Improving Patient Safety - A Systems Approach

Welcome to this WikiEducator course: Improving Patient Safety:
Communicating About Error, Closing the Feedback Loop

A Systems Approach for Healthcare Professionals created by T. Winter, University of San Francisco

About This Program (read this first)

then...Click here for printable Treasure Hunt form to complete this course

Safe-guarding Care

Objectives

Objectives for this course are: Name 2 of the Institute of Medicine’s (IOM) 6 Aims for Improvement List 2 reasons why a systematic, consistent strategy such as a surgical checklist can improve safety and quality of care Name 4 web resources with information for improving patient care. Define "systems issues" in the context of healthcare. Provide you definition of "bottom-up change". Recall an error you were involved in or aware of in the past. List 2 systems factors that might have contributed to that error, or list 2 changes you would make to to prevent others from making a similar error List 1 benefit of providing feedback to staff and managers who report errors and near misses. Provide feedback to WikiEducator page creator with suggestions for improvement of this course

Safe-guarding Care

Definitions

Terms used in Patient Safety: Systems, Systems Thinking: A system is defined as a network of interdependent components that work together to try to accomplish a specific aim (Deming 1986). Here is a link to Wikipedia definition of Systems Thinking [1] Culture of Safety: As defined by Harvard affiliate CRICO/RMF: The institutional attitude toward patient safety—and toward improving patient safety—is often called the “culture of safety.” Most organizations are striving to improve patient safety, to move toward an optimal culture of safety. Such goals are not easily achieved, they cannot be achieved by mandate. Even the best designed safety programs have to work within the local culture. What is the local culture? Simply put, organizational culture is “the way we do things here.” It is the combination of institutional history, leadership, budget reality, and staff experience: the underlying sense of appropriate behavior and practice that prevails throughout the workplace Accessed 11/6/09 from: http://www.rmf.harvard.edu/education-interventions/materials-for-instructors/culture-of-safety/index.aspx

Safe-guarding Care

Assignment

“Treasure Hunt” for Patient Safety Using Web Resources links below and the Treasure Hunt form (if you haven't already printed the form here is is again: click here), then... go on an internet exploration to answer the following questions: 1. Name at least 2 of the Institute of Medicine’s (IOM) 6 Aims for Improvement 2. List 2 reasons why a systematic, consistent strategy such as a surgical checklist can improve safety and quality of care 3. Name 4 web resources with information for improving patient care. 4. Provide your definition “systems issues” in the context of healthcare. 5. Provide your definition of “bottom-up change.” 6. Recall on error you were involved in or aware of, in the past. List 2 systems factors that might have contributed to that error, or list 2 changes you would make to help prevent others from making a similar error 7. List 1 benefit of providing feedback when errors and near misses are reported. 8. Please provide feedback to WikiEducator page creator with suggestions for improvement of this course. What worked well? What needs improvement? What did you find difficult about using this page or format? We need your feedback!

Safe-guarding Care

Web Resources

...for completing your Treasure Hunt are listed below

General Information on Patient Safety and Quality

• Institute for Healthcare Improvement (IHI) Open School video Defining Quality (4 minutes, 36 seconds): [2]

• IHI webpage Across the Chasm: Six Aims for Changing the Health Care System: [3]

• IHI Open School video Why do Errors Happen, and How Can We Prevent Them (4 minutes, 42 seconds):[4]

• Why Report Errors? A news report re: an Australian hospital's increased safety with increased error reporting (1 minute 38 seconds): [5]

• Addressing Medical Error: Promoting Patient Safety video featuring Brian Liang MD, JD (anesthesiologist, pilot, lawyer) (47 minutes, 22 seconds): [6]

• Slideshow from SlideShare Reducing Medical Error and Increasing Patient Safety, by Richard Smith, editor of the British Medical Journal: (29 slides): [7]

• Agency on Healthcare Research and Quality (AHRQ) 2008 Quality and Disparities reports show that the annual rate of improvement in health care quality is very low, and patient safety is actually getting worse rather than better (audio - 3 minutes, 28 seconds) : [8]

• IHI Open School video The Future (Challenges in Healthcare) national healthcare leaders discussing current issues, and where do we go from here (7 minutes, 8 seconds): [9]

• World Health Organization (WHO) website Safe Surgery Saves Lives, with information on implementing surgical checklists: [10]

• A great resource book about systems and quality: Quality by Design: A clinical microsystem approach edited by Eugene C. Nelson, Paul B Batalden, Marjorie M. Godrey (pages 5 and 13 are of particular interest for this class, on systems). Explore the book here: [11]

Frontline Staff Perspective:

• IHI Open School video Change Driven From the Bottom Up (1 hour, 12 minutes): [12]
• IHI Open School slideshow Change Driven From the Bottom Up a quick summary of above video: slideshow
• IHI website on providing feedback to front-line staff [13]

Patient Perspective:

• "Hurt By Medicine: Patients Talk" audio from Harvard affiliate CRICO/RMF: [14]

• For the patient/consumer perspective, visit Consumers Union Safe Patient Project website: [15] and watch the videos with patient stories (5 videos 2-3 minutes each): [16]

International Perspective:

• A flyer for the Canadian Safety Competencies Framework, in a one page format: [17]

• Information on patient safety from the European Union public health website:[18]

• WHO patient safety website: [19]

• Junior doctors make mistakes in 8% of hospital prescriptions, study finds: [20]

For further information on the topic of Patient Safety, here are some more articles and videos you might be interested in:

• National Patient Safety Foundation video (long, but very good overview) "To Err is Human" Report Retrospective and the Decade Ahead [21]

• IHI White Paper - Engaging Physicians': [22]

• Agency for Healthcare Research and Quality (AHRQ) Patient Safety Tools: [23]

• Joint Commission website on patient safety: [24]

• Here is the entire document, in PDF format for the Canadian Safety Competencies Framework:[25]

Assessment

Please evaluate this course Click here for printable form, and submit with your Treasure Hunt form for course credit

For References: click here

                                  http://3.bp.blogspot.com/_jcFDWu1jEPk/SIi6bi8WqCI/AAAAAAAAAG0/yrWdopKEYUo/s200/0926162957_patient_safety.gif

"Patient Safety" image found on Google Images accessed 11/17/09 from:http://www.wellsphere.com/healthcare-industry-policy-article/joint-commission-2009-national-patient-safety-standards-reality-compared-with-expectations/540411