy**

Quote: From "In conversation with Lucian Leape", father of the modern
patient safety movement. {Wachter}

[In Training & Education (including CE and CME)]{.underline}

> In orientation classes, at seminars, during resource council meetings,
> in other and individual settings.
>
> Helping develop the student curriculum
>
> Pointing to existing CE, CNE & CME requirements
>
> Sharing during reference services activities

[On the Website -- Current News]{.underline}

Lift up Current News, for example recent evidence based research (and
provide recent articles/reports), benchmarking information, alerts

Include celebrations: "Good Catch"; System changes due to FMEA, other

> Include availability of library/librarians
>
> Include reporting resources

[Connect and Educate]{.underline}

> Visit nursing stations, departments & people
>
> For example, put icons on nursing computers
>
> Support Magnet Status & JCAHO IM requirements

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