Patient Safety

 

Key Points:

  • Safe behaviors save patient lives.
    • Effectively hand off information using a standardized format
    • Pay attention to detail and minimize distractions
    • Speak up about patient care concerns and be receptive when others do the same with you
    • Communicate in a respectful, nonjudgmental manner
    • Be supportive of your colleagues
    • Ask for help when you need it
  • The root cause of many patient safety incidents is suboptimal communication.
  • Hospital medical errors have been identified as the third leading cause of death in the U.S.
  • Safety is enhanced by a Fair and Just Culture
    • Human error (mistake) is consoled
    • Risky behavior (conscious choice to do something but the risk is not recognized or is believed justified) is counseled
    • Reckless behavior (conscious disregard of a known substantial risk) undergoes corrective action

 

Objectives:

  • Actively practice safe behaviors to contribute to a strong culture of safety
  • Respond to patient safety incidents based on a Fair and Just Culture
  • Report patient safety incidents and near misses, so they can be addressed with safer systems
  • Encourage trainees to speak up when they have a patient safety concern and to ask for help when uncertain

 

Recommended Resources: 

Brief Review

Watch

♥Building a psychologically safe workplace. Amy Edmondson at TEDxHGSE. TEDx Talks. 11 minutes.
https://youtu.be/LhoLuui9gX8

Top 10 Patient Safety Concerns for 2015. ECRI Institute. 4 minutes.
https://youtu.be/Wk6kdV2n-_A

Integrating Quality Improvement and Patient Safety Across the Continuum of Medical Education. AAMC webinar. 60 min.
https://www.aamc.org/initiatives/cei/349726/teachingforqualityintegratingqualityimprovementandpatientsafety.html

♥Just Culture: Evaluating Behavioral Choices. Cooperative of American Physicians. 9 minutes.
https://youtu.be/Q47jOh0nRJ0

Read

The Case of the Justified Junior by Eve Purdy & Teresa Chan. ALiEM MEdIC Series case 1.11.
http://aliem.com/wp-content/uploads/Case-of-the-Justified-Junior.pdf

Safety and Medical Education by Sumant Ranji, MD. Agency for Healthcare Research and Quality (AHRQ) Annual Perspective 2014.
http://psnet.ahrq.gov/perspective.aspx?perspectiveID=171

Aboumatar HJ, Thompson D, Wu A, Dawson P, Colbert J, Marsteller J, Kent P, Lubomski LH, Paine L, Pronovost P. Development and evaluation of a 3-day patient safety curriculum to advance knowledge, self-efficacy and system thinking among medical students. BMJ Qual Saf. 2012 May;21(5):416-22. doi: 10.1136/bmjqs-2011-000463. PubMed PMID: 22421912.
http://www.ncbi.nlm.nih.gov/pubmed/22421912

Do

♥Mayo Clinic Quality Academy Educational Resources. 12 free modules introducing quality improvement, patient safety, evidence-based medicine, and health policy. Certificates can be printed for each completed module.
http://qiresources.mayo.edu/

Peterson G, Bramhall J. Patient Safety Training: National Patient Safety Goals and CMS Hospital Quality. MedEdPORTAL Publications; 2013. Multimedia.
https://www.mededportal.org/publication/9560

Otis W, Sweeney L, Rojek A, Lindquist D. A Simulation-Based Resource for Improving Patient Safety and Improving the Patient Experience . MedEdPORTAL Publications; 2013.
https://www.mededportal.org/publication/9322

Cumbler E, Glasheen J. Teaching Patient Safety via a Structured Review of Medical Errors: A Novel Approach to Educating Residents about Medical Error, Disclosure, and Malpractice. MedEdPORTAL Publications; 2007. A four-module comprehensive approach to medical error education covering systems pressures, latent flaws, and psychological tendencies that predispose to individual mistakes. This is paired with instruction on disclosure of and appropriate response to medical error. The program combines each didactic subject with interactive case-based analysis of adverse events using a novel structured form to guide discussion.
https://www.mededportal.org/publication/761

 

In-Depth Review

Watch

♥The Science of Improving Patient Safety. Johns Hopkins Medicine. 33 minutes.
https://youtu.be/jxxkz-WeV_w

Is It Safe? Designing a Culture of Patient Safety. Marty Scott. TEDx Talks. 19 minutes.
https://youtu.be/o58wHQ_dPJc

Lessons Learned from ECRI Institute: Enhancing the RCA Process. ECRI Institute. 26 minutes.
https://youtu.be/lXTd_kG6oK8?list=PLEvm6gjNpayPJvRDfYUZpjo63pV-4Adof

Read

♥Agency for Healthcare Research and Quality (AHRQ) Patient Safety Primers. Key concepts in patient safety. Each primer defines a topic, offers background information on its epidemiology and context, and highlights relevant content from both AHRQ PSNet and AHRQ WebM&M. 28 topics.
http://psnet.ahrq.gov/primerHome.aspx

Agency for Healthcare Research and Quality (AHRQ) Patient Safety Network. Features links to the latest tools, literature, and news in patient safety, as well as an annotated collection of patient safety resources and advanced customization.
http://psnet.ahrq.gov/

 Do 

TeamSTEPPS® Master Trainer Course. Online. Agency for Healthcare Research and Quality (AHRQ). TeamSTEPPS® (Team Strategies and Tools to Enhance Performance and Patient Safety) is an evidence-based approach to improve communication and teamwork among health care teams. TeamSTEPPS Master Trainers serve within their institutions to help prepare for, implement, and champion the TeamSTEPPS teamwork approach. Those interested in learning more about TeamSTEPPS are encouraged to register free of charge for TeamSTEPPS online learning. Participants in the group-paced cohort have four months to complete 11 modules, watch three Webinars, and conduct a virtual “teach-back” session. Upon completion of all course activities, participants are certified as TeamSTEPPS Master Trainers. AHRQ’s subject matter experts are available throughout the course to assist participants with questions and challenges regarding implementation of teamwork initiatives in health care. Options to take the entire TeamSTEPPS Master Training curriculum at a self-paced rate or to take individual parts of the TeamSTEPPS curriculum without becoming a Master Trainer also are available.
https://tslms.org/login/index.php

The Science of Safety in Healthcare. Coursera, Johns Hopkins University.
https://www.coursera.org/course/healthcaresafety

Patient Safety Certificate Program. Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medical. Online or in person. $ Fee Required
http://www.hopkinsmedicine.org/armstrong_institute/training_services/workshops/certificate_programs/