Patient safety is a priority in America's hospitals 24/7, 52 weeks of the year, but recently a week has been set aside in which we can share our interest in safer health care with our local communities. That week is National Patient Safety Awareness Week, which will be observed nationwide March 9-15. This year's theme is "Communication and Partnership: Safety starts with all of us."
National Patient Safety Awareness Week was launched in 2002 by PULSE (Persons United Limiting Substandards and Errors in Healthcare), a non-profit organization working to improve patient safety, and the U.S. Department of Veterans Affairs National Center for Patient Safety (VA NCPS). National Patient Safety Awareness Week is now supported by several states and numerous organizations, including the National Patient Safety Foundation of which the AHA is a member. We anticipate that patient safety will receive increased attention this year as a result of recent news articles about errors in care. Each time harm comes to a patient, we are reminded of the need to continually improve.
National Patient Safety Awareness Week is an educational and awareness building effort designed to promote an understanding that hospitals, doctors, nurses, patients, policymakers and others involved in health care can take steps to improve safety. This year's theme of communication and partnership creates an opportunity for us to think particularly about how we can improve communication with our patients and their families.
What to Expect During Patient Safety Awareness Week
The National Patient Safety Foundation will hold its annual meeting during National Patient Safety Awareness Week. In collaboration with other sponsors of the week, they have planned press conferences and will likely issue several press statements; as a result, hospitals may receive inquiries from your local press about issues of patient safety. In preparation, you may wish to put together some information on what projects your hospital has underway to improve the safety of your care. Highlight efforts such as:
- The use of clinical pharmacists on rounds, computerized physician order entry, or unit dosing to reduce the chance of a patient getting the wrong drug or the wrong dose of a drug.
- Using the "sign your site surgery" program to prevent wrong site surgery.
- Improving your patient education process and materials to ensure patients know how to continue their treatment to promote complete recovery once they have been discharged.
- Any of the projects your patient safety committee has undertaken.
This is a good time to promote stories in your local newspaper focusing not only what you have done, but what plans you have to address other issues of concern relative to patient safety (medication errors, nosocomial infections, etc.) You may be asked what patient's can do before, during, and after hospitalization to improve the safety of their health care. You should expect the question of whether your hospital has a policy requiring disclosure of errors to the affected patients and their families and be prepared to answer it.
Here are a few talking points that the AHA will be using in our patient safety communications. Feel free to incorporate them into yours.
- At the core of our complex health care system, we are people taking care of people. And it's a job we take seriously. Hospitals work vigilantly, constantly, to improve patient safety.
- The nation's hospitals are committed to improving patient safety and continuously work to do so. Patient safety takes the involvement of everyone - consumers, physicians, hospitals, and other providers of care, and manufacturers - to prevent errors and improve the quality of care for all Americans.
- As we observe patient safety week, we want to make you aware of the programs in place here at [LOCAL HOSPITAL] because safety starts with all of us.
We know that patient safety is a priority for hospitals. The AHA, in collaboration with numerous interested organizations, has repeatedly emphasized that the safe delivery of care is the fundamental cornerstone for providing high quality care to patients. To help hospitals achieve a safer environment and safer care delivery to foster a "culture of safety," the AHA has created numerous tools and resources.
For example, last year our Strategies for Leadership Toolkit Improving Patient Safety featured resources developed by the VA NCPS to help hospitals identify those aspects of care that may be at high-risk for causing patient harm. More recently, we distributed Strategies for Leadership Evidence-based Medicine for Effective Patient Care, which focuses on the important role of evidence-based medicine in improving quality patient safety.
What follows is a list of resources and materials that we have distributed to the field. More information is available at www.aha.org under "Quality and Patient Safety."
AHA SAFETY RESOURCES PROVIDED TO HOSPITALS
- AHA Quality Advisories (1999 & 2000), highlights successful practices related to medication safety.
- Leadership forums (2) for CEOs on challenges of patient safety/medical error.
- Beyond Blame, a short documentary video produced by Bridge Medical Inc.
- Reducing Medical Errors and Improving Patient Safety: Success Stories from the Front Lines of Medicine, distributed in conjunction with the National Coalition on Health Care.
- The ISMP Medication Safety Self-Assessment, distributed in conjunction with Institute for Safe Medication Practice. Results were used to create Pathways for Medication Safety - see below.
- Strategies for Leadership An Invitation to Conversation Quality of Care Video Series targeted at hospital trustees:
- Improving Patient Safety
- The Quality Imperative - A Roundtable Discussion
- Patient Service
- Addressing Medication Errors In Hospitals: A Practical Tool, developed in conjunction with Protocare Sciences and the California Healthcare Foundation.
- AHA Quality Advisory - Partnering with Patients, suggestions on how to involve consumers/patients in medication safety.
- Monthly patient safety calls (2000 - present) - directed at State Hospital Associations
- Pathways for Medication Safety, three tools developed by the Health Research & Education Trust, AHA, and the Institute for Safe Mediation Practices with a grant from the Commonwealth Fund to improve the safety of the medication delivery process. Visit www.medpathways.info.
Leading a Strategic Planning Effort
Looking Collectively At Risk
Assessing Bedside Bar-code Readiness
Culture of Safety
- AHA Quality Advisory: "A Culture of Safety" highlights elements of a "culture of safety" with an emphasis on patient communication and the need for open disclosure.
- American Society for Healthcare Risk Management (ASHRM) white paper: ASHRM Perspective on Disclosure of Unanticipated Outcome Information," issued in conjunction with the AHA.
- Strategies for Leadership: Hospital Executives and Their Role in Patient Safety, a pocket-size guide to help hospitals' senior management gauge their knowledge and activities on creating a culture of safety. Developed in conjunction with Jim Conway of the Dana-Farber Cancer Institute
- Strategies for Leadership: An Organizational Approach to Patient Safety describes the organizational tactics and strategies needed to create a culture of safety. Developed in conjunction with Nancy Wilson, MD, VHA Inc.
- Strategies for Leadership A Toolkit for Improving Patient Safety, developed in conjunction with the VA NCPS, features a video, CD-ROM and workbooks to help hospitals conduct Healthcare Failure Mode and Effect Analysis and root cause analyses.
- AHA Guide to Computerized Physician Order Entry Systems, a white paper on CPOE -related issues.
- The Challenge of Assessing Patient Safety in America's Hospitals, a white paper developed by Protocare Sciences for the AHA.
- The American Hospital Quest for Quality Award, recognizing organizations that have developed a "culture of safety."
- Patient Safety Fellowships through the AHA's Health Forum.
What More Can Be Done
In addition to use of the various tools and resources highlighted in the preceding section, hospitals and health care systems can reach out to their community to better understand their concerns regarding patient safety and to promote a better understanding as to how you are addressing the issue of patient safety. In particular, highlighting not only what you have done to improve patient safety, but also how you and your medical staff are focusing on communicating with patients and their loved ones and involving them in decisions concerning their healthcare.
- Educational forums. Focus on activities that you have engaged in within your hospital to improve patient safety as well as patient communication and their involvement in decision-making. Other improvement activities where focus could be brought include:
Work on the Joint Commission on
Accreditation of Healthcare Organizations
National Patient Safety Goals.
Implementation of specific technologies to improve patient safety - bar coding, computerized physician
order entry, specific infection control precautions to reduce nosocomial infections, etc.
Specific collaborative projects that your organization may have been a participant. The Institute for
Healthcare Improvement, VHA Inc., and Premier have all sponsored specific collaboratives directed
at improving patient safety.
Implementation and use of the tools and resources provided to you by the AHA.
Discussion forums. Reach out to your community to better understand what their concerns may be relative to patient safety and how your hospital may be able to alleviate these concerns. Also, what are their expectations concerning communication and involvement in health care decision-making.
- Place educational fact sheets and pamphlets that address issues relative to patient safety where patients and families can easily get to it. Provide information on admission and discharge. Numerous resources are available for your use:
National Patient Safety Foundation (www.npsf.org
Institute for Safe Medication Practices (www.ismp.org)
National Council on Patient Information and Education (www.talkaboutrx.org)
Agency for Healthcare Quality and Research (www.ahrq.gov)
- Reach out to other organizations in your community (both health-related and community-focused) to develop activities that will improve patient safety. Work with local extended care and assisted living facilities to address safety issues of mutual concern.
Patient/Family/Consumer Involvement in Hospital Activities
- Consider establishing a consumer/patient advisory council.
- Consider developing a Patient and Family Resource Center where patients and families can obtain information concerning safety as well as information related to specific medical conditions.
- Involve medical staff and patients/consumers in discussions about recent hospital experiences with a particular focus on patient decision-making and communication needs.
- Host a discussion for hospital staff, led by a patient/family member that has experienced a medical error, to facilitate a better understanding as to what impact an error has on a patient and their loved ones, what changes could or did occur as a result of the error, and expectations of the patient and their loved ones.
Additional tools to help hospitals and clinicians improve patient safety have become available recently. These include:
- The new Web site, www.webmm.ahrq.gov, features stories of errors that have occurred, the systems flaws that were discovered by analyzing the causes of the errors, and expert commentary on how such errors can be prevented. Developed by researchers at University of California at San Francisco and sponsored by AHRQ, the site is an excellent tool for patient safety committees and others who can begin by asking, "Could this error have happened here? If so, what are we doing to protect our patients against such an event?"
- A February 26 Journal of the American Medical Association (JAMA) article by James Gallagher and colleagues, describes what patients and their family members want to know about adverse events and how to better provide emotional support and information when an injury occurs
Improving patient safety and the safety of the environment of care is something that we do 24/7 365 days a year. National Patient Safety Awareness Week affords America's hospitals an opportunity to highlight the activities in which we continually engage to improve patient safety and involve patients in their health care decisions.