Thomas Davis, CRNA, MAE, DNAP candidate
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In 1999 the Institute of Medicine rocked the healthcare world with the scathing report that every year up to 98,000 people in the United States die due to medical errors. Despite nearly 20 years of safety initiatives being introduced in hospitals nationwide, medical errors continue to be the third leading cause of death in the United States; a situation that can best be corrected by healthcare providers on the frontline of patient care.
It is easy to get the consensus of doctors, nurses and support staff to commit to patient safety; however, changing the workplace culture and making patient safety a priority can be a daunting task. Fortunately, organizations have emerged to assist frontline workers who are committed to making healthcare safe and reliable for the patients they serve.
If you are committed to ensuring patient safety, you are not alone. Here are resources to help you achieve the goal of eliminating ALL preventable medical errors.
Anesthesia patient safety foundation (APSF) The APSF was founded in 1985 with the defined goal of improving patient safety related to anesthesia. The board of directors is a group representing a wide variety of stakeholders including anesthesiologists, nurse anesthetists, nurses, manufacturers of equipment and drugs, regulators, risk managers, attorneys, insurers, and engineers. The APSF newsletter is published in 5 languages and provides a wealth of information related to patient safety that supports the organization’s mission: “The APSF’s mission is to improve the quality of care for patients during anesthesia and surgery by encouraging and conducting patient safety research and education as well as related programs and campaigns.” The AANA is an active partner with the APSF in promoting patient safety.
Patient safety movement The patient safety movement has a stated goal of zero preventable medical errors by the year 2020. The organization approaches patient safety by identifying risks to patients, challenging technology to assist by creating solutions, ensuring that providers follow established policy, and directly providing education to patients and their families regarding risks. The patient safety movement bypasses the medical establishment by directly providing information to patients and their families to alert them to the risks of hospitalization. The organization now offers the patient aider app that alerts family members regarding risks to their loved ones and provides questions to ask those who are providing care.
AHRQ (Agency for Healthcare Research and Quality) The AHRQ has the organizational mission; “…to produce evidence to make healthcare safer, higher quality, more accessible, equitable and affordable, and to work with HHS and other partners to make sure that evidence is understood and used.” The AHRQ website has a section titled “evidence now” that outlines evidence-based information designed to help healthcare providers with clinical decision making. The AHRQ site is a valuable resource for those who constantly update their practice based on the available best practice statistics.
Armstrong institute for patient safety and quality (The Johns Hopkins) The Armstrong institute for patient safety is housed at The Johns Hopkins Hospital and is committed to making healthcare safe for every patient, everywhere. The organization is dedicated to their mission: We partner with patients, their loved ones and all interested parties to end preventable harm, to continuously improve patient outcomes and experience, and to eliminate waste in health care. To ensure that providers at the grassroots level have the tools necessary for safe practice, the Armstrong institute provides patient safety courses for healthcare workers. Individuals can earn CME by attending courses in Baltimore or their employer can arrange for the Armstrong institute to travel to their location and present safety workshops.
Institute for Healthcare Improvement (IHI) The IHI has a global interest in improving the overall health of the world population through initiatives aimed at public health as well as education of healthcare providers in developing countries. In the US, the IHI focuses on system improvement, whereas in developing areas of the world, issues such as vaccination and water purification are priorities. As self-described on their web site, “We are an institute without walls, and together, we work as a cohesive unit with, common knowledge, common systems and unconditional teamwork. In all we do, we adhere to the principle of “all teach, all learn.”
AANA The AANA has a commitment to patient safety and their web site has numerous articles intended to improve patient safety. Topics such as opioids, radiation and OR distractions are just a few of those available on the AANA web site. The Professional practice division has published evidence-based practice resources to aid clinical decision making.
AORN CRNAs are not the only people in the OR who are committed to patient safety. The AORN “is committed to promoting patient safety by advancing the profession through scholarly inquiry to identify, verify, and expand the body of perioperative nursing knowledge.” The organization has published a patient safety position statement to guide the activity of nursing staff in the OR.
Center for Medicare/Medicaid services (CMS) CMS is a major payor for healthcare services in the US and has a vested interest in patient safety. The organization establishes standards and updates them annually to create criteria that must be followed in order to receive reimbursement for services. CMS seeks to improve patient safety by making healthcare providers accountable for the quality of care that is provided.
The Joint Commission (TJC) The Joint Commission accredits healthcare organizations throughout the United States and certifies that they meet or exceed established standards, including standards for patient safety. TJC has released the National Patient Safety Goals for 2019. Currently, safety priorities are patient identification, syringe labeling and blood administration. Areas of emphasis are updated to reflect perceived threats to patient safety.
Center for patient safety Established in 2005, the Center for patient safety is an independent, non-profit organization dedicated to promoting safe and quality healthcare. The organization is a resource for healthcare providers and offers information via blog, safety alerts and legal updates.
Centers for Disease Control and Prevention (CDC) The CDC is a government agency with the mission “to protect America from health, safety and security threats, both foreign and in the U.S. Whether diseases start at home or abroad, are chronic or acute, curable or preventable, human error or deliberate attack, CDC fights disease and supports communities and citizens to do the same.” The CDC national healthcare safety network tracks medical errors, issues statistical reports and issues alerts related to patient safety.
Patient safety company The patient safety company is an important bridge between safety initiatives and digital technology. The company offers software to support safety initiatives including incident management, patient satisfaction, workplace culture assessment, information security and peer support. They will also develop custom software for unique safety projects.
Patient safety is everybody’s business and making a commitment to ensuring a safe environment for your patient is easy on an intellectual level. Reviewing the resources listed above provides information and support for your effort; however, knowledge is useless until it is put into action. Making the transition from good intention to good practice requires a plan. The Kotter model for implementing change is a useful way to initiate a safety initiative in the healthcare environment. My previous blog, Kotter, for a change (Oct. 21, 2018), describes the model and how it can be used to make patient safety a priority in your workplace.
This article introduces the vast resources available to those who are committed to improving patient safety and provides a model for implementing change. It is up to each individual reader to convert patient safety from a theoretical “we ought to” to the reality of a workplace where safety is job one.
“Safety is not an intellectual exercise to keep us in work. It is a matter of life and death. It is the sum of our contributions to safety management that determines whether the people we work with live or die” ~Sir Brian Appleton
Tom is a noted author, speaker and mentor. Contact tom@procrna.com for information about the 4-part values-based leadership webinar series.