1. Patient Safety Resources Seminar Part II - Resources

2. 2 Goal of Patient Safety to identify and eliminate errors

3. 3 Addressing Patient Safety Legislation Research Recognition Education Patient Involvement Library Connections & Advocacy

4. 4 Legislation title slide Legislation

5. 5 Legislating Patient Safety Consumer Product Safety Act 1972 Safe Medical Device Amendments 1990 National Literacy Act 1991 HIPAA 1996 Healthcare Research and Quality Act 1999 Patient Safety and Quality Improvement Act 2005 Health Care Safety Net Act 2008 American Recovery and Reinvestment Act 2009 (HITECH) Affordable Care Act 2010

6. 6 Legislation Issues Malpractice regulations – NOT patient safety; often considered so by media Mandatory patient notification – 11 states require patients be notified of adverse events Nurse Staffing – Nurse to patients staffing ratios: CA in 1999 – Restricted/Regulated mandatory overtime: 17 states Mandated Patient Safety Officers – 5 states require this position, 1 for a voluntary program

7. 7 Federal & State Legislation Reporting Agencies – Patient Safety and Quality Improvement Act of 2005 – Departments of Health began collecting reporting information and/or providing educational materials – 81 Patient Safety Organizations (PSOs) in 28 states and the District of Columbia ( http://www.pso.ahrq.gov) Electronic Health Records (EHRs) (http://www.healthit.gov) – Medicare Prescription Drug Act 2003 – American Recovery and Reinvestment Act of 2009 (ARRA), Title XIII: Health Information Technology for Economic and Clinical Health Act (HITECH Act) – Incentives for installing EHR systems

8. 8 State Reporting Systems See: http://www.nashp.org/patient-safety-toolkit/ and http://www.qups.org

9. 9 State Apology /“I’m Sorry” Laws See: http://www.qups.org/, http://www.sorryworks.net/apology-laws-cms-143, and http://www.emreportcard.org/

10. 10 States with Prescription Drug Monitoring Programs See America’s Emergency Care Environment, A State by State Report Card, 2014 edition http://www.emreportcard.org/

11. 11 Legislation Resources I America’s Emergency Care Environment http//www.emreportcard.org Congress.gov – Library of Congress legislative information Health Information and the Law – George Washington University http://www.healthinfolaw.org/topics/61 National Academy for State Health Policy http://www.nashp.org National Conference of State Legislatures http://www.ncsl.org QuPS.org – states’ policy and initiatives (only through 2012) USA.gov – links to state legislatures

12. 12 Legislation Resources II Patient Safety Organizations (AHRQ approved) http://www.pso.ahrq.gov/ Health professional organizations Patient Safety Coalitions – Local and state coalitions and organizations, plus specialized groups for patients and/or health professionals, are continuously forming State/Federal organizations with patient safety sections, components or initiatives (e.g. departments of health and AHRQ.gov)

13. 13 Research Research title slide

14. 14 Research Patient Safety Funding – Government: Agency for Healthcare Research and Quality (AHRQ), National Institutes of Health, National Institute of Nursing Research, National Science Foundation, Grants.gov – Non-Profit/Private foundations: Commonwealth Fund, National Patient Safety Foundation, Robert Wood Johnson Foundation – Other agencies: Centers for Medicare and Medicaid Services through the Affordable Care Act funding

15. 15 Research Resources Health Services Research Projects in Progress – NLM HSRProj: http://www.nlm.nih.gov/hsrproj/ Information databases – Public: Joint Commission Sentinel Event Statistics, Medicare Compare (hospital, physician, etc.) – Member: Quantros MedMarx, MedSun – Private: HealthGrades Article sources – PubMed.gov & pubmedcentral.gov

16. 16 Recognition title slide Recognition Librarians can offer support in processes and suggest new opportunities

17. 17 Certificates/Degrees University offered Programs (in person and online) – Patient Safety Certificate: University of Wisconsin-Madison http://www.engr.wisc.edu/ie/current/patientsafety/ – Master of Patient Safety: MCPHS Online https://online.mcphs.edu/programs/patient%20safety%20mps – Patient Safety Leadership: University of Illinois at Chicago http://psl.scs.uic.edu/ Additional Sources – Certification in Health Care Quality and Management: ABQAURP: http://www.abqaurp.org – Quality and Patient Safety Certificate: Harvard Quality Colloquium: http://www.qualitycolloquium.com/certificate.html

18. 18 Education/Certification Medical Education (ACGME) – Milestones with patient safety requirements Recertification requiring patient safety topics – Physicians in FL and PA – Pharmacists in DC, FL, HI, NY, OR, and PA Other professional certifications – Safety Mangers, Patient Safety Officers, Healthcare Safety Professionals (IBFCSM) – Patient Safety Professionals (NPSF)

19. 19 Accreditation The Joint Commission – National Patient Safety Goals (NPSGs) o Identify safety risks inherent in patient population (Goal #15) o Patient’s rights including the right to receive understandable information (RI Standards) o Universal Protocols – Sentinel Events o Support for required Root Cause Analysis’ Healthcare Facilities Accreditation Program (HFAP)

20. 20 Awards AHA-McKesson Quest for Quality Prize http://www.aha.org/about/awards/q4q/ AHTF-ACCE Marvin Shepherd Patient Safety Award http://thehtf.org/shepherd.asp ANCC Magnet Recognition Program http://www.nursecredentialing.org/Magnet.aspx ISMP Cheers Award http://www.ismp.org/Cheers/ NIST Malcolm Baldrige National Quality Program http://www.nist.gov/baldrige/ NQF John M. Eisenberg Award for Patient Safety and Quality http://www.qualityforum.org/eisenberg_award/

21. 21 Education title slide Education

22. 22 Add Patient Safety Issues In Training & Education – Morning report – 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

23. 23 Lift up Patient Safety Topics Health literacy – Appropriate cultural references, understandable language State and federal legislation – Requirements for reporting, health records, insurance Accreditation/Certification – Requirements and changes from The Joint Commission, national associations Evidence based – medicine, nursing, practice; guidelines Error types and definitions – Human mistakes (e.g. diagnosis, slips), system errors Patient advocacy

24. 24 Share in Programs Approaches to change – Root Cause Analysis (RCA) – Retrospective – Failure Modes and Effects Analysis (FMEA) – Prospective – Human Factors and Systems Engineering – Human abilities/characteristics affecting design/operation – LEAN / Six Sigma – Identify value and measure flow – Probabilistic Risk Analysis (PRA) – Examine processes starting with outcomes

25. 25 Share Tools Communication Tools – Crew Resource Management (CRM), – Situation-Background-Assessment- Recommendation (SBAR) – Patient/Problem, Assessment/Actions, Continuing/Changes, Evaluation (PACE) Tool Sources – AHRQ: Data infographics, quality databases, measurement resources, PSNET, WebM&M – CDC: Latest news, public heath materials

26. 26 Offer Opportunities II Web-based education – including CE/CME/CNE Alerts options – ISMP, FDA, AORN, My NCBI, NIH, WHO Specialized newsletters – Device safety, anesthesia, Sorry Works! Discussion lists and forums – Medication Safety Officers Society (http://www.asmso.org/) Blogs, Facebook, Tweets, Videos – Rants of a Patient Safety Advocate: http://patientsafetyadvocate.blogspot.com – Wachter’s world: http://community.the-hospitalist.org

27. 27 Make Connections For those experiencing medical error – Patients and families o P.U.L.S.E.: http://www.pulseamerica.org/ o Consumers Advancing Patient Safety (CAPS) http://www.patientsafety.org – Medical professionals o Medically Induced Trauma Support Services (MITSS) http://www.mitss.org/ o Sorry Works! Coalition http://sorryworks.net/ For Patient Education – Supporting nurse and patient educators – Brochures, flyers, surveys

28. 28 Patient Safety MeSH Terms PubMed MeSH related to patient safety issues – Iatrogenic Disease – Disease Transmission, Professional-to-Patient – Drug Administration Routes – Hospitalization (includes Length of Stay, Patient Admission, Patient Discharge, and Patient Transfer) – Investigative Techniques (includes Equipment Safety) – Medical Errors (includes Diagnostic Errors, Medication Errors and Observer Variation) – Also: Patient Participation, Patient Harm, Patient Safety, and Risk Management

29. 29 PubMed Searching Tips USE DETAILS to clean up a search – E.g. searching for patient safety gives the result: ("patient safety"[MeSH Terms] OR ("patient"[All Fields] AND "safety"[All Fields]) OR "patient safety"[All Fields]) – Delete: ("patient"[All Fields] AND "safety"[All Fields]) Health Literacy – Find this search term under the Topic-Specific Queries link “Patient Safety” – Using the phrase with quotes will turn off automatic term mapping, only articles using this specific phrase will be found

30. 30 Professional Development Conferences/Seminars/Workshops – NPSF, AHRQ, medical associations, coalitions Books, Journals, Newsletters – Quality Chasm series http://www.nap.edu/ – Patient Safety and Quality Healthcare http://www.psqh.com/ Podcasts and Videos – Drug Safety Podcasts (FDA) http://www.fda.gov/Drugs/DrugSafety/DrugSafetyPodcasts/ – Healthcare 411 http://www.healthcare411.ahrq.gov/

31. 31 Patient Involvement title slide Patient Involvement

32. 32 The Patient in Patient Safety The Agency for Healthcare Research and Quality (AHRQ) is one of several organizations with a section of their website focused on resources for patients and family members Patient advocates (often starting with their own experiences) have created advocacy organizations and written books to help others

33. 33 What Each Patient Can Do Individual Advocacy – In doctor & hospital visits – Share information Create a Personal Health Record or keep 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

34. 34 Support a Patient as an Advocate Patient Advocate – For friends and family – Go with the patient to appointments, be with them in the hospital and clinics – Listen and take 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.

35. 35 Represent the Patient Perspective Patient Advocacy – In health care organizations – Learn about the broader issues of patient safety – Work to improve safety at the organization and individual unit level – Serve on committees and boards, ex. Patient Safety Advisory Committee – Assist on rounds (still rare) – Support staff and families – Become a Patient Representative

36. 36 Become Involved Patient 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

37. 37 Patient Resources I Questions To Ask Your Doctor [before, during and after your appointment] (AHRQ) http://www.ahrq.gov/patients-consumers/patient- involvement/ask-your-doctor/ Speak Up Initiatives (and brochures) http://www.jointcommission.org/speakup.aspx Talking with your doctor: a guide for older people (NIA) https://www.nia.nih.gov/health/publication/talking-your-doctor/ We Care about Your Safety (video) http://www.emmisafety.com/ashrm/Emmi.html

38. 38 Patient Resources II Become more familiar with the medicine you take (ISMP) http://www.consumermedsafety.org/ How to Create a Pill Card (AHRQ) http://www.ahrq.gov/patients-consumers/diagnosis- treatment/treatments/pillcard/ Medicines and You: a guide for older adults (FDA) http://www.fda.gov/Drugs/ResourcesForYou/ucm163959.htm Personal Health Records (NLM) https://www.nlm.nih.gov/medlineplus/personalhealthrecords.html

39. 39 NLM Patient Resources II ClinicalTrials.gov – http://clinicaltrials.gov Drug Information Portal – http://druginfo.nlm.nih.gov Genetics Home Reference – http://ghr.nlm.nih.gov Household Products Database – http://hpd.nlm.nih.gov MedlinePlus – http://medlineplus.gov NIH Senior Health – http://nihseniorhealth.gov Pillbox – http://pillbox.nlm.nih.gov PubMed – http://pubmed.gov Tox Town – http://toxtown.nlm.nih.gov

40. 40 Additional Resource Examples Advocacy Organizations – CAPS, Empowered patient, PULSE Conferences incorporating patient input – NPSF, Local coalitions Medical Error Support – MITSS, PULSE Research and Government Sites – AHRQ, CDC, NLM Reporting Errors – FDA, ISMP

41. 41 Library Connections & Advocacy title slide Library Connections and Advocacy

42. 42 Librarian’s Critical Role Dr. Robert Wachter: So, a medical school librarian set off the modern patient safety movement? Lucian Leape, MD: Ergo, there we go. Wachter R. In conversation with Lucian Leape, MD. WebM&M. 2006(Aug): Perspectives on Safety. http://webmm.ahrq.gov/perspective.aspx?perspectiveID=28

43. 43 Library Connections & Advocacy How is Your Library Involved in Patient Safety (or how will it be)? Hint: Start where you are!

44. 44 Share Information I Traditional Library Services – Reference materials: digital and print – Just in time: Stat for emergency room – Respond to questions raised on rounds or in committees – Answer patient and family questions – Literature searches for o Drug use and clinical adverse events o For specific adverse events, FMEAs, and RCAs o Research studies or questions

45. 45 Reach Out with Information Alert and Advisory Services – Recalls (e.g. FDA Drug recalls) – Tables of contents (e.g. through PubMed My NCBI) – Clinical Alerts – Drug updates – Infection control reports – Disease pandemics – New treatments

46. 46 Services Make a Difference Value of Library and Information Services in Patient Care Study – A study to understand the value of the health library, information services and the librarian; Partnership of the National Network of Libraries of Medicine Middle Atlantic Region and the University of North Carolina at Chapel Hill – Read Marshall JG, Sollenberger J, Easterby ‐ Gannett S, et al. The value of library and information services in patient care: Results of a multi ‐ site study. Journal of the Medical Library Association 2013 Jan;101(1):39 ‐ 46. PMID: 23418404

47. 47 Become (as) Plugged In (as you can) Participate – On patient safety committees, patient family advisory boards, quality and risk-oriented teams – On rounds, RCA/FMEA task forces – In morbidity and mortality conferences, journal clubs, medication safety councils Connect and Educate – Safety officers, Advocates and Directors – Executives: CEO, CNO, CME – Institutional leaders: Directors, Lawyers, Liaisons

48. 48 Support Your Institution Connect to Programs – Policies, procedures, employee handbooks – Balanced Score Card, Quality Indicators – Electronic Health Records (EHR/EMR/PHR) (MedlinePlus Connect) – Patient Educators, Consumer support – Magnet Status/Joint Commission preparations – Annual reports, special reports

49. 49 Consider Information Pages Address Issues and Needs – 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

50. 50 Lift up the News Bring it all together – Evidence based resource, benchmarking information, statics – Alerts: clinical, drug, consumer, etc. – Institution involvement in patient safety o Progress in specific areas o Patient safety campaigns and programs – National legislation, professional requirements – National and international events

51. 51 Share and Celebrate Help Tell the Story – Programs: Institutional successes o Good Catch programs o Safety Awards and those who earned them o Patient experience and satisfaction reports – Individual stories – Methods: Speak up o Newsletters, Blogs, Tweets, even write articles Don’t forget to include: Librarians making a difference

52. 52 Continue to Reach Out Health Fairs – Mishap Mansion/Room of Horrors Special days/weeks – National Time Out Day, Patient Safety Awareness Week In the community – Assist at community affairs department projects – Partner with other libraries, especially public – Serve as Community Liaison to professional advisory committees

53. 53 AND…

54. 54 In Summary All of the roles of the library ultimately support Patient Safety - Michelle Eberle, 2007

55. Patient Safety Resource Seminar: Librarians on the Front Lines Holly Ann Burt, MLIS, MDiv Available at: http://nnlm.gov/training/patientsafety