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

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

3. 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

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

5. National Patient Safety Collaborative

6. 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

7. 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

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

10. 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

11. 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.

12. 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.

13. And that’s only the first issue…

14. Infusion pump safety
What are your top 3 concerns?

15. Thank you!