When you are working on improving patient safety, what organizations come to mind?

Problem Multiple national organizations working on patient safety Can lead to duplicative efforts

Complicated Simple Complex Complexity Theory Simple – inputs and outputs are known; they can be managed by following a recipe or a set of rules Complicated – involve substantial uncertainties, the solutions may not be known, but they are potentially knowable. Once you figure it out, you can repeat the process. Complex – like raising a child; we may have a general sense of what works, the actual formula is unknowable. So people are complex. Our patients are complex. A treatment that may work for one patient may not work for another. Need to match our approaches to the types of problems at hand. Checklist, protocols to make sure to get the stupid stuff right. System where we follow the checklist but allow one to use their judgement. Create or facilitate conditions where things go right. Simple Gawande, Atul. The Checklist Manifesto: How To Get Things Right. New York, N.Y. : Metropolitan Books, 2010. Complex

Update on Joint Commission Patient Safety Initiatives Gerry Castro, PhD, MPH Project Director, Patient Safety Initiatives April 20th, 2018

National Patient Safety Collaborative

Purpose Bring together prominent patient safety organizations to collectively work on mutually identified safety concerns Doing something together that we were not able to do by ourselves

PSO, Illinois Hospital Association, AHRQ safety centers (UT southwest), CDC may need multiple representatives (maternal fetal medicine for example, Dan Budnitz) Government participation TBD: CMS, FDA, CDC

Identify mutual priority issues Pain management Health information technology Infusion pump safety

Pain management Non-pharmacological treatments Clinician education Patient engagement Patient assessment Discharge education ID and monitoring of patients at high risk Quality improvement Access to PDMP Opioid diversion Organizations are at different stages, “don’t know, what they don’t know” – determine how best to help

Prescribing habits are a contributing factor, but there are underlying environmental and societal causes for why people seek opioids Paint big picture of our role and what we can do about it. Reframing the opioid the crisis as an overarching societal complex problem of which health care community has specific area to address.

Initial users/acute pain Dependent but functional Addicted Abuse, drug seeking behavior The group will focus on the consideration of the “first prescription” with special attention to the assessment that precedes it. The group felt to define this as a patient safety concern and to provide resources to help clinicians, patients and organizations to make the best decision possible.

And that’s only the first issue…

Infusion pump safety What are your top 3 concerns?

Thank you! gcastro@jointcommission.org