# Presentation: 153407

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

- Holly Ann Burt, MLIS, MDiv

- Ohio Health Sciences Library Association
- October 19, 2007

## 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

- 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

## “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.

- 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**

## 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 

**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

## 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

**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 (C**3**RS) – 2005

## 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

**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

- 	_**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.

**Notes:**
Working definition – Know what the definition is in your institution

## Definitions in Patient Safety

**Definitions in Patient Safety**

**Error: failure of a planned action or use of a wrong plan **

**Notes:**
Error: 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}

Adverse event: 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}

Near miss: 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}

Sentinel event: 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}

## Definitions in Patient Safety

**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. ***

**Notes:**
Adverse Event: 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
Rather, events that could not be predicted ahead of time: individual’s reaction to a drug

Preventable adverse event: an adverse event caused by error.

Reportable events depend on institution and state requirements.

## Patient Safety Systems

- Emergency Room

**Patient Safety Systems**

- Barrier/Defense

- Patient

**Notes:**
Near Miss
	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 

## Patient Safety Systems

**Patient Safety Systems**

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

**Notes:**
Emergency Room
    Latent: Overcrowding lead 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 [latent]: 7% of errors were due to equipment failures {Thomas}

Admissions
    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 - 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 - 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
    Latent error: 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 – authority gradient: Resident/junior doctor not responding to/contacting attending with questions/concerns {Cosby} 

Pharmacy – medication errors most completely studied of all errors
    Similar packaging / Sound-alike names - “Celebrex – Cerebyx – Celexa” {JCAHO}
    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 - front line of defense, sharp end
    Understaffed {Savill}
    No policies or checklists to follow {Sazama}
    Demo mode {Gosbee}
    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 
    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 {Sazma}

Error winds it’s way through the system, patient injured or killed, 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)

-    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

**Notes:**
Why haven’t we “solved it” after eight years
Jose Eric Martinez, August 2, 1996, 17 errors in Root Cause Analysis {Turnbull}
Bad Apple analogy - fire nurse, new nurse, possibility for same problem
Those who read the Turnbull article: which can you name? 

Physician: 
    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: 
   no follow-up on questioned order (after no response), not caught when tech filled order
Medication policy:  
   no clear policy on questioning orders, handwritten form, use of zeros, infant weight not required
Authority gradient: 
   pharmacist to nurse, nurse to physician
Response issues: 
   resident to pharmacist, nurse to pharmacist
Shift change: 
   resident gave verbal information to next shift
Mechanical issue: 
   beeper turned off
Violation: 
   faxed order to pharmacy followed by hard copy

## System Errors (Latent)
Communication
Heavy workload/Fatigue
Incomplete or unwritten policies
Inadequate training or supervision
Inadequate maintenance of equipment/buildings

_**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

## 
    Quality	

-     **Quality**
**  **

**Intersection of Patient Safety**

- Evidenced-Based Medicine/Nursing
- Guidelines
- Training
- Processes
- Forms
- Measurements / Benchmarking

**Notes:**
Quality 
“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
Measurements: AHRQ patient safety indicators, NQF performance measures 

## 

								 Safety

- 								 **Safety**

**Intersection of Patient Safety**

-   Environment
-  Room arrangement
-  Distractions/Noise
-  Acuity/Census
-   Equipment / Materials
-  False alarms
-  Bathroom floors/rails
-  Electrical systems

**Notes:**
Safety
“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} 
Demo mode on pumps, HFE {Gosbee}
Health professionals increasingly involved in design phase {Malhotr}

## 

  Management 

**  ****Management**** **

**Intersection of Patient Safety**

- Policies/Processes
-   Disclosure
-   Hours
-   Reporting
-   Discipline
-   Participation (e.g. on rounds)

-   Business case
-   Response     to concerns
-   Culture

_**Leadership**_

**Notes:**
Management  
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

**                                                              ****Culture**

**Intersection of Patient Safety**

-   Communication
-  Authority gradient
-  Patient input
-  Health literacy

-   Reporting
-  Sharing or silence
-  Support or firing
-  Change welcomed or not

**Notes:**
Culture
Safety culture {ECRI}
Communication, Chain of command for questioning orders {Cosby}{Turnbull}
Patient Input {Munch}

## 
    Quality	
								 Safety

                                                              Culture
  Management

-     **Quality**
- 								 **Safety**
**                                                              ****Culture**
**  ****Management**

**Intersection of Patient Safety**

## Areas / Departments
Family Practice
Outpatient 
Emergency Room 
Radiology
Surgery
ICU / NICU / CCU
Housekeeping
Pathology

- 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

## 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
Communication
reporting, information sharing, encouragement/resistance

- 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
- Communication
- reporting, information sharing, encouragement/resistance

**Exploring Patient Safety**

## Events - using tools like RCA
Near miss 
Adverse event / Clinical event 
Preventable adverse event
Reportable event
Sentinel event

- Near miss
- Adverse event / Clinical event
- Preventable adverse event
- Reportable event
- Sentinel event

**Exploring Patient Safety**

**Notes:**
RCA – Root Cause Analysis

## 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.

**Notes:**
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}

## Dr. Robert Wachter: 
	So, a medical school librarian set off the modern patient safety movement?

Lucian Leape, MD: 
	Ergo, there we go.

**	****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

## 
    Quality	                                                    Safety

                                                                 Library and
 Patient                                                            information
 Safety                                                             services

                                                                      Culture
  Management

-     **Quality**	                                                    **Safety**
-                ** ****                                                 ****Library and**
** ****Patient                                                            information**
** ****Safety                                                             services**
**                                                                      ****Culture**
**  ****Management**

**Intersection of Patient Safety**