Regional Workshop:Regional Workshop: ""Radiation Protection Culture in Radiation Protection Culture in Medicine”Medicine”

Th P i V iTh P i V iThe Patient VoiceThe Patient Voice

PATIENTS FOR PATIENT SAFETY PATIENTS FOR PATIENT SAFETY PFPSPFPSWHO PATIENT SAFETY PROGRAMMEWHO PATIENT SAFETY PROGRAMME

Dr. Jorge César MartínezDr. Jorge César Martínez

CHICAGO 2007 Patient Safety WorkshopCHICAGO 2007 Patient Safety Workshop

“It may be part of human nature to “It may be part of human nature to err, but is also part of human err, but is also part of human nature to create solutions findnature to create solutions findnature to create solutions, find nature to create solutions, find better alternatives and meet the better alternatives and meet the challenges ahead.”challenges ahead.”

“First Do No Harm.”“First Do No Harm.”

HippocratesHippocrates4th Century A.D.

Patients for Patient Safety

• Strengthen capacity, communication, advocacy PFPS Network

• Collaborate with WHO, national, international organizations

Policy-makers

• Create and share knowledge through research, education and training

Academic institutions

• Facilitate patient engagement at hospitals and health-care facilities

Health-care providers and health care facilities

• Collaborate with NGOs and professional organizations

Civil society, NGOs p gNGOs

How patients are engaged?

• As advocates and catalyst for change:   ‐ Telling stories ‐ put 

Margaret Murphy (Ireland) •Lead Advisor to WHO an patient engagement

•Chair of the PFPS Strategy Group•Member of the WHO Patient Safety Curriculum 

Guides committeeg g pa human face behind patient 

safety statistics

• As advisors on professional

Guides committee•Recently reappointed as a lay member of the Irish 

Medical Council (regulatory body) for the 2013‐2018 period

• As advisors‐ on professional, accreditation and regulatory committees and boards and 

contribute to policy 

Johanna Trimble (Canada) - On committee developing continuing 

physician education on use of medication for the elderly

development

• As educators to students and health professionals

Maryann Murray (Canada) ‐ Provided input to help change legislation after the 

(health professionals ADE (her 21 year old daughter died of heart failure after taking contra‐

indicated medication

What can be learned from this personal story?Patient VoicePatient Voice

PFPS PFPS

1. Patients who know what to expect during treatment can help identify potential incidents before they occur.

2. Telling a story is a way to enable reflections that do not jump from the pages of statistical reportsnot jump from the pages of statistical reports.

Errors Errors ==NOT ALL THE COST CAN BE DIRECTLY NOT ALL THE COST CAN BE DIRECTLY

MEASUREDMEASURED LLoss of trust in the system by patientsoss of trust in the system by patients Longer hospital stay or disability produce physicalLonger hospital stay or disability produce physicalLonger hospital stay or disability produce physical Longer hospital stay or disability produce physical

and psychological discomfortand psychological discomfort Health care professionals: loss of morale and Health care professionals: loss of morale and p f fp f f

frustrationfrustration

WHO COMMITMENTS IN PATIENT SAFETY: WHO COMMITMENTS IN PATIENT SAFETY:

PFPSPFPSTRAININGTRAINING

THE NEXT GENERATIONTHE NEXT GENERATION

Knowledge, skills and attitudes Knowledge, skills and attitudes g ,g ,needed for 21needed for 21stst century carecentury care

Accept patients as partnersAccept patients as partnersR l h h “ f ” dR l h h “ f ” d Realise that the “experience of care” needs to Realise that the “experience of care” needs to be improvedbe improvedU d d h f d llU d d h f d ll Understand the importance of data collection, Understand the importance of data collection, error analysis and feedback in a just culture in error analysis and feedback in a just culture in driving improvementdriving improvementdriving improvementdriving improvement

Critical Success Factors

Creation of an organization of “safety culture” instead of “blame culture”instead of blame culture

Patient safety as “the” top priority, not“a” priority

Leadership by engagement …and modelp y g g

Patient VoicePatient VoicePFPSPFPS Recommendations / SolutionsRecommendations / SolutionsPFPS PFPS –– Recommendations / SolutionsRecommendations / Solutions

L i bj ti f t tiL i bj ti f t tiLearning objective for next generations:Learning objective for next generations:Understand the ways in which patients and Understand the ways in which patients and carers can be involved as partners in health carers can be involved as partners in health care both in preventing harm and learning and care both in preventing harm and learning and healing from an adverse eventhealing from an adverse event

Patient VoicePatient VoicePFPSPFPS –– Recommendations / SolutionsRecommendations / SolutionsPFPS PFPS –– Recommendations / SolutionsRecommendations / Solutions

Performance requirements for next generationsPerformance requirements for next generations actively encourages patients and carers to share informationactively encourages patients and carers to share information shows empathy honesty and respect for patients and carersshows empathy honesty and respect for patients and carers shows empathy, honesty and respect for patients and carersshows empathy, honesty and respect for patients and carers communicates effectivelycommunicates effectively obtaining informed consentobtaining informed consent shows respect for each patient’s differences, religious and shows respect for each patient’s differences, religious and

cultural beliefs, and individual needscultural beliefs, and individual needs describes and understands the basic steps in an open describes and understands the basic steps in an open

d ld ldisclosure processdisclosure process apply patient engagement thinking in all clinical activitiesapply patient engagement thinking in all clinical activities demonstrates ability to recognize the place of patient and demonstrates ability to recognize the place of patient and y g p f py g p f p

carer engagement in good clinical managementcarer engagement in good clinical management

Patient VoicePatient VoiceSS d i / S l id i / S l iPFPS PFPS –– Recommendations / SolutionsRecommendations / Solutions

Performance requirements for next Performance requirements for next generationsgenerationsoo SSh li t i killh li t i killoo SSharpen listening skillsharpen listening skillsoo PPay attention to patient perceptionsay attention to patient perceptionsoo IInvite the patient to discuss detailsnvite the patient to discuss detailsoo KKnow the factsnow the factsoo EExplore emotions and deliver empathyxplore emotions and deliver empathyoo SStrategize next steps with patient ortrategize next steps with patient oroo SStrategize next steps with patient or trategize next steps with patient or

familyfamily

Patient VoicePatient VoicePFPS PFPS –– Recommendations / SolutionsRecommendations / Solutions

Share: experiencesShare: experiences-- strengthsstrengths-- limitationslimitationsShare: experiencesShare: experiences strengthsstrengths limitations limitations help help

i di id l d i ti l hi di id l d i ti l hindividuals and organizations learn howindividuals and organizations learn howimprove activitiesimprove activities

Patient VoicePatient VoicePFPS PFPS -- ChallengeChallenge Many individual Champions are Many individual Champions are

performing an excellent job and performing an excellent job and p g jp g jproposalsproposals

The impact analysis produceThe impact analysis produce The impact analysis produce The impact analysis produce recommendations of how to translate recommendations of how to translate awareness into evidenceawareness into evidence--basedbasedawareness into evidenceawareness into evidence based based interventions to reduce patient harminterventions to reduce patient harm

Radiation safety issues seen from the patient perspective WHOWHO

PFPSPFPS1. Lack of access to appropriate diagnostics and

t t t

PFPSPFPS

treatment2. Delayed diagnostic imaging resulting in delayed

treatmenttreatment3. Misinterpretations and resulting misdiagnosis4 Unnecessary tests and ineffective treatment4. Unnecessary tests and ineffective treatment5. Errors in administering diagnostic tests and

treatmenttreatment6. Unacceptable effects of treatment

THE CURRENT REALITY

Existence of a low level of patient understanding

The need for an effective method of communicating risks and benefits

Knowledge gaps which prevent patients from assessing options

Patients and the wider public unaware of the risks associated with imagingg g

THE SOLUTIONTHE SOLUTION Patient education which would facilitate meaningful

interaction between patient and providerinteraction between patient and provider

Addressing the deficit in easily accessible i f tiinformation

Implementing a consultation process at policy making level which includes patient representation and values the patient perspective.

Prevention of medical radiation incidentsPrevention of medical radiation incidentsPrevention of medical radiation incidentsPrevention of medical radiation incidents

What needs to beWhat needs to be What WHO can doWhat WHO can doWhat needs to be What needs to be donedone

What WHO can doWhat WHO can doEngage change leaders Engage change leaders in finding ways to teachin finding ways to teach

Implement and Implement and support voluntary support voluntary

in finding ways to teach in finding ways to teach patients to speak up when patients to speak up when something seems ”wrong”something seems ”wrong”

educational safety educational safety reporting systemsreporting systems

Help qualify patient Help qualify patient safety reporting systemssafety reporting systems

Harmonize Harmonize taxonnomy in relation taxonnomy in relation

Help define taxonomy Help define taxonomy that could be meaningful that could be meaningful i ti t ’ i id ti ti t ’ i id tto medical radiation to medical radiation

incidents and accidentsincidents and accidentsin patients’ incident in patients’ incident reportsreports

Patient VoicePatient VoicePFPS PFPS -- ChallengeChallenge How demonstrate that patient care is safer How demonstrate that patient care is safer

because of patient engagementbecause of patient engagementddandand

how the effect of PFPS is perceived by how the effect of PFPS is perceived by HealthHealth--Care ProvidersCare ProvidersHealthHealth--Care ProvidersCare Providers

are measures difficult to make visiblesare measures difficult to make visiblesare measures difficult to make visiblesare measures difficult to make visiblesbutbut

should be our goalshould be our goalshould be our goalshould be our goal

Muchas pequeñas cosasMuchas pequeñas cosasMany little thingsMany little thingsMuchas pequeñas cosas,Muchas pequeñas cosas,hechas por hechas por Many little thingsMany little things

muchas pequeñas personas,muchas pequeñas personas,en muchos pequeños lugares en muchos pequeños lugares Done by many Done by many little peoplelittle peopleen muchos pequeños lugares, en muchos pequeños lugares, podrán cambiar podrán cambiar

l f d l Til f d l TiIn many little placesIn many little placesla faz de la Tierra.la faz de la Tierra.In many little placesIn many little places

Could change the face of the worldCould change the face of the worldCould change the face of the world.Could change the face of the world.