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PATIENT SAFETYthrough
COMMUNICATION
March 11, 2008
BACKGROUND on MIPS:BACKGROUND on MIPS: Independent, non-profit corporation Independent, non-profit corporation Created in May 2004Created in May 2004 Governed by 12 member board:Governed by 12 member board:
Majority (7) elected by our membership and 5 Majority (7) elected by our membership and 5 appointed by Minister of Healthappointed by Minister of Health
Board – citizens, providers, administratorsBoard – citizens, providers, administrators
MISSION
To promote patient safety and quality health care for Manitobans
Objective 1
Promote patient safety activities in Manitoba health care system.
Objective 2
Identify emerging patient safety & quality care issues.
Objective 3
Promote “best practices” in patient safety.
Objective 4
Raise awareness of patient safety issues.
MIPS PATIENT ADVISORY COMMITTEEMIPS PATIENT ADVISORY COMMITTEE
““MPAC”MPAC”
MPAC
Provide a voice for patients/families interested in patient safety & its promotion in healthcare settings
Do activities to promote MIPS mission & objectives
Create long-term strategies for patient & family involvement in MB Health care system
Canadian Adverse Events Study (2004):
The results suggest that, of the almost 2.5 million annual hospital admissions in Canada similar to the type studied, about:
7. 5% (185,000) of adult hospital admissions (acute care) resulted in an adverse event
Of these, 37% (70,000) were considered preventable, and
9000-24000 died.
FACTSFACTS
Safety in Long-Term Care Settings (2008)Wagner & Rust
Accidental injury - most common adverse event among nursing home residents with dementia & psychosis
Falls - most frequently reported adverse event in LTC settings
Medications- 42% of all adverse drug events preventable
FACTSFACTS
“Patient safety is everyone’s responsibility.”
PATIENT SAFETY IS A COMMON GOAL
Reduce preventable harm to patients Provide the safest quality care possible
DO I PROMOTE PATIENT SAFETY?
Ask yourself: Do I value resident safety?
Do I communicate effectively with residents & their families?
Do I do all that I can to promote patient safety in my organization?
ACTION CHECKLIST(Reality Check)
Do I:
1. Communicate in respectful open, honest manner daily?
2. Communicate regularly with families & HC team?
3. Provide families with timely health information?
4. Use plain language and visual clues when discussing the patient with families?
5. Regularly ask families to clarify what was discussed?
ACTION CHECKLIST
DO I:
6. Encourage families to ask questions?
7. Discuss patient safety with families & HC team?
8. Look for latent safety threats every day?
9. Report/disclose any errors or potential errors that may impact on patients?
DO I PROMOTE PATIENT SAFETY??
BUILDING BLOCKS TO
PATIENT SAFETY
BUILDING BLOCKS TO PATIENT SAFETY
CommunicationCommunication
COMMUNICATION
Why is it important?
Bridge between HC providers, patients/ families & rest of HC team to achieve patient safety & quality care.
Communication Root cause of 70% of sentinel events reported to
the Joint Commission, US.
WHAT TYPE OF COMMUNICATION IS NEEDED ?
Verbal & Non-Verbal Respectful Honest Mutually trusting Accepting Empathetic
COMMUNICATION
Interdisciplinary Engage family Care planning Reporting/disclosing incidents Medication safety Critical to culture of safety Timely shared
BUILDING BLOCKS TO PATIENT SAFETY
CommunicationCommunication
ActionAction
What can you-Health Care Provider- do?What can you-Health Care Provider- do?
ACTIONS OF HEALTH CARE PROVIDERS
1. Open two-way communication
2. Ongoing involvement
3. Ongoing sharing
4. Teamwork
5. Advocate for Culture of Patient Safety
ACTION
1. OPEN TWO-WAY COMMUNICATION:
• Talk with families/care givers.
• Listen to families/care givers.
• Talk with HC team.
• Listen to HC team.
ACTION
2. ONGOING INVOLVEMENT:
• Families/care givers in health decisions
• Health care team
• Upper management
ACTION
3. ONGOING SHARING of:
• Patient information
• Importance of patient safety
• Latent threats to patient safety
• Reporting/disclosure of adverse events
With:
• Families/care givers • Rest of HC team
ACTION4. TEAMWORK:
• Effectively collaborate with others
• Give and receive feedback on performance
• “No Blame” approach to incident reporting & analysis
ACTION5. ADVOCATE - CULTURE of PATIENT SAFETY
• Be a site “champion”
• Stay positive
• Involve families in important decisions
• Be persistent
BUILDING BLOCKS TO PATIENT SAFETY
Communication
Action
Support
SUPPORT:
1. Is there a patient safety culture? Is patient safety:
A top priority in your organization & among leaders?
Viewed as a positive concept? The focus of attention for all organizational
activities?
SUPPORT:
2. Is there a collaborative environment?
“Blame-free reporting system” Proactive approach (errors/problems anticipated) Share information (3 Cs) Accountability - safety is everyone’s responsibility Monitoring of situations & actions taken
SUPPORT:
3. Are families/care givers involved in process of patient safety improvement?
4. Is there a clear organizational policy?
5. Are there adequate resources to respond to identified concerns?
SUPPORT:
For residents,
Balance
Patient Safety Quality of Life/Independence
TOOL for FAMILIES & HC PROVIDERS
Is It … Safe to Ask?
ISTA
It’s Safe to Ask Offers information and tips
for providers and patients/families to:
Enhance clear communication
Make care a more positive experience
Increase health literacy
Help reduce adverse events
It’s Safe to Ask (ISTA) Target Groups:
1. Public Groups in Manitoba (such as elderly, low literacy, people with disabilities)
1. Health care providers
It’s Safe to Ask
1. What is my health problem?
2. What do I need to do?
3. Why do I need to do this?
What are the values behind in ISTA?
1. Know your rights as patients/families.
Personal Health Information Act (PHIA) Right of patient to receive healthcare instructions
and information in a way they/care givers can understand. (Standards for PCH #1 Pte Bill of Rights)
2. Ask questions.
What is MPAC telling families/care givers?
Communicate with HC providers: Ask questions
Learn some medical terminology
Seek credible resources
Gain support
Material translated into: Amharic English
Arabic French
Chinese Cree
Ojibway Oji-Cree
Eritrean German
Korean Punjabi
Russian Spanish
Tagalog 15 languages!15 languages!
PHASE 2, ISTA
Medication CardMedication Card
Patient Safety is achievable!Everyone must be willing to:
Communicate
Act
Support
Look for Look for windows of windows of opportunityopportunity
FAMILY STORIES
COMING TOGETHER IS A BEGINNING.COMING TOGETHER IS A BEGINNING.
KEEPING TOGETHER IS PROGRESS.KEEPING TOGETHER IS PROGRESS.
WORKING TOGETHER IS SUCCESS.WORKING TOGETHER IS SUCCESS.
Henry FordHenry Ford