Patient Safety: Where are we and where do we want to go?

Transcription

1 Patient Safety: Where are we and where do we want to go? Denice Stewart, DDS, MHSA Senior Associate Dean, Clinical Affairs Professor, Community Dentistry

2 We re moving!

3

4

5 Occupancy July 1, 2014

6 As of October, 2013

7 Objectives overview of the current state of patient safety systems describe what constitutes a patient safety system present critical steps in establishing a dental patient safety system review example efforts underway in dentistry

8 Objectives overview of the current state of patient safety systems describe what constitutes a patient safety system present critical steps in establishing a dental patient safety system review some example efforts underway in dentistry

9

10 What is patient safety? Patient safety was defined by the IOM as the prevention of harm to patients the system of care delivery that (1)prevents errors; (2) learns from the errors that do occur; and (3) is built on a culture of safety that involves health care professionals, organizations, and patients.

11

12 Is there really a safety problem? Wrong site surgery btw 1995 and 2010, 956 WSS were reported to the Joint Commission Medication errors harm ~1.5 million Americans each year resulting in more than $3.5 billion in extra medical costs Health care-acquired infection - 1 out of 20 hospitalized patients contract HAI

13 Objectives overview of the state of patient safety systems in medicine and dentistry, describe what constitutes a patient safety system present critical steps in establishing a dental patient safety system review some example efforts underway in dentistry

14 Essential elements of a patient safety system Emanuel L, et al. What Exactly is Patient Safety? In Henriksen K, Battles JB, Keyes MA et al, editors. Advances in patient safety: new directions and alternative approaches (Vol1: Assessment); Rockville Md; Agency for Healthcare Research and Quality; 2008 Aug.

15 Patient safety vocabulary Safety: freedom from accidental injury Adverse event: an injury resulting from a medical intervention (i.e., not due to the underlying clinical condition of the patient) Preventable adverse event: an adverse event that was attributable to a clinical error. Error: the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim; not all errors result in injury. Errors can include problems in practice, products, procedures, and systems. Institute of Medicine

16 Objectives overview of the state of patient safety systems in medicine and dentistry, describe what constitutes a patient safety system present critical steps in establishing a dental patient safety system review some example efforts underway in dentistry

17 Steps to patient safety Build a safety culture Lead and support the practice team Integrate risk management activity Promote reporting Involve and communicate with patients and public Learn and share safety lessons Implement solutions to prevent harm National Patient Safety Agency, National Reporting and Learning Service, National Health Service.

18 culture communication Tools education reporting teamwork trending and tracking

19 culture communication Tools education reporting teamwork trending and tracking

20 The safety culture of an organization is the product of individual and group values, attitudes, perceptions, competencies, and patterns of behavior that determine the commitment to, and the style and proficiency of, an organization's health and safety management. Health and Safety Commission Advisory Committee on the Safety of Nuclear Installations. (1993). Organizing for safety: Third report of the ACSNI study group on human factors. Sudbury, UK : HSE Books. Why is culture important?

21 Key features of a positive patient safety culture Patient Safety Primer, Safety Culture. Agency for Healthcare Research and Quality. acknowledgment of the high-risk nature of activities and determination to achieve consistently safe operations; a blame free environment in which individuals report errors or near misses without fear of repercussion or punishment; encouragement of collaboration across ranks and disciplines to seek solutions to patient safety problems.

22 Teamwork Plays an important role in causation and prevention of AEs Staff perceptions of teamwork are related to quality and safety Effective teams have high levels of communication, coordination, and leadership Acta Anaesthesiol Scand Feb;53(2): doi: /j x. Teamwork and patient safety in dynamic domains of healthcare: a review of the literature. Manser T.

23 Objectives overview of the state of patient safety systems in medicine and dentistry, describe what constitutes a patient safety system and present critical steps in establishing a dental patient safety system review some example efforts underway in dentistry

24 Survey of patient safety culture Medical Office Survey on Patient Safety Culture. January Agency for Healthcare Research and Quality, Rockville, MD. /medical-office/ resources/index.html Patient safety and quality issues Information exchange and communication Work pressure and pace Teamwork Staff training Office processes and standardization Communication openness Patient care tracking /follow up Communication about error Leadership support for safety Organizational Learning Overall perceptions of patient safety and quality

25 Attitudes toward Patient Safety Standards US Dental Schools: UCSF AHRQ survey instrument administered to dental faculty, students and support staff and to hospital staff Dental ratings higher than hospital in overall perceptions of safety, management support for safety, and teamwork. Dental below hospital in frequency of adverse events reports, and organizational learning/ci Peggy Leong, Jay Afrow, Hans Peter Weber, Howard Howell. JDE 72(4): 2008

26 Dental Education: University of Pacific Evaluation of a Clinical Outcomes Assessment Tool in a US Dental School. Jeffrey Wood, Nader Nadershahi, Richard Fredekind. JDE 67(1): 2003

27 University of Louisville An Initiative to Prepare Adult Nurse Practitioners and Family Nurse Practitioners (ANP/FNP) and Dental Students for Deliberative Interprofessional Collaborative Practice Theresa G. Mayfield, D.M.D. Associate Dean for Clinical Affairs University of Louisville School of Dentistry Presented at ADEA CCI Summer 2013 Liaisons Meeting, Portland, OR

28 Editorial

29 Dean UHS Board Associate Deans for Clinical Affairs and Patient Services Quality Improvement Committee Sedation & Medical Emergency Preparedness Committee Infection Control Sub-Committee Dept Chairs & Specialty Program Directors Health & Safety Officer Director of QI Patient Relations Coordinator Student, Staff Patient Injury RCA or remediation UORs filed by provider Adverse Patient Event or Outcomes Group Leaders of care review with students AE/QORs filed by Group Leaders Feedback to students to correct deficiencies Student completes new /periodic exam Chart Audit by Office of Clinical Affairs Patient Complaint Resolved with Patient Relations Coordinator or with RM Clinical Interaction Report Feedback to students to correct deficiencies Students provide treatment IC Audit by Health & Safety Team Feedback to students on quality of care Students complete phase of treatment PTRs with faculty Feedback to students, residents Patients receive treatment Pt Satisfaction Survey completed by patients Safe Environment Quality of Care Patient Satisfaction

30 Developing a Patient Safety System for Dentistry R01, 5-Year NIH/NIDCR Grant Dental Schools of University of Texas Houston, Harvard University, University of California San Francisco, Oregon Health & Science University 1.Develop the tools to document dental AEs 2.Generate a classification scheme and repository to organize AEs 3.Enable five dental organizations to systematically collect and analyze AEs

31 Acknowledgments Karla Kent, PhD Oregon Health & Science University Elsbeth Kalenderian, DDS, MPH Rachel Ramoni, DMD, ScD Harvard Medical School Muhammad Walji, PhD UT Houston

32 Questions, comments?