1. Patient Safety Resource Seminar Part II - Resources

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

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

4. 4 Legislation title slide Legislation

5. 5 State Legislation I Malpractice regulations Mandatory and/or voluntary reporting – Some form of reporting (adverse events, hospital acquired infections, etc.) in 43 states plus DC Mandatory patient notification – 11 states require patients be notified of adverse events Apologies permitted – 35 states plus DC have enacted apology laws excluding expressions of sympathy as an admission of liability Visit: http://www.nashp.org/pst-nashp, http://www.qups.org/ and http://www.sorryworks.net/

6. 6 Federal & State Legislation Patient Safety Officers mandated – Point of contact in the hospital, report events, and coordinate activities to provide safety to patients – 5 states require this position, 1 for a voluntary program – Patient Safety Officers are found in most states and several countries Reporting Agencies established – Federal Patient Safety and Quality Improvement Act of 2005 – Departments of Health began collecting reporting information and/or providing educational materials – 76 Patient Safety Organizations (PSOs) in 30 states and the District of Columbia - http://www.pso.ahrq.gov/ http://www.pso.ahrq.gov/

7. 7 State Legislation II Staffing Issues – Nurse to patients staffing ratios: CA in 1999 – Restricted/Regulated mandatory overtime for nurses: 16 states Pharmaceutical laws – 36 states and DC starting in MN in 1993 – Safety topics include electronic prescription requirements; regulations on forms, labels or packaging; legibility issues; internet sales; and reporting rules – 41 state if reuse/recycling is included

8. 8 Federal Legislation Electronic Prescription and Health Records Programs – Medicare Prescription Drug Act 2003 – American Recovery & Reinvestment Act of 2009 – The Patient Protection & Affordable Care Act of 2010 and Health Care & Education Reconciliation Act of 2010 (Affordable Care Act) o Health Information Technology for Economic and Clinical Health Act (HITECH Act)

9. 9 Legislation Resources I Library of Congress legislative information http://thomas.loc.gov/ National Academy for State Health Policy Patient Safety Toolbox http://www.nashp.org/pst-nashp National Conference of State Legislatures http://www.ncsl.org/ QuPS.org – states’ public and private policy / initiatives USA.gov – links to state legislatures

10. 10 Legislation Resources II Health professional organizations Patient Safety Organizations Patient Safety Coalitions – Local and state coalitions and organizations, plus specialized groups for patients and/or health professionals, are continuously forming – 19 coalitions formed since 1997 State/Federal organizations with patient safety sections, components or initiatives

11. 11 Research Research title slide

12. 12 Research Patient Safety Grants – Government: Agency for Healthcare Research and Quality (AHRQ), US HHS, 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: Blue Cross/Blue Shield

13. 13 Research Resources Health Services Research Projects in Progress – NLM HSRProj: http://www.nlm.nih.gov/hsrproj/ Informational databases – public: Joint Commission Sentinel Events, HHS Hospital Compare – member: Quantros/MedMarx, MedSun – private: HealthGrades Article sources – PubMed.gov & PubMedCentral.gov

14. 14 Recognition title slide Recognition

15. 15 Recognition: Accreditation Hospitals and Health Centers – Joint Commission Requirements o Encourage patients’ active involvement in their own care as a patient safety strategy (Standards) o The organization identifies safety risks inherent in its patient population (National Patient Safety Goal #15) o Support information needs for other goals http://www.jointcommission.org/standards_information/npsgs.aspx – Sentinel Events o Support for required Root Cause Analysis’ http://www.jointcommission.org/sentinel_event.aspx

16. 16 Recognition: Certification Health professionals - recertification requirements include patient safety topics – Doctors in FL and PA – Pharmacists in FL, HI and NY Students and residents - required to take patient safety courses – New York Medical College – Hospital residency programs ACGME standard - 80-hour work week

17. 17 Recognition: Degrees Graduate Certificate – University of Wisconsin-Madison http://www.engr.wisc.edu/ie/current/patientsafety/ Masters Degree – Thomas Jefferson University http://www.jefferson.edu/population_health/quality_safety/ – University of Illinois http://www.uic.edu/orgs/online/patient-safety-leadership/ Additional Certificate Programs – ABQAURP http://www.abqaurp.org/certification.asp – Harvard Quality Colloquium http://www.qualitycolloquium.com/certificate.html

18. 18 Recognition: Awards NIST Malcolm Baldrige National Quality Program http://www.nist.gov/baldrige/ Joint Commission John M. Eisenberg Award for Patient Safety and Quality http://www.jointcommission.org/topics/eisenberg_award.aspx ANCC Magnet Recognition Program http://www.nursecredentialing.org/Magnet.aspx AHA-McKesson Quest for Quality Prize http://www.aha.org/about/awards/q4q/ ISMP Cheers Award http://www.ismp.org/Cheers/ AHTF-ACCE Marvin Shepherd Patient Safety Award http://thehtf.org/shepherd.asp

19. 19 Patient Involvement title slide Patient Involvement

20. 20 Patient Involvement: Campaign AHRQ’s has created online videos and public service announcements for TV and radio Use the “Build Your Question List” to prepare for medical appointments www.ahrq.gov/questions/

21. 21 Patient Involvement: Personal 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

22. 22 Patient Involvement: Advocate 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.

23. 23 Patient Involvement: Representative 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

24. 24 Patient Involvement: Activist 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

25. 25 Patient Involvement Resources I 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 – Before Your Appointment http://www.ahrq.gov/questions/beforeappt.htm – Speak Up Initiatives (and brochures) http://www.jointcommission.org/speakup.aspx – We Care about Your Safety (video) http://www.emmisafety.com/ashrm/Emmi.html

26. 26 Patient Involvement Resources II Online Information – Check Your Medicines: Tips for Using Medicines Safely http://www.ahrq.gov/consumer/checkmeds.htm – Personal Health Records http://www.nlm.nih.gov/medlineplus/personalhealthrecords.html – Medicines and You: A Guide for Older Adults http://www.fda.gov/Drugs/ResourcesForYou/ucm163959.htm – Where Medical Errors Occur and Steps You Can Take to Avoid Them http://www.ahrq.gov/consumer/cc/cc121807.htm

27. 27 Patient Involvement Resources III 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

28. 28 Education title slide Education

29. 29 Education: Teaching Topics Health literacy – Easy to read, Language appropriate Legislation Accreditation/Certification requirements – Joint Commission changes Evidence Based Medicine/Nursing, Research Based Practice Consumer resources & advocacy

30. 30 Education: Opportunities I 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 Education: Opportunities II Web-based education including CE/CME/CNE Alert services ISMP, FDA, AORN, My NCBI, NIH, WHO Email Discussions ─ NPSF Patientsafety-L http://www.npsf.org/psf/ ─ American Society of Medication Safety Officers http://www.asmso.org/ Blogs and Wikis ─ Joint Commission WikiHealthCare TM http://wikihealthcare.jointcommission.org / ─ Blogs for Hospital Librarians http://mla-hls.wikispaces.com/Blogs

32. 32 Education: Connections For those experiencing medical error Patients and families ─ P.U.L.S.E. http://www.pulseamerica.org/ ─ 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/

33. 33 Tools title slide Tools

34. 34 Tools: Examining Events I Root Cause Analysis (RCA) – 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

35. 35 Tools: Examining Events II 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

36. 36 Tools: Resources 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 Quality Indicators www.qualityindicators.ahrq.gov Consulting agencies ( Concerning Joint Commission, focusing on processes, in-house training) – Joint Commission Resources www.jcrinc.com

37. 37 Tools: NLM Resources I RCA / FMEA Support, Evidenced-Based Medicine/Nursing – PubMed PubMed.gov search for events and/or processes – PubMed Clinical Queries identify related reviews – PubMed Topic-Specific Queries additional subject filters – NIH Clinical Alerts & Advisories www.nlm.nih.gov/databases/alerts

38. 38 Tools: NLM Resources II RCA / FMEA Support, Evidenced-Based Medicine/Nursing (continued) – PubMed My NCBI Alerts track 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

39. 39 Tools: PubMed I PubMed Search Strategies – MeSH Terms related to patient safety issues o Disease Transmission, Professional-to-Patient o Drug Administration Routes o Hospitalization (includes Length of Stay, Patient Admission, Patient Discharge, and Patient Transfer) o Investigative Techniques (includes Equipment Safety) o Medical Errors (includes Diagnostic Errors, Medication Errors and Observer Variation) o Patient Participation o Patient Safety (or the broader term Safety)

40. 40 Tools: PubMed II PubMed Search Strategies (continued) – USE DETAILS to clean up a search E.g. searching for patient safety gives the result: ("patients"[MeSH Terms] OR "patients"[All Fields] OR "patient"[All Fields]) AND ("safety"[MeSH Terms] OR "safety"[All Fields]) – Health Literacy – find 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

41. 41 Tools: NLM Patient Resources I Patient and Family Concerns – MedlinePlus - medlineplus.gov general searches, patient safety page – Drug Information Portal - druginfo.nlm.nih.gov searches across NLM, NIH and FDA databases – Pillbox - pillbox.nlm.nih.gov identify unknown pills by color, shape, etc. – Dietary Supplements Labels Database - dietarysupplements.nlm.nih.gov including label ingredients – NIH Senior Health - nihseniorhealth.gov information for seniors and their care givers

42. 42 Tools: NLM Patient Resources II Patient and Family Concerns (continued) – Genetics Home Reference - ghr.nlm.nih.gov study genetic conditions and the responsible genes – ClinicalTrials.gov - clinicaltrials.gov current and previous studies – Household Products Database - hpd.nlm.nih.gov health and safety information – Tox Town - toxtown.nlm.nih.gov toxicology geared for school children – PubMed - pubmed.gov journal article citation database

43. 43 Library Connections & Advocacy title slide Library Connections & Advocacy

44. 44 Advocacy: 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

45. 45 Library Connections & Advocacy How is Your Library Involved in Patient Safety (or how will it be)?

46. 46 Advocacy: Start Where You Are 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

47. 47 Advocacy: Education 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

48. 48 Advocacy: Reach Out 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

49. 49 Advocacy: Focused Service I 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 Electronic Health Records (MedlinePlus Connect)

50. 50 Advocacy: Focused Service II 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

51. 51 Advocacy: Intra-/Internet I 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

52. 52 Advocacy: Intra-/Internet II 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

53. 53 Advocacy: Outreach I And MORE: – Health Fairs Mishap Mansion/Room of Horrors Patient Safety Awareness Week – In the community Assist at community affairs department projects Partner with other libraries Serve as Community Liaison to professional advisory committees

54. 54 Advocacy: Outreach II And ….

55. 55 Library Connections & Advocacy In Summary: All of the roles of the library ultimately support Patient Safety - Michelle Eberle, 2007

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