1. Patients for Patient Safety M argaret Murphy, Patient Advocate External Lead Advisor Patients for Patient Safety WHO Patient Safety PRIMM LONDON 23 January 2015 Philadelphi a August, 2009 THE PATIENT EXPERIENCE AS A CATALYST FOR MEDICATION OPTIMIZATION In honour of those who have died, those who have been left disabled, our loved ones today, we will strive for excellence, so that all people receiving healthcare are as safe as possible, as soon as possible. This is our pledge of partnership

2. INTRODUCTION  The patient as a collaborative partner  Patient Autonomy  Patient Centred Care  WHO Patients for Patient Safety  Patient and Family as a constant in the continuum of care.  The Report Safety First 2006

3. Yesteryear vs Today  The patient expectation  Mystique vs blind faith  Patient responsibility and understanding of complexity of care  Report of Irish Commission Knowledgeable Patients receiving safe & effective care from skilled professionals in appropriate environments with assessed outcomes  Compliance, adherence, education of patients  Equipping and training professionals

4. THE PROCESS  The need for robust diagnosis  Deficits in consultation process  Patient Centred Care  The elderly patient – a personal experience  The elderly patient – a community experience.  Errors of commission and omission

5. FURTHER CONSIDERATIONS  Risks / Benefits  Supporting the patient o Written instructions and alerts o Reflective listening  Transition points and perceived discrepancies  Medication Reconciliation – a role for the patient?  Clinician role at transition points

6. AREAS FOR SPECIAL ATTENTION  The high-risk patient  When administering high-risk drugs  Patient Centred Care  Medication safety in psychiatry  Ethical issues – patient autonomy vs patient competence to decide  Untrained or inadequately trained personnel  Empowering/reassuring patient & family

7. CAUSES OF MEDICATION ERROR Leape, Bates, Cullen, et al JAMA 1995  Lack of knowledge about the drug  Lack of information about the patient  Violation of rules  Slips and memory lapses  Errors of transcription  Faulty checking of patient identity  Faulty interaction with other services (communication)  Faulty dose checking  Infusion pump problems  Inadequate patient monitoring  Drug stocking & delivery problems  Preparation errors  Lack of standardisation

8. CHALLENGES, INITIATIVES (Global and Local)  Responsibility and Accountability  Cultural shift  WHO – PS Curriculum & 3 rd Global Challenge  JCI and Medication Safety  Encouraging and Educating Patients  The role of the community pharmacist  A Danish example - An Irish example

9. ‘Let’s Talk Medication Safety’  The Basics: Why, Name, Dose, How often, How long, Side effects, Storage  Understanding your Medicine: Prescription, Over-the-counter, complementary, herbal, alternative  Names: Brand and Generic  Useful tips for safe use of medicine  Do and Don’t list  Following instructions  Storing  Tips for when admitted to hospital & questions to ask  Tips for when discharged & questions to ask  Keeping a medication list and what to include on that list.

10. More than anything, what distinguishes the great from the mediocre, is not so much that they fail less, it is that they rescue more. - Atul Gawande - A Resolution Going Forward -

11.  Disclosure = ?  Blame vs Integrity and Professionalism  Learning?  Preventing recurrence?  The burden of error  Respectful Management of Serious Clinical Events - IHI THE ACID TEST DISCLOSURE and the LIVED EXPERIENCE

12. Patients for Patient Safety The London Declaration - a vision statement for Patients for Patient Safety, written at 1 st PFPS workshop by patients and families from every region of WHO In honour of those who have died, those who have been left disabled, our loved ones today, we will strive for excellence, so that all people receiving healthcare are as safe as possible, as soon as possible. This is our pledge of partnership margaretmurphyireland@gmail.com “To err is human, to cover up is unforgivable but to fail to learn is inexcusable.” -Sir Liam Donaldson,Chair, WHO Patient Safety