Patient Safety Resource Seminar Part II - Resources
<ul><li>to identify  </li></ul><ul><li>and eliminate  </li></ul><ul><li>errors </li></ul>Goal of Patient Safety:
Addressing Patient Safety <ul><li>Legislation </li></ul><ul><li>Certification/Accreditation/Recognition </li></ul><ul><li>...
Federal & Provincial Legislation <ul><li>Malpractice regulations </li></ul><ul><li>Adverse Reaction Reporting  </li></ul><...
Federal & Provincial Legislation <ul><li>Disclosure </li></ul><ul><ul><li>Patient notification of adverse events  </li></u...
Federal & Provincial Legislation <ul><li>Canadian Patient Safety Institute  </li></ul><ul><li>Potential regulations </li><...
Legislation Resources <ul><li>Department of Justice  </li></ul><ul><ul><li>Justice Laws Web Site  http://laws.justice.gc.c...
Accreditation <ul><li>Hospitals and Health Centers </li></ul><ul><ul><li>CCHSA Patient Safety Goals & ROPs </li></ul></ul>...
Certification <ul><li>Health professionals:   </li></ul><ul><ul><li>recertification requirements to include patient safety...
Recognition Programs <ul><li>CRPNBC  Awards of Excellence </li></ul><ul><li>MOHLTC  Innovation Awards </li></ul><ul><li>CC...
Research <ul><li>Patient Safety Grants </li></ul><ul><ul><li>Federal, Regional, Local </li></ul></ul><ul><ul><ul><li>CHSRF...
Research Resources <ul><li>Health Services Research Projects   in Progress   </li></ul><ul><ul><li>HSRProj:  http://www.nl...
Education Opportunities <ul><li>Conferences/Seminars/Workshops </li></ul><ul><ul><li>National & Regional, Medical associat...
Education Topics <ul><li>Health literacy </li></ul><ul><ul><li>Easy to read </li></ul></ul><ul><ul><li>Language appropriat...
Communication Resources <ul><li>Listservs </li></ul><ul><ul><li>NPSF, JC-ICPS </li></ul></ul><ul><li>Websites  </li></ul><...
Support Agencies  <ul><li>For those experiencing medical error   </li></ul><ul><ul><li>Patients and families </li></ul></u...
<ul><li>RCA – Root Cause Analysis  </li></ul><ul><ul><li>Examining events </li></ul></ul><ul><li>Failure Modes and Effects...
<ul><li>Human Factors Engineering  </li></ul><ul><ul><li>Human abilities/characteristics affecting design/operation  </li>...
<ul><li>Software </li></ul><ul><ul><li>EMR, bar-coding, RCA  </li></ul></ul><ul><li>Consulting agencies </li></ul><ul><ul>...
<ul><li>RCA / FMEA Support </li></ul><ul><ul><li>PubMed   </li></ul></ul><ul><ul><ul><li>search for similar events and/or ...
<ul><li>RCA / FMEA Support  (continued) </li></ul><ul><ul><li>PubMed Clinical Queries   </li></ul></ul><ul><ul><ul><li>ide...
<ul><li>Evidenced - Based Medicine/Nursing </li></ul><ul><ul><li>PubMed  </li></ul></ul><ul><ul><li>general citation searc...
<ul><li>Patient & Family Concerns </li></ul><ul><ul><li>MedlinePlus   </li></ul></ul><ul><ul><li>general searches, patient...
<ul><li>How is Your Library  </li></ul><ul><li>involved in Patient Safety </li></ul><ul><li>(or how will it be)? </li></ul...
<ul><li>In Training & Education </li></ul><ul><ul><li>Student Curriculum  </li></ul></ul><ul><ul><ul><li>Pharmacy </li></u...
<ul><li>With Reference Services </li></ul><ul><ul><li>Literature Searches </li></ul></ul><ul><ul><ul><li>Stat for Emergenc...
<ul><li>With Reference Services </li></ul><ul><ul><li>Alerts </li></ul></ul><ul><ul><ul><li>Recalls </li></ul></ul></ul><u...
<ul><li>On the Website </li></ul><ul><ul><li>Information Pages </li></ul></ul><ul><ul><ul><li>For patients and families </...
<ul><li>Beyond the Library </li></ul><ul><ul><li>In the hospital </li></ul></ul><ul><ul><ul><li>Safety Fairs and programs ...
<ul><li>In Summary: </li></ul><ul><li>All of the roles of the library ultimately support Patient Safety </li></ul><ul><li>...
Patient Safety Resource Seminar:  Librarians on the Front Lines Holly Ann Burt ,  MLIS, MDiv Available at: http://nnlm.gov...
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  • Adverse Reactions Reporting mandatory for companies, voluntary for health professionals {Health Canada} Mandatory/Voluntary Reporting - Patients want disclosure, to know what happened, how consequences will be mitigated, how reoccurrences will be prevented {Gallagher} SK, MB, ON, QC {Hoffman, OHA} BCAS - British Columbia Anesthesiologists’ Society Critical Incident Reporting Service (CIRS) {Merchant} Studies in Canada {Health Canada}
  • Disclosure is “absolutely the right thing to do.” {Pinker} Position statements {CPSI, under Additional Patient Safety Resources in the Resource List } Patient notification {CPSI, Hoffman} Guidelines/Policies {CPSI, OHA, under Additional Patient Safety Resources in the Resource List } Apology - States ... have enacted laws excluding expressions of sympathy (e.g., “I’m sorry that you are hurt”) after accidents as proof of liability. {Cohen} Liability - BC {Merchant}
  • CPSI {NPCPS} Possibilities Staffing {Ellis} Overtime {SEIU} Work-week {ACGME}
  • Where libraries can intersect with accreditation rules CCHSA Patient Safety Goals &amp; ROPs {CCHSA} CCHSA 2007 Performance Measures {CCHSA}
  • Health Professionals Doctors: every 2 yr - FL 2 hrs, PA 12 hrs {AMA} Students/Residents Medical Schools – Queens University Undergraduate School of Medicine Phase III {Gibson} Residency requirements 2005-2008 PAIRO-CAHO Agreement {PAIO}
  • CRPNBC - http://www.crpnbc.ca/ MOHLTC - http://mohexpoform.innovasium.com/ CCHSE/CCDSS - http://www.cchse.org/default_awards.asp?active_page_id=53 OHA - http://www.oha.com/client/OHA/OHA_LP4W_LND_WebStation.nsf/page/Patient+Safety+Awards WRHA - http://www.wrha.mb.ca/healthinfo/patientsafety/files/2007CallforSubmissions.pdf
  • Canadian CHSRF/FCRSS: http://www.chsrf.ca/funding_opportunities/ CIRH/IRSC: http://www.cihr-irsc.gc.ca/e/780.html CPSI/ICSP: http://www.patientsafetyinstitute.ca/research/funding_opportunities.html Health Sciences Centre Foundation: http://www.hscfoundation.mb.ca/research.asp International Occasional funding of international projects: Robert Wood Johnson Foundation: http://www.rwjf.org/applications/
  • HSRProj : Lists over 371 patient safety related projects including funder, PI and project information Databases MedEffect: http://www.hc-sc.gc.ca/dhp-mps/medeff/ JCAHO: http://www.jointcommission.org/SentinelEvents/Statistics/
  • Conferences/Seminars Variety of national organizations, medical associations, regional health programs and local health system programs Special programs for study Publications Five journals: International Journal for Quality in Health Care, Quality &amp; Safety in Health Care (2002), Joint Commission on Journal on Quality and Safety (2003), Patient Safety &amp; Quality Healthcare (2004 - online), Journal of Patient Safety (2005) Newsletters &amp; Bulletins: CPSI/ICSP, ISMP, TIPS, CAPSlink Columns: AORN J, Manitoba RN J { http://www.crnm.mb.ca/} Web-based &amp; Home-study Including audio conferences, web-based training programs, on-line articles, CME/CNE/CE programs, etc.
  • Example of current programs that exist in the U.S. Patients/Families P.U.L.S.E. - http://www.pulseamerica.org/ Voice4Patients.com - http://voice4patients.com/ Medical professionals Medically Induced Trauma Support Services (MITSS) - http://www.mitss.org/ Sorry Works! Coalition - http://sorryworks.net/ Other support agencies American Society of Medication Safety Officers (ASMSO) - http://www.asmso.org/ Patient Safety Officers Section (PSOS) through the American Institute for Healthcare Quality (AIHQ) of the American Board of Quality Assurance and Utilization Review Physicians (ABQAURP) - https://www.abqaurp.org/psos.asp
  • RCA - Jose Eric Martinez {Turnbull} FMEA - patient identification, medication processed, blood sampling {Akpon} Six Sigma - DMAIC (Define, Measure, Analyze, Improve, Control) methodology {ASQ} PRA – or ST-PRA (sociotechnical PRA) {Marx}
  • HFE - {Gosbee} CRM – {Salas} SBAR – {Haig}
  • Resources

    1. 1. Patient Safety Resource Seminar Part II - Resources
    2. 2. <ul><li>to identify </li></ul><ul><li>and eliminate </li></ul><ul><li>errors </li></ul>Goal of Patient Safety:
    3. 3. Addressing Patient Safety <ul><li>Legislation </li></ul><ul><li>Certification/Accreditation/Recognition </li></ul><ul><li>Research </li></ul><ul><li>Education/Communication </li></ul><ul><li>Support Agencies </li></ul><ul><li>Tools & Resources </li></ul><ul><li>Library Connections & Advocacy </li></ul>
    4. 4. Federal & Provincial Legislation <ul><li>Malpractice regulations </li></ul><ul><li>Adverse Reaction Reporting </li></ul><ul><ul><li>MedEffect: drugs and health products </li></ul></ul><ul><li>Mandatory and/or voluntary medical error reporting </li></ul><ul><ul><li>SK, MB, ON, QC </li></ul></ul><ul><ul><li>BCAS - CIRS </li></ul></ul>
    5. 5. Federal & Provincial Legislation <ul><li>Disclosure </li></ul><ul><ul><li>Patient notification of adverse events </li></ul></ul><ul><ul><ul><li>Position statements: CMA, CNA </li></ul></ul></ul><ul><ul><ul><li>Legislation: MB, QC </li></ul></ul></ul><ul><ul><ul><li>Guidelines/Policies: AB, BC, NF/LB, NS, ON, PE, SK </li></ul></ul></ul><ul><ul><li>Liability protection for disclosure </li></ul></ul><ul><ul><ul><li>British Columbia Evidence Act </li></ul></ul></ul>
    6. 6. Federal & Provincial Legislation <ul><li>Canadian Patient Safety Institute </li></ul><ul><li>Potential regulations </li></ul><ul><ul><li>Nurse to patients staffing ratios </li></ul></ul><ul><ul><li>Mandatory overtime prohibited </li></ul></ul><ul><ul><li>Hours in a work-week </li></ul></ul>
    7. 7. Legislation Resources <ul><li>Department of Justice </li></ul><ul><ul><li>Justice Laws Web Site http://laws.justice.gc.ca/ </li></ul></ul><ul><li>Health Law Institutes </li></ul><ul><ul><li>Dalhousie University http://hli.law.dal.ca/ </li></ul></ul><ul><ul><li>University of Alberta http://www.law.ualberta.ca/centres/hli/ </li></ul></ul>
    8. 8. Accreditation <ul><li>Hospitals and Health Centers </li></ul><ul><ul><li>CCHSA Patient Safety Goals & ROPs </li></ul></ul><ul><ul><ul><li>Culture: One prospective analysis per year </li></ul></ul></ul><ul><ul><ul><li>Communication: Inform and educate patients/clients </li></ul></ul></ul><ul><ul><ul><li>Worklife/Workforce: Annual education/training to staff, support preventive maintenance program </li></ul></ul></ul><ul><ul><ul><li>Infection control: Guidelines </li></ul></ul></ul><ul><ul><li>CCHSA 2007 Performance Measures </li></ul></ul><ul><ul><ul><li>Patient Safety Education </li></ul></ul></ul>
    9. 9. Certification <ul><li>Health professionals: </li></ul><ul><ul><li>recertification requirements to include patient safety topics </li></ul></ul><ul><li>Students and residents: </li></ul><ul><ul><li>Required to take patient safety courses </li></ul></ul><ul><ul><li>Topics included in residency programs </li></ul></ul><ul><li>Maximum Duty Hours: </li></ul><ul><ul><li>Less than than two or more consecutive periods of call for residents (Ontario) </li></ul></ul>
    10. 10. Recognition Programs <ul><li>CRPNBC Awards of Excellence </li></ul><ul><li>MOHLTC Innovation Awards </li></ul><ul><li>CCHSE/CCDSS Awards Program </li></ul><ul><li>WRHA Leading Us to Excellence </li></ul><ul><li>OHA Innovation in Patient Safety Award </li></ul><ul><li>Individual conferences </li></ul>
    11. 11. Research <ul><li>Patient Safety Grants </li></ul><ul><ul><li>Federal, Regional, Local </li></ul></ul><ul><ul><ul><li>CHSRF/FCRSS </li></ul></ul></ul><ul><ul><ul><li>CIRH/IRSC </li></ul></ul></ul><ul><ul><ul><li>CPSI/ICSP </li></ul></ul></ul><ul><ul><ul><li>Health Sciences Centre Foundation </li></ul></ul></ul><ul><ul><li>International </li></ul></ul><ul><ul><ul><li>Robert Wood Johnson Foundation </li></ul></ul></ul>
    12. 12. Research Resources <ul><li>Health Services Research Projects in Progress </li></ul><ul><ul><li>HSRProj: http://www.nlm.nih.gov/hsrproj/ </li></ul></ul><ul><li>Informational databases </li></ul><ul><ul><li>MedEffects </li></ul></ul><ul><ul><li>JCAHO Sentinel Events </li></ul></ul><ul><li>Journal Sources </li></ul><ul><ul><li>PubMed.gov </li></ul></ul><ul><ul><li>PubMedCentral.gov </li></ul></ul>
    13. 13. Education Opportunities <ul><li>Conferences/Seminars/Workshops </li></ul><ul><ul><li>National & Regional, Medical associations </li></ul></ul><ul><ul><li>CPSI 2006 Patient Safety Studentship Program </li></ul></ul><ul><li>Publications </li></ul><ul><ul><li>Five journals, numerous newsletters and columns </li></ul></ul><ul><li>Web-based modules and home study resources </li></ul><ul><li>In-house training </li></ul><ul><ul><li>Created by library, brought in from outside </li></ul></ul>
    14. 14. Education Topics <ul><li>Health literacy </li></ul><ul><ul><li>Easy to read </li></ul></ul><ul><ul><li>Language appropriate </li></ul></ul><ul><li>Legislation </li></ul><ul><li>Accreditation </li></ul><ul><ul><li>CCHSA changes </li></ul></ul><ul><li>Nursing issues & resources </li></ul><ul><li>EBM / EBM </li></ul>
    15. 15. Communication Resources <ul><li>Listservs </li></ul><ul><ul><li>NPSF, JC-ICPS </li></ul></ul><ul><li>Websites </li></ul><ul><ul><li>Government, non-profit, professional, publicly owned, internal </li></ul></ul><ul><ul><li>Focused: health professionals, administration, patients & families </li></ul></ul><ul><li>Alert services </li></ul><ul><ul><li>MedEffects, ISMP, AORN, My NCBI (NLM PubMed), FDA, </li></ul></ul>
    16. 16. Support Agencies <ul><li>For those experiencing medical error </li></ul><ul><ul><li>Patients and families </li></ul></ul><ul><ul><ul><li>P.U.L.S.E. </li></ul></ul></ul><ul><ul><ul><li>Voice4Patients.com </li></ul></ul></ul><ul><ul><li>Medical professionals </li></ul></ul><ul><ul><ul><li>Medically Induced Trauma Support Services (MITSS) </li></ul></ul></ul><ul><ul><ul><li>Sorry Works! Coalition </li></ul></ul></ul><ul><ul><li>Other leadership support agencies </li></ul></ul>
    17. 17. <ul><li>RCA – Root Cause Analysis </li></ul><ul><ul><li>Examining events </li></ul></ul><ul><li>Failure Modes and Effects Analysis (FMEA) </li></ul><ul><ul><li>Examining processes </li></ul></ul><ul><li>Six Sigma </li></ul><ul><ul><li>Measurement studies </li></ul></ul><ul><li>Probabilistic Risk Analysis (PRA) </li></ul><ul><ul><li>Examining processes starting with outcomes </li></ul></ul>Patient Safety Tools
    18. 18. <ul><li>Human Factors Engineering </li></ul><ul><ul><li>Human abilities/characteristics affecting design/operation </li></ul></ul><ul><li>Crew Resource Management (CRM) </li></ul><ul><ul><li>Communication, team working </li></ul></ul><ul><li>Situation-Background-Assessment-Recommendation (SBAR) </li></ul><ul><ul><li>Communication, team working </li></ul></ul>Patient Safety Tools
    19. 19. <ul><li>Software </li></ul><ul><ul><li>EMR, bar-coding, RCA </li></ul></ul><ul><li>Consulting agencies </li></ul><ul><ul><li>Concerning CCHSA/CCASS, focusing on processes, in-house training </li></ul></ul><ul><li>Web-based information </li></ul><ul><ul><li>Forms, tool-kits, articles </li></ul></ul>Tools Resources
    20. 20. <ul><li>RCA / FMEA Support </li></ul><ul><ul><li>PubMed </li></ul></ul><ul><ul><ul><li>search for similar events and/or processes </li></ul></ul></ul><ul><ul><li>My NCBI Alerts </li></ul></ul><ul><ul><ul><li>tracked related events/processes </li></ul></ul></ul><ul><ul><li>NIH Clinical Alerts & Advisories </li></ul></ul><ul><ul><li>My NCBI Collections </li></ul></ul><ul><ul><ul><li>save related citations for reference, publication, CCHSA/CCASS , etc. </li></ul></ul></ul>NLM Resources
    21. 21. <ul><li>RCA / FMEA Support (continued) </li></ul><ul><ul><li>PubMed Clinical Queries </li></ul></ul><ul><ul><ul><li>identify related reviews </li></ul></ul></ul><ul><ul><li>HSDB in TOXNET </li></ul></ul><ul><ul><li>follow-up on toxicology issues in the Hazardous Substance Data Bank </li></ul></ul><ul><ul><li>HSRProj </li></ul></ul><ul><ul><ul><li>current projects on topics </li></ul></ul></ul><ul><ul><li>Radiation Event Medical Management </li></ul></ul><ul><ul><ul><li>focusing on all aspects of radiation events </li></ul></ul></ul>NLM Resources
    22. 22. <ul><li>Evidenced - Based Medicine/Nursing </li></ul><ul><ul><li>PubMed </li></ul></ul><ul><ul><li>general citation search </li></ul></ul><ul><ul><li>PubMed Clinical Queries </li></ul></ul><ul><ul><li>identify specific reviews </li></ul></ul><ul><ul><li>PubMed My NCBI </li></ul></ul><ul><ul><li>for both alerts and citation collections </li></ul></ul>NLM Resources
    23. 23. <ul><li>Patient & Family Concerns </li></ul><ul><ul><li>MedlinePlus </li></ul></ul><ul><ul><li>general searches, patient safety page </li></ul></ul><ul><ul><li>Household Products Database </li></ul></ul><ul><ul><ul><li>toxicology issues </li></ul></ul></ul><ul><ul><li>ClinicalTrials.gov </li></ul></ul><ul><ul><li>current and previous studies </li></ul></ul><ul><ul><li>ToxTown </li></ul></ul><ul><ul><li> toxicology geared for school children </li></ul></ul>NLM Resources
    24. 24. <ul><li>How is Your Library </li></ul><ul><li>involved in Patient Safety </li></ul><ul><li>(or how will it be)? </li></ul>Library Connections & Advocacy
    25. 25. <ul><li>In Training & Education </li></ul><ul><ul><li>Student Curriculum </li></ul></ul><ul><ul><ul><li>Pharmacy </li></ul></ul></ul><ul><ul><ul><li>Nurses </li></ul></ul></ul><ul><ul><li>Assist with CME/CNE/CE requirements </li></ul></ul><ul><ul><ul><li>Physicians, Residents, Nurses </li></ul></ul></ul><ul><ul><li>Focus on computer skills, EMB, searching </li></ul></ul><ul><ul><li>Teach in Orientation classes </li></ul></ul><ul><ul><li>Prepare on-line tutorials and resources </li></ul></ul>Library Connections & Advocacy
    26. 26. <ul><li>With Reference Services </li></ul><ul><ul><li>Literature Searches </li></ul></ul><ul><ul><ul><li>Stat for Emergency Room </li></ul></ul></ul><ul><ul><ul><li>Nursing Education Department </li></ul></ul></ul><ul><ul><ul><li>Monthly Infection Control Reports </li></ul></ul></ul><ul><ul><ul><li>Drug Use for Employees </li></ul></ul></ul>Library Connections & Advocacy
    27. 27. <ul><li>With Reference Services </li></ul><ul><ul><li>Alerts </li></ul></ul><ul><ul><ul><li>Recalls </li></ul></ul></ul><ul><ul><ul><li>Tables of Contents </li></ul></ul></ul><ul><ul><ul><li>Clinical Alerts </li></ul></ul></ul><ul><ul><ul><li>Drug Updates </li></ul></ul></ul>Library Connections & Advocacy
    28. 28. <ul><li>On the Website </li></ul><ul><ul><li>Information Pages </li></ul></ul><ul><ul><ul><li>For patients and families </li></ul></ul></ul><ul><ul><ul><li>For employees and health professionals </li></ul></ul></ul><ul><ul><li>Celebrations </li></ul></ul><ul><ul><ul><li>Good Catch </li></ul></ul></ul><ul><ul><ul><li>System changes due to FMEA </li></ul></ul></ul><ul><ul><li>Current News </li></ul></ul><ul><ul><ul><li>Evidence Based & Benchmarking information </li></ul></ul></ul><ul><ul><ul><li>Alerts </li></ul></ul></ul>Library Connections & Advocacy
    29. 29. <ul><li>Beyond the Library </li></ul><ul><ul><li>In the hospital </li></ul></ul><ul><ul><ul><li>Safety Fairs and programs </li></ul></ul></ul><ul><ul><ul><li>Visiting stations, departments & people </li></ul></ul></ul><ul><ul><ul><li>Serving on committees, councils & panels </li></ul></ul></ul><ul><ul><ul><li>Support accreditation requirements </li></ul></ul></ul><ul><ul><li>In the community </li></ul></ul><ul><ul><ul><li>Assist at community affairs department projects </li></ul></ul></ul><ul><ul><ul><li>Accept speaking engagements </li></ul></ul></ul><ul><ul><li>Share your stories </li></ul></ul>Library Connections & Advocacy
    30. 30. <ul><li>In Summary: </li></ul><ul><li>All of the roles of the library ultimately support Patient Safety </li></ul><ul><li>- Michelle Eberle, 2007 </li></ul>Library Connections & Advocacy
    31. 31. Patient Safety Resource Seminar: Librarians on the Front Lines Holly Ann Burt , MLIS, MDiv Available at: http://nnlm.gov/training/patientsafety/
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