Teaching of Patient Safety in Pharmacy Curriculum

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  • Agency for Healthcare Research & Quality (AHRQ)
  • Having contributed and worked in a culture of patient safety, manage safety risks. Optimize human and environmental factors and finally identify and disclose AEs.
  • This blueprint integrates the patients safety course together with other professional courses in health sciences.
  • The lines are perfectly straight and parallel.
    Why don’t they look straight?
    Our brain is playing a trick on us - the way we perceive things isn’t always what’s going on (reality).
  • All common situations for inexperienced staff.
  • All common situations for inexperienced staff.
  • The optimum level of performance is reached when the level of arousal is neither too high or too low.
    Boredom is a problem if we are doing a highly automated and repetitive task, e.g. transcribing medication charts:
    may be easy to commit a transcribing error
  • Teaching of Patient Safety in Pharmacy Curriculum

    1. 1. Teaching of Patient Safety in Pharmacy Curriculum Presented at the 3rd Annual Conference of SPER at Lovely Professional University, Punjab, India, March 8, 2014 Dr. Bhaswat S Chakraborty Sr. Vice President & Chair – R&D Core Committee Cadila Pharmaceuticals Ltd
    2. 2. Pharmacy Practice • • • • • • • Academia, Research Industry Community Hospital Regulatory Long term care … All need to be concerned with patient safety
    3. 3. Examples of Public Safety Initiatives (USA) • NTSB – Evolution of the Air Commerce Act of 1926 • 1938 Food Drug and Cosmetic Act • OSHA – Occupational Safety and Health Act of 1970 • Departments of Public Safety (fire, rescue, ambulance, police etc.) • Homeland Security Act of 2002 All countries have such legislation
    4. 4. Context Authors Linda T. Kohn, Janet M. Corrigan, and Molla S. Donaldson, Editors; Committee on Quality of Health Care in America, Institute of Medicine Description •Experts estimate that as many as 98,000 people die in any given year from medical errors that occur in hospitals. •That's more than die from motor vehicle accidents, breast cancer, and AIDS •Financial cost to the human tragedy, and medical error easily rises to the top ranks of urgent, widespread public problems.
    5. 5. To Err is Human: Building a Safer Health System • This book was the first report within a larger project (Quality of Healthcare in America) • Developed by 38-person committee • Rationale: – – – – – Immense burden of harm Preventable and shouldn’t happen Understandable concept by Americans Sizeable evidence base Healthcare system is rapidly evolving Probably this was not expected of a health care system
    6. 6. To Err is Human: Building a Safer Health System Major Recommendations (National Agenda): • Center for Patient Safety within AHRQ • Nationwide mandatory reporting system (death/serious harm) and encourage voluntary reporting of all errors • Peer-review protections to data • Performance standards and expectations • Safe use of drugs (pre and post marketing) • Priority for organizations and professionals
    7. 7. To Err is Human: Building a Safer Health System “ A major force for improving patient safety is the intrinsic motivation of healthcare providers, shaped by professional ethics, norms and expectations” • Definitions: – Safety – Freedom from accidental injury – Error – Failure of a planned action to be completed as intended OR use of a wrong plan to achieve an aim – Harm – any negative outcome
    8. 8. Three Reporting Categories • Incident: Any unintended or unexpected incident which could have, or did, lead to harm for one or more patients • Near miss or Close call: An event or situation that did not produce patient injury, but only because of chance • Unsafe condition: Unsatisfactory physical condition existing in the workplace environment immediately prior to an incident or event All three categories must be attended
    9. 9. High-Reliability Organizations (HROs) • Operate in hazardous conditions and have fewer than expected adverse events • Examples: – air traffic control, nuclear power plants, aircraft carriers. • Common Key Features – Preoccupation with failure – Sensitivity to operations – Culture of safety All HROs have characteristic hazard minimization approach
    10. 10. National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) • Four categories of reporting – Error – Error, No harm – Error, Harm – Error, Death Probably this was not expected of a health care system
    11. 11. National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP)
    12. 12. Components of Any Culture • • • • Values Attitudes Norms Beliefs • Practices • Policies • Behaviors The way we do business around here
    13. 13. Culture of Safety Key Features: • Acknowledge high-risk nature • Achieve consistently safe operations • Promote blame-free environment that encourages the reporting of errors and near misses • Employ collaboration (ranks/disciplines) to seek solutions to safety problems • Organizational commitment of necessary resources
    14. 14. Measuring Safety Climate Elements Commonly Measured: • Easy to learn from mistakes • Errors are handled appropriately • Clinical leaders listen to me and care about my concerns • Leadership is safety-driven • My suggestions are acted upon • I am encouraged to report safety concerns • I know proper administrative channels Mistakes are not ignored rather learned from
    15. 15. Why Patient Safety Education for Pharmacists? • Health care system is an enormous bliss to humanity and yet there are horrific errors and system failures • All health-care students, including Pharmacists, must prepare themselves to practise safe care • Patient safety knowledge applies to all areas of practice • Pharmacists need to know and manage – how systems impact on the quality and safety of health care – how poor communication can lead to AEs – More... • Patient safety is not a traditional stand-alone discipline; rather, it is one that integrates into all areas of health care Pharmacist provide multi-level resistance to errors & harms
    16. 16. How were WHO Curriculum Guide topics selected? • The Curriculum Guide covers 11 topics • A lot came from Australian and Canadian experiences • Three main stages were used in the development of the Framework content and structure – initial review of knowledge and development of framework outline – additional searching for content and assignment of knowledge, skills, behaviours and attitudes – development of performance-based format • The Canadian approach provides an interprofessional, practical and useful patient safety framework – using knowledge, skills, and attitudes required by all health-care professionals
    17. 17. The Canadian Framework of Safety Competencies Source: The Safety Competencies, Canadian Patient Safety Institute, 2009
    18. 18. The WHO Curriculum Guide Topics 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. What is patient safety? Why applying human factors is important for patient safety Understanding systems and the effect of complexity on patient care Being an effective team player Learning from errors to prevent harm Understanding and managing clinical risk Using quality-improvement methods to improve care Engaging with patients and carers Infection prevention and control Patient safety and invasive procedures Improving medication safety The topics are taught over 4-5 curricular years
    19. 19. When and What to Teach
    20. 20. Integrating Patient Safety Education Into Health Professional Curricula Source: M. Walton, Sydney School of Public Health, University of Sydney, Sydney, Australia, 2010
    21. 21. Skills Training • • • • • • • • • Communicating risk; Asking permission; Accepting refusal; Being honest with patients; Empowering patients–helping patients be active participants in their own care; Keeping patients and relatives informed; Hand hygiene; Patient-centred focus during history taking and appropriate examinations; Clinical reasoning–diagnostic error, consideration of risk benefit ratio of procedures, investigations and management plans. Skills are practiced over & over
    22. 22. Miller’s Triangle Source: Miller GE. The assessment of clinical skills/competence/performance.AcademicMedicine,1990
    23. 23. Educational Principles • Main objective of any teaching is to transfer the (classroom) learning to workplace • Context is highly relevant • Contextualize patient safety principles • Use examples that are realistic for your setting • Identify practical applications • Use examples that are of interest or soon will be relevant to students Case example While observing a surgical operation, a nursing student notices that the surgeon is closing the wound and there is still a pack inside the patient. The student is not sure if the surgeon is aware of the pack and is wondering whether to speak up. Right teaching will teach her to speak up in all such situations Inspiration to do
    24. 24. Teaching Styles • One authority identifies six important roles of the Teacher/Professor : – Information provider – Role model – Facilitator – Assessor – Planner – Resource producer
    25. 25. The WHO Curriculum Guide Topics 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. What is patient safety? Why applying human factors is important for patient safety Understanding systems and the effect of complexity on patient care Being an effective team player Learning from errors to prevent harm Understanding and managing clinical risk Using quality-improvement methods to improve care Engaging with patients and carers Infection prevention and control Patient safety and invasive procedures Improving medication safety
    26. 26. 1. What is patient safety? A patient safety model of health care Emmanuel et al 2008
    27. 27. Patient Safety • Students should: – understand the multiple factors involved in failures – avoid blaming – practise evidenced-based care – maintain continuity of care for patients – be aware of the importance of self-care – act ethically everyday
    28. 28. 2. What is human factors? • The study of all the factors that make it easier to do the work in the right way • Apply wherever humans work • also sometimes known as ergonomics • Examples • order medications electronically • hand off information • move patients If all of these tasks become easier for the health-care provider, then patient safety can improve.
    29. 29. Are the lines crooked or straight? Optillusions.com
    30. 30. What is an error? • The failure of a planned action to achieve its intended outcome • A deviation between what was actually done and what should have been done • Easier: “Doing the wrong thing when meaning to do the right thing.”
    31. 31. Situations associated with an increased risk of error • unfamiliarity with the task* • inexperience* • shortage of time • inadequate checking • poor procedures • poor human equipment interface Vincent * Especially if combined with lack of supervision
    32. 32. Performance level Stress and Performance Area of “optimum” stress High stress Anxiety, panic Low stress Boredom Stress level Yerkes, R. M., & Dodson, J. D. (1908) The relation of strength of stimulus to rapidity of habit-formation. Journal of Comparative Neurology and Psychology, 18, 459-482
    33. 33. 2. Systems and Effect of Complexity on Patient Care • The study of all the factors that make it easier to do the work in the right way • Apply wherever humans work • also sometimes known as ergonomics • Examples • order medications electronically • hand off information • move patients If all of these tasks become easier for the health-care provider, then patient safety can improve.
    34. 34. 5. Learning from Errors to Prevent Harm • Error: Doing the wrong thing when meaning to do the right thing • Violation: A deliberate deviation from an accepted protocol or standard of care • Incident monitoring: collecting and analysing information about any events that could have harmed or did harm anyone in the organization • Incident monitoring: a fundamental component of an organization’s ability to learn from error Error management is removing error traps by monitoring
    35. 35. Performance Am I safe to work today?
    36. 36. Root Cause Analysis • A rigorous, confidential approach to answering: – What happened? – Why did it happen? – What are we going to do to prevent it from happening again? – How will we know that our actions improved patient safety?
    37. 37. 11. Improving Medication Safety • Prescribing involves choosing an appropriate medication for a given clinical situation taking individual patient factors into account such as allergies • selecting the administration route, dose, time and regimen • communicating details of the plan with: – whoever will administer the medication (written-transcribing and/or verbal) – and the patient • documentation
    38. 38. How can Prescribing Go Wrong? • Inadequate knowledge about drug indications and contraindications • Ignoring individual patient factors e.g. allergies, pregnancy, co-morbidities, other medications • Wrong patient, wrong dose, wrong time, wrong drug, wrong route • Inadequate communication (written, verbal) • Documentation - illegible, incomplete, ambiguous • Mathematical error when calculating dosage • Incorrect data entry when using computerized prescribing e.g. duplication, omission, wrong number
    39. 39. Look-a-like and Sound-a-like Medications • Celebrex (an anti-inflammatory) • Cerebryx (an anticonvulsant) • Celexa (an antidepressant) • Avoiding such confusion – know accepted local terminology – write neatly, print if necessary – avoid trailing zeros • e.g. write 1 not 1.0 – use leading zeros • e.g. write 0.1 not .1
    40. 40. Finally, Pharmacovigilance • Any curriculum in patient safety would be incomplete without teaching pharmacovigilance (PV) • PV has emerged as a standalone course and a well practiced domain of patient safety all over the world • PV involves – Monitoring, evaluation and implementation of drug safety – Detection and quantitation • of adverse drug reactions (ADRs) • novel or partially known – previously unknown – known hazard ↑frequency or ↑severity • in their Clinical nature, Severity or Frequency
    41. 41. Conclusions • A huge body of evidence exists indicating that patients are not always safe in the modern health care system • Harm mainly comes from therapeutic failures, medication errors, neglect of patients, wrong dispensing, inadequate supply and also lack of education and good practices of care givers • Teaching patients safety to health care students like doctors and pharmacists is one of the best approaches to mitigate some of the safety problems • WHO curriculum guide for multi professionals is a very rich resource to address teaching and learning of patient safety • Patient safety and Pharmacovigilance must be taught and integrated at both undergraduate and graduate levels of pharmacy educations • All highly reliable organizations make sure that safety of the people that they serve comes first
    42. 42. Acknowledgement: Ms. Raji Nair Thank you Very Much 42

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