# Presentation: 016427

## Part II - Resources

**Part II - Resources**

## to identify 
and eliminate 
errors

**and eliminate **
**errors**

**Goal of Patient Safety:**** **

## Legislation
Research 
Recognition
Patient Involvement 
Education
Tools
Library Connections & Advocacy

**Legislation**
**Research **
**Recognition**
**Patient Involvement **
**Education**
**Tools**
**Library Connections & Advocacy**

## 
Legislation

**Legislation**

## Malpractice regulations
Mandatory and/or voluntary reporting
Required in 26 states plus DC (as of October 2007)
Mandatory notification 
6 states require patients be notified of adverse events
Apologies permitted
35 states have enacted laws excluding expressions of sympathy after accidents as proof of liability

     At:  http://www.pstoolbox.org/   and   http://www.ashrm.org/ashrm/resources/disclosurelaws.html 

**Malpractice regulations**
**Mandatory and/or voluntary reporting**
- Required in 26 states plus DC (as of October 2007)
**Mandatory notification **
- 6 states require patients be notified of adverse events
**Apologies permitted**
- 35 states have enacted laws excluding expressions of sympathy after accidents as proof of liability
-      At:  http://www.pstoolbox.org/   and   http://www.ashrm.org/ashrm/resources/disclosurelaws.html

## Patient Safety Officers (PSO) mandated 
Point of contact in the hospital, report events, and coordinate activities to provide safety to patients
4 states require PSOs 
PSOs are found in most states and several countries
Reporting agencies established
Federal Patient Safety and Quality Improvement Act of 2005 
Several states have formed centers to collect data and disseminate information on medical errors
Departments of Health may also collect reporting information

**Patient Safety Officers (PSO) mandated**** **
- Point of contact in the hospital, report events, and coordinate activities to provide safety to patients
- 4 states require PSOs
- PSOs are found in most states and several countries
**Reporting agencies established**
- Federal Patient Safety and Quality Improvement Act of 2005
- Several states have formed centers to collect data and disseminate information on medical errors
- Departments of Health may also collect reporting information

**Notes:**
P.S. Officer (from various websites)
4 states - PA (2002), FL (2003), NV (2003), WY (2005)

Reporting Agencies established  (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

## Nurse to patients staffing ratios
Enacted in CA in 1999; passed MA House
Prohibiting mandatory overtime
9 states (including CA)
Pharmaceutical marketing laws
22 states and DC starting in MN in 1993
Electronic prescription programs
Medicare Prescription Drug Act 2003
State programs, requirements, databases

Pharmaceutical marking laws at: http://www.ncsl.org/ 

**Nurse to patients staffing ratios**
- Enacted in CA in 1999; passed MA House
**Prohibiting mandatory overtime**
- 9 states (including CA)
**Pharmaceutical marketing laws**
- 22 states and DC starting in MN in 1993
**Electronic prescription programs**
- Medicare Prescription Drug Act 2003
- State programs, requirements, databases
- Pharmaceutical marking laws at: http://www.ncsl.org/

**Notes:**
Other laws addressing patient safety issues
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), 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 {Brinckerhoff} 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} 

## National Academy for State Health Policy 
Patient Safety Toolbox for States http://www.pstoolbox.org/
American Society for Healthcare Risk Management
http://www.ashrm.org/ashrm/resources/disclosurelaws.html
Library of Congress legislative information http://thomas.loc.gov/
National Conference of State Legislatures http://www.ncsl.org/

**National Academy for State Health Policy**
- Patient Safety Toolbox for States http://www.pstoolbox.org/
**American Society for Healthcare Risk Management**
- http://www.ashrm.org/ashrm/resources/disclosurelaws.html
**Library of Congress legislative information** http://thomas.loc.gov/
**National Conference of State Legislatures **http://www.ncsl.org/

## USA.gov 
links to state legislature information
Patient Safety Coalitions
Specialized and state coalitions continuously forming
Health professional organizations 
State organizations with patient safety sections, components or initiatives 
Often included in departments of health

**USA.gov **
- links to state legislature information
**Patient Safety Coalitions**
- Specialized and state coalitions continuously forming
**Health professional organizations**
**State organizations** with patient safety sections, components or initiatives
- Often included in departments of health

## 
Research

**Research**

## Patient Safety Grants
Government: Agency for Healthcare Research and Quality (AHRQ), US DHHS, National Institutes of Health, National Institute of Nursing Research, National Science Foundation
Non-Profit/Private foundations: Commonwealth Fund, National Patient Safety Foundation, Robert Wood Johnson Foundation
Other agencies: Blue Cross/Blue Shield

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

**Patient Safety Grants**
**Government:** Agency for Healthcare Research and Quality (AHRQ), US DHHS, National Institutes of Health, National Institute of Nursing Research, National Science Foundation
**Non-Profit/Private foundations:** Commonwealth Fund, National Patient Safety Foundation, Robert Wood Johnson Foundation
**Other agencies:** Blue Cross/Blue Shield
- Collected from:  http://www.omnicell.com/about_omnicell/patient_safety/grants.asp

## Health Services Research Projects in Progress 
NLM HSRProj: http://www.nlm.nih.gov/hsrproj/
Informational databases
public: Joint Commission Sentinel Events
member: USP MedMarx, MedSun
private: HealthGrades
Article sources
PubMed.gov 
PubMedCentral.gov

**Health Services Research Projects** **in Progress**
**NLM HSRProj**: http://www.nlm.nih.gov/hsrproj/
**Informational databases**
**public:** Joint Commission Sentinel Events
**member:** USP MedMarx, MedSun
**private:** HealthGrades
**Article sources**
**PubMed.gov **
**PubMedCentral.gov**

## 
Recognition

**Recognition**

## Hospitals and Health Centers 
 National Patient Safety Goals
Encourage patients’ active involvement in their own care as a patient safety strategy (#13)
The organization identifies safety risks inherent in its patient population (#15)
Support information needs for other goals
http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/
Sentinel Events
Support required Root Cause Analysis
http://www.jointcommission.org/SentinelEvents/

**Hospitals and Health Centers **
** ****National Patient Safety Goals**
- Encourage patients’ active involvement in their own care as a patient safety strategy (#13)
- The organization identifies safety risks inherent in its patient population (#15)
- Support information needs for other goals
- http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/
**Sentinel Events**
- Support required Root Cause Analysis
- http://www.jointcommission.org/SentinelEvents/

**Notes:**
NPSG: {Joint Commission (2009)}
Sentinel Events: {Joint Commission (2007)}

## Health professionals - recertification requirements include patient safety topics
Doctors in FL and PA 
Pharmacists in FL and NY 
Students and residents - required to take patient safety courses
New York Medical College
Hospital residency programs
ACGME standard - 80-hour work week 

**Health professionals** - recertification requirements include patient safety topics
- Doctors in FL and PA
- Pharmacists in FL and NY
**Students and residents** - required to take patient safety courses
- New York Medical College
- Hospital residency programs
**ACGME standard** - 80-hour work week** **

**Notes:**
Health Professionals 
Doctors: every 2 yr - FL 2 hrs, PA 12 hrs {AMA}
Pharmacists: FL 2 hrs/2 yrs, NY 3 hrs/3yrs {NABP (called)}
Students/Residents 
Medical Schools – NY Med College {Halbach}
Residency program – Johns Hopkins, MD {Young}
Residency requirements - ACGME (2003) {ACGME} 

## Graduate Certificate 
University of Wisconsin-Madison http://www.engr.wisc.edu/ie/current/patientsafety/
Masters Degree 
Northwestern University Institute for Healthcare Studies http://www.medschool.northwestern.edu/ihs/
University of Illinois Global Campus http://global.uillinois.edu/programs/patient-safety/ 
Additional Certificate Programs
Harvard Quality Colloquium http://www.qualitycolloquium.com/certificate.html 
ABQAURP http://www.abqaurp.org/certification.asp 

**Graduate Certificate **
*University of Wisconsin-Madison* http://www.engr.wisc.edu/ie/current/patientsafety/
**Masters Degree **
*Northwestern University Institute for Healthcare Studies* http://www.medschool.northwestern.edu/ihs/
*University of Illinois Global Campus* http://global.uillinois.edu/programs/patient-safety/
**Additional Certificate Programs**
*Harvard Quality Colloquium* http://www.qualitycolloquium.com/certificate.html
*ABQAURP* http://www.abqaurp.org/certification.asp

## NIST Malcolm Baldrige National Quality Program http://www.quality.nist.gov/ 
Joint Commission John M. Eisenberg Award for Patient Safety and Quality http://www.jointcommission.org/PatientSafety/EisenbergAward/ 
ANCC Magnet Recognition Program http://www.nursecredentialing.org/Magnet.aspx
AHA-McKesson Quest for Quality Prize http://www.aha.org/aha/news-center/awards/quest-for-quality/
ISMP Cheers Award http://www.ismp.org/Cheers/ 
AHTF-ACCE Marvin Shepherd Patient Safety Award http://www.acce-htf.org/shepherd.asp

**NIST**** ***Malcolm Baldrige National Quality Program*** **http://www.quality.nist.gov/
**Joint Commission**** ***John M. Eisenberg Award for Patient Safety and Quality* http://www.jointcommission.org/PatientSafety/EisenbergAward/
**ANCC**** ***Magnet Recognition Program* http://www.nursecredentialing.org/Magnet.aspx
**AHA-McKesson**** ***Quest for Quality Prize* http://www.aha.org/aha/news-center/awards/quest-for-quality/
**ISMP** Cheers Award http://www.ismp.org/Cheers/
**AHTF-ACCE**** ***Marvin Shepherd Patient Safety Award* http://www.acce-htf.org/shepherd.asp

## 
Patient Involvement

**Patient Involvement**

## Questions are the Answer http://www.ahrq.gov/questionsaretheanswer/

## Individual Advocacy – In doctor & hospital visits
Share information 
Create lists of health problems, previous operations, etc.
List or bring all medications, supplements, and vitamins
Get information
Ask questions about treatments, medications, etc. 
Research illnesses and treatments
Bring an Advocate
Know what to do before leaving
Ask about medications and future appointments 

**Individual Advocacy **– In doctor & hospital visits
**Share information**
- Create lists of health problems, previous operations, etc.
- List or bring all medications, supplements, and vitamins
**Get information**
- Ask questions about treatments, medications, etc.
- Research illnesses and treatments
**Bring an Advocate**
**Know what to do before leaving**
- Ask about medications and future appointments

**Notes:**
Individual {Gibson}

## Patient Advocate – For friends and family
Willingness to go with the patient to appointments, be with them in the hospital and clinics
Listening and taking notes
Speak up when necessary to clarify an issue and to ask a question
Question when something does not seem right in the hospital, nursing homes, clinics, etc.

**Patient Advocate **– For friends and family
- Willingness to go with the patient to appointments, be with them in the hospital and clinics
- Listening and taking notes
- Speak up when necessary to clarify an issue and to ask a question
- Question when something does not seem right in the hospital, nursing homes, clinics, etc.

**Notes:**
Advocate {NPSF} – going with patient to doctor/ hospital, being willing to speak up.  

## Patient Representative – In health care organizations 
Work to improve safety at the organization and individual unit level
Serve on committees and boards
Assist on rounds (still rare)
Support staff and families

**Patient Representative **– In health care organizations
- Work to improve safety at the organization and individual unit level
- Serve on committees and boards
- Assist on rounds (still rare)
- Support staff and families

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

## Patient Participant/Activist
Participate on state and regional coalitions and organizations and/or
Serve nationally 
Advocate for public reporting and accountability of hospital and health system performance 
Volunteer, make donations, work with fund-raising
Be aware of state and national legislation, contact legislators 

**Patient Participant/Activist**
- Participate on state and regional coalitions and organizations and/or
- Serve nationally
- Advocate for public reporting and accountability of hospital and health system performance
- Volunteer, make donations, work with fund-raising
- Be aware of state and national legislation, contact legislators

- 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

**Notes:**
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

## Online Information
5 Steps to Safer Health Care http://www.ahrq.gov/consumer/5steps.htm
20 Tips to Prevent Medical Errors http://www.ahrq.gov/consumer/20tips.htm
Be Prepared for Medical Appointments http://www.ahrq.gov/qual/beprepared.htm
We Care about Your Safety (video) http://www.ashrm.org/ashrm/foundation/emmisafety/
Speak Up Initiatives (and brochures) http://www.jointcommission.org/PatientSafety/SpeakUp/

**Online Information**
**5 Steps to Safer Health Care** http://www.ahrq.gov/consumer/5steps.htm
**20 Tips to Prevent Medical Errors** http://www.ahrq.gov/consumer/20tips.htm
**Be Prepared for Medical Appointments** http://www.ahrq.gov/qual/beprepared.htm
**We Care about Your Safety **(video) http://www.ashrm.org/ashrm/foundation/emmisafety/
**Speak Up Initiatives** (and brochures) http://www.jointcommission.org/PatientSafety/SpeakUp/

## Online Information
Check Your Medicines: Tips for Using Medicines Safely http://www.ahrq.gov/consumer/checkmeds.htm
Drug Information Portal             http://druginfo.nlm.nih.gov/
My Medicine Record http://www.fda.gov/cder/consumerinfo/my_medicine_record.htm 
Questions are the Answer (video) http://www.ahrq.gov/questionsaretheanswer/
What You Can Do to Make Healthcare Safer http://www.npsf.org/download/WhatYouCanDo.pdf

**Online Information**
**Check Your Medicines: Tips for Using Medicines Safely **http://www.ahrq.gov/consumer/checkmeds.htm
**Drug Information Portal**             http://druginfo.nlm.nih.gov/
**My Medicine Record** http://www.fda.gov/cder/consumerinfo/my_medicine_record.htm** **
**Questions are the Answer*** *(video)* *http://www.ahrq.gov/questionsaretheanswer/
**What You Can Do to Make Healthcare Safer **http://www.npsf.org/download/WhatYouCanDo.pdf

## More Information
Websites: AHRQ, NLM, etc.
Alerts: My NCBI, etc.
Organizations: staff, committees, leaders, etc.
Conferences: NPSF, etc.
Advocacy 
Websites: CAPS, PULSE, NPSF, etc.
Legislation resources
Medical Error Support
Websites: MITSS, PULSE, Voice4Patients

**More Information**
- Websites: AHRQ, NLM, etc.
- Alerts: My NCBI, etc.
- Organizations: staff, committees, leaders, etc.
- Conferences: NPSF, etc.
**Advocacy **
- Websites: CAPS, PULSE, NPSF, etc.
- Legislation resources
**Medical Error Support**
- Websites: MITSS, PULSE, Voice4Patients

**Notes:**
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

**Education**

## Health literacy
Easy to read, Language appropriate
Legislation
Accreditation/Certification requirements
 Joint Commission changes
EBM / EBN / RBP
Nursing issues & resources
Consumer resources & advocacy

**Health literacy**
- Easy to read, Language appropriate
**Legislation**
**Accreditation/Certification requirements**
-  Joint Commission changes
**EBM / EBN / RBP**
**Nursing issues & resources**
**Consumer resources & advocacy**

## Conferences/Seminars/Workshops
NPSF, AHRQ, medical associations, coalitions
Publications
Journals, numerous newsletters/columns
Web-based
Self-learning, CE/CME/CNE
Additional training
Created by library, brought in from outside 

**Conferences/Seminars/Workshops**
- NPSF, AHRQ, medical associations, coalitions
**Publications**
- Journals, numerous newsletters/columns
**Web-based**
- Self-learning, CE/CME/CNE
**Additional training**
- Created by library, brought in from outside** **

**Notes:**
Opportunities for everyone to learn more about patient safety
Conferences/Seminars 
NPSF - The first major conference was by NPSF in 1996 at Annenberg.  Many other groups now include patient safety modules in their meetings
Publications
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, Nursing
Web-based Education 
Some are free, other cost – see the Resources list

## Books and Journals
Quality Chasm online series  http://www.nap.edu/
Patient Safety and Quality Healthcare http://www.psqh.com/ 
Podcasts and Videos
Healthcare 411   http://www.healthcare411.ahrq.gov/ 
Drug Safety Podcasts (FDA): http://www.fda.gov/cder/drug/podcast/ 
Alert services
ISMP, FDA, AORN, My NCBI, NIH, WHO

**Books and Journals**
*Quality Chasm* online series  http://www.nap.edu/
*Patient Safety and Quality Healthcare* http://www.psqh.com/
**Podcasts and Videos**
- Healthcare 411   http://www.healthcare411.ahrq.gov/
- Drug Safety Podcasts (FDA): http://www.fda.gov/cder/drug/podcast/
**Alert services**
- ISMP, FDA, AORN, My NCBI, NIH, WHO

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

## For those experiencing medical error 

Patients and families
P.U.L.S.E. http://www.pulseamerica.org/ 
Voice4Patients.com
Consumers Advancing Patient Safety (CAPS) http://www.patientsafety.org/ 
Medical professionals
Medically Induced Trauma Support Services (MITSS) http://www.mitss.org/
Sorry Works! Coalition http://sorryworks.net/

**For those experiencing medical error**** **
** **
**Patients and families**
- P.U.L.S.E. http://www.pulseamerica.org/
- Voice4Patients.com
- Consumers Advancing Patient Safety (CAPS) http://www.patientsafety.org/
**Medical professionals**
- Medically Induced Trauma Support Services (MITSS) http://www.mitss.org/
- Sorry Works! Coalition http://sorryworks.net/

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

## For those in leadership 

Safety Officers
American Society of Medication Safety Officers http://www.asmso.org/
Patient Safety Officers Society http://www.psos.org/
Healthcare Leadership Council (HLC) http://www.hlc.org/

**For those in leadership**** **
** **
**Safety Officers**
- American Society of Medication Safety Officers http://www.asmso.org/
- Patient Safety Officers Society http://www.psos.org/
**Healthcare Leadership Council (HLC) **http://www.hlc.org/

**Notes:**
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)

## For everyone 

Email Discussions
NPSF Patientsafety-L    http://www.npsf.org/psf/ 
Blogs and Wikis
Joint Commission WikiHealthCareTM http://wikihealthcare.jointcommission.org/  
Blogs for Hospital Librarians   http://mla-hls.wikispaces.com/Blogs 

**For everyone**** **
**Email Discussions**
- NPSF *Patientsafety-L*    http://www.npsf.org/psf/
**Blogs and Wikis**
- Joint Commission WikiHealthCareTM http://wikihealthcare.jointcommission.org/
- Blogs for Hospital Librarians   http://mla-hls.wikispaces.com/Blogs

**Notes:**
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

**Tools**

## RCA – Root Cause Analysis 
Examining events
Incident Decision Tree 
Examining events
Failure Modes and Effects Analysis (FMEA)
Examining processes
Probabilistic Risk Analysis (PRA)
Examining processes starting with outcomes
Six Sigma
Measurement studies

- Examining events
**Incident Decision Tree**
- Examining events
**Failure Modes and Effects Analysis (FMEA)**
- Examining processes
**Probabilistic Risk Analysis (PRA)**
- Examining processes starting with outcomes
**Six Sigma**
- Measurement studies

**Tools: Examining Events**

## Human Factors Engineering 
Human abilities/characteristics affecting design/operation 
Crew Resource Management (CRM) 
Communication, team working
Situation-Background-Assessment-Recommendation (SBAR) 
Communication, team working
Patient/Problem, Assessment/Actions, Continuing/Changes, Evaluation  (PACE)
Communication

- Human abilities/characteristics affecting design/operation
**Crew Resource Management (CRM)**
- Communication, team working
**Situation-Background-Assessment-Recommendation (SBAR)**
- Communication, team working
**Patient/Problem, Assessment/Actions, Continuing/Changes, Evaluation  (PACE)**
- Communication

**Tools: Examining Events**

**Notes:**
HFE - {Gosbee}
CRM – {Salas}
SBAR – {Haig} with tools at IHI
PACE - {Schroeder}

## 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/

- 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/

**Tools: Resources**

**Notes:**
Examples of available resources

## RCA / FMEA Support, Evidenced-Based Medicine/Nursing
PubMed   PubMed.gov
search for events and/or processes
PubMed Clinical Queries PubMed.gov 
identify related reviews
PubMed Special Queries  PubMed.gov 
	additional subject filters
NIH Clinical Alerts & Advisories www.nlm.nih.gov/databases/alerts

**PubMed****   **PubMed.gov
- search for events and/or processes
**PubMed Clinical Queries**** **PubMed.gov
- identify related reviews
**PubMed Special Queries** ** **PubMed.gov
- 	additional subject filters
**NIH Clinical Alerts & Advisories **www.nlm.nih.gov/databases/alerts

**Tools: NLM Resources**

**Notes:**
Things to look for in doing research {Thomas}

## RCA / FMEA Support, Evidenced - Based Medicine/Nursing (continued)
PubMed My NCBI Alerts 
tracked events/processes, keep current on research
PubMed My NCBI Collections 
save related and critical citations
Hazardous Substance Data Bank (HSDB)   toxnet.nlm.nih.gov    research toxicology issues
Radiation Event Medical Management 
remm.nlm.gov   focus on radiation events

**PubMed My NCBI Alerts**
- tracked events/processes, keep current on research
**PubMed My NCBI Collections**
- save related and critical citations
**Hazardous Substance Data Bank (HSDB)**   toxnet.nlm.nih.gov    research toxicology issues
**Radiation Event Medical Management **
- remm.nlm.gov   focus on radiation events

**Tools: NLM Resources**

## PubMed Search Strategies
MeSH Terms related to patient safety issues
Medical Errors including Diagnostic Errors, Medication Errors and Observer Variation
Disease Transmission, Professional-to-Patient
Safety including Safety Management
Patient Participation
Hospitalization including Length of Stay, Patient Admission, Patient Discharge, and Patient Transfer
Investigative Techniques including Drug Administration Routes and Equipment Safety

**MeSH Terms** related to patient safety issues
**Medical Errors **including Diagnostic Errors, Medication Errors and Observer Variation
**Disease Transmission, Professional-to-Patient**
**Safety **including Safety Management
**Patient Participation**
**Hospitalization** including Length of Stay, Patient Admission, Patient Discharge, and Patient Transfer
**Investigative Techniques **including Drug Administration Routes and Equipment Safety

**Tools: NLM Resources**

## PubMed Search Strategies
Health Literacy (under Special Queries)
“Patient Safety”  - note, using the phrase with quotes will turn off automatic term mapping
USE DETAILS to clean up the search
      Searching for patient safety now gives the result: ("patients"[MeSH Terms] OR "patients"[All Fields] OR "patient"[All Fields]) AND ("safety"[MeSH Terms] OR "safety"[All Fields])

**Health Literacy **(under Special Queries)
**“****Patient Safety”  **- note, using the phrase with quotes will turn off automatic term mapping
**USE DETAILS **to clean up the search
**      **Searching for patient safety now gives the result: ("patients"[MeSH Terms] OR "patients"[All Fields] OR "patient"[All Fields]) AND ("safety"[MeSH Terms] OR "safety"[All Fields])

**Tools: NLM Resources**

## Patient & Family Concerns
MedlinePlus medlineplus.gov
	general searches, patient safety page
Household Products Database hpd.nlm.nih.gov     toxicology issues
ClinicalTrials.gov clinicaltrials.gov
	current and previous studies
Drug Information Portal druginfo.nlm.nih.gov
	searches across NLM, NIH and FDA databases

**MedlinePlus** medlineplus.gov
- 	general searches, patient safety page
**Household Products Database **hpd.nlm.nih.gov     toxicology issues
**ClinicalTrials.gov** clinicaltrials.gov
- 	current and previous studies
**Drug Information Portal** druginfo.nlm.nih.gov
- 	searches across NLM, NIH and FDA databases

**Tools: NLM Resources**

## Patient & Family Concerns (continued)
ToxTown  toxtown.nlm.nih.gov 
	 toxicology geared for school children
Dietary Supplements Labels Database
	dietarysupplements.nlm.nih.gov  manufacturer labels
Senior Health  nihseniorhealth.gov 
	easy to navigate, for seniors and their care-givers
PubMed My NCBI  pubmed.gov 
	 set up alerts on topics of concern

**ToxTown  **toxtown.nlm.nih.gov
- 	 toxicology geared for school children
**Dietary Supplements Labels Database**
- 	dietarysupplements.nlm.nih.gov  manufacturer labels
**Senior Health  **nihseniorhealth.gov
- 	easy to navigate, for seniors and their care-givers
**PubMed My NCBI  **pubmed.gov
- 	 set up alerts on topics of concern

**Tools: NLM Resources**

## 
Library Connections     & Advocacy

**Library Connections     & Advocacy**

## 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.**

**Library Connections & Advocacy**

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

## How is Your Library 
Involved in Patient Safety
(or how will it be)?

**Involved in Patient Safety**
**(or how will it be)?**

**Library Connections & Advocacy**

## In Training & Education
Student Curriculum development
CME/CNE/CE requirements assistance 
Including patient safety when focusing on computer skills, EMB, searching, etc.
During orientation classes and introductions
On-line tutorials and resources preparation
In reference services, e.g. with patients and families, health professionals

- Student Curriculum development
- CME/CNE/CE requirements assistance
- Including patient safety when focusing on computer skills, EMB, searching, etc.
- During orientation classes and introductions
- On-line tutorials and resources preparation
- In reference services, e.g. with patients and families, health professionals

**Library Connections & Advocacy**

**Notes:**
In Training & Education (including CE and CME)
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

## With Literature Searches
Stat for Emergency Room
Nursing Education Department
Monthly Infection Control Reports
Drug Use and Clinical Adverse Events
Patient/Family Questions
Specifics Adverse Events, FMEAs, RCAs
Research Studies

- Stat for Emergency Room
- Nursing Education Department
- Monthly Infection Control Reports
- Drug Use and Clinical Adverse Events
- Patient/Family Questions
- Specifics Adverse Events, FMEAs, RCAs
- Research Studies

**Library Connections & Advocacy**

## Participation
On Patient Safety committees, teams and boards
Attending related M&Ms, councils, committees and meetings
(Hospitals:) On Rounds, providing RCA support
Connect and Educate
Safety Officers, Advocates and Directors
Executives: CEO, CNO, CME and others
Institutional leaders: Directors, Lawyers, Liaisons

- On Patient Safety committees, teams and boards
- Attending related M&Ms, councils, committees and meetings
- (Hospitals:) On Rounds, providing RCA support
**Connect and Educate**
- Safety Officers, Advocates and Directors
- Executives: CEO, CNO, CME and others
- Institutional leaders: Directors, Lawyers, Liaisons

**Library Connections & Advocacy**

**Notes:**
Visit nursing stations, departments & people - For example, put icons on nursing computers 

## Creating & Sharing Information
For Patient Education
Brochures, Flyers, Surveys
Supporting nurses and patient educators
In Telling Stories   
Of library involvement, institutional successes, individual joys or concerns
In Newsletters, on Blogs, with Articles, through the Intra- or Internet 

**For Patient Education**
- Brochures, Flyers, Surveys
- Supporting nurses and patient educators
**In Telling Stories****   **
- Of library involvement, institutional successes, individual joys or concerns
- In Newsletters, on Blogs, with Articles, through the Intra- or Internet

**Library Connections & Advocacy**

## Creating & Sharing Information
Through Alert Services
Recalls, Tables of Contents, Clinical Alerts, Drug Updates, Diseases and Treatments
Supporting Institutional Resources and Needs 
Balanced Score Card, Indicators, Legislation
Magnet Status, Joint Commission preparations
Policies, Procedures, Employee Handbooks

**Through Alert Services**
- Recalls, Tables of Contents, Clinical Alerts, Drug Updates, Diseases and Treatments
**Supporting Institutional Resources and Needs**** **
- Balanced Score Card, Indicators, Legislation
- Magnet Status, Joint Commission preparations
- Policies, Procedures, Employee Handbooks

**Library Connections & Advocacy**

## On the Website
Information Pages
On library contributions to patient safety
For patients and families
For advocates and liaisons
For health professionals and first responders
For students and researchers
For institutional leadership - executives, directors, managers, officers, and others
For those involved with legislation issues

**Information Pages**
- On library contributions to patient safety
- For patients and families
- For advocates and liaisons
- For health professionals and first responders
- For students and researchers
- For institutional leadership - executives, directors, managers, officers, and others
- For those involved with legislation issues

**Library Connections & Advocacy**

## On the Website
Current News
Evidence Based & Benchmarking information
Alerts – Clinical, Drug, Consumer, etc.
How the Institution is involved in patient safety; Institutional progress in specific areas
Patient Safety Campaigns
Legislation affecting the institution
(Hospitals:) Good Catch
Librarians making a difference

**Current News**
- Evidence Based & Benchmarking information
- Alerts – Clinical, Drug, Consumer, etc.
- How the Institution is involved in patient safety; Institutional progress in specific areas
- Patient Safety Campaigns
- Legislation affecting the institution
- (Hospitals:) Good Catch
- Librarians making a difference

**Library Connections & Advocacy**

**Notes:**
On the Website
Create Information Pages for patients and families, and for employees and health professionals
Include celebrations: “Good Catch”; System changes due to FMEA, other
Lift up Current News, for example recent evidence based research (and provide recent articles/reports), benchmarking information, alerts
Include availability of library/librarians
Include reporting resources

## And MORE:  
Health Fairs 
Mishap Mansion/Room of Horrors
Patient Safety Awareness Week
In the community
Assist at community affairs department projects
Accept speaking engagements
Serve as Community Liaison to professional advisory committees

**Health Fairs **
- Mishap Mansion/Room of Horrors
- Patient Safety Awareness Week
**In the community**
- Assist at community affairs department projects
- Accept speaking engagements
- Serve as Community Liaison to professional advisory committees

**Library Connections & Advocacy**

## 
And ....

**And ....**

**Library Connections & Advocacy**

## In Summary:

All of the roles of the library ultimately support Patient Safety

- Michelle Eberle, 2007

** **
**All of the roles of the library ultimately support Patient Safety**
**- Michelle Eberle, 2007**

**Library Connections & Advocacy**

## Holly Ann Burt, MLIS, MDiv

- Holly Ann Burt, MLIS, MDiv

**Available at:**
**http://nnlm.gov/training/patientsafety/**