2. Patient Safety An Overview

3. Patient Safety is freedom from injury or illness resulting from the processes of healthcare NQF 2001

4. Patient Safety Healthcare Errors Are The Top Worry Of Patients --The National Forum for Healthcare Quality

5. Driving Forces For Patient Safety n at least 44,000 and perhaps as many as 98,000 deaths per year related to medical errors n the lowest estimate exceeds the number attributable to the 8th leading cause of death n medication errors account for 1 0f 854 inpatient hospital deaths, and 1 of 131 outpatient deaths The Institute Of Medicines Report: To Err Is Human Source:http://www4.nationalacademies.org/iom/iomhome.nsf

6. Driving Forces For Patient Safety Leapfrog Groups-Large corporations/employers contracting for healthcare with patient safety incentives Private/public entities-ISMP, NPSF, AHQR, NQF

7. Driving Forces for Patient Safety Regulatory bodies--HCFA, JCAHO JCAHO –Sentinel Event Policy mid 1990s –New Standards Effective July 1, 2001 –Patient Safety Goals, 2003/2004 HCFA –New QA/PI Condition of Participation, March 03

8. Driving Forces for Patient Safety The New Consumer n Well informed n Well Educated n Has Quality Expectations

9. The Call to Action! Healthcare is a decade or more behind other high-risk industries in its attention to ensuring basic safety. Aviation has focused on building safe systems …since WW II. Between 1990 and 1994, the U.S. Airline fatality rate was one-third the rate experienced in mid century. In 1998, there were no deaths in the U.S. in commercial Aviation. -- To Err Is Human (IOM)

10. Why do errors happen? n Accidents are a form of information about a system. n Health care services is a complex and technological industry prone to accidents n When large systems fail, it is due to multiple faults that occur together n Errors are due most often to the convergence of multiple contributing factors -- To Err Is Human (IOM)

11. Healthcare Errors Most Likely to Occur When: n Many and varied interactions with technology n Many individuals involved in care; multiple handoffs for care n High acuity of illness or injury n Environment prone to distraction n Need for rapid decisions; time-pressured n High volume, unpredictable patient flow --NQF

12. Creating a Culture of Safety n Acknowledge high-risk, error prone nature of modern healthcare n Widespread shared acceptance of responsibility for risk reduction n Encourage open communication about safety concerns in a non- punitive environment, facilitating reporting of errors and safety concerns n Learn from errors n Embrace accountability for patient safety n Implement known safe practices --NQF 2001

13. Patient Safety What healthcare professionals can do: Report errors, near-misses and unsafe practices Adopt and blend proven safe practices into your daily routines. Familiarize yourself with current topics in patient safety

14. Patient Safety Websites of interest: ISMP--Institute for Safe Medication Practices (ismp.org) NQF--National Forum for Healthcare Quality Measurement and Reporting (qualityforum.org) AHRQ--Agency for Healthcare Research and Quality (ashq.gov) NPSF--National Patient Safety Foundation (npsf.org )

15. Patient Safety Patient Safety Must Be Our # 1 Priority