PATIENT SAFETY

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PATIENT SAFETY through COMMUNICATION Ma
rch 11, 2008
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• BACKGROUND on MIPS
• Independent, non-profit corporation
• Created in May 2004
• Governed by 12 member board
• Majority (7) elected by our membership and 5
  appointed by Minister of Health
• Board citizens, providers, administrators

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• MISSION
• To promote patient safety and quality health care
  for Manitobans

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Objective 1 Promote patient safety activities in
Manitoba health care system.
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Objective 2 Identify emerging patient safety
quality care issues.
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Objective 3 Promote best practices in patient
safety.
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Objective 4 Raise awareness of patient safety
issues.
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MIPS PATIENT ADVISORY COMMITTEE MPAC
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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

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FACTS

• 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.

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Safety in Long-Term Care Settings (2008)Wagner
Rust
FACTS

• 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

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• Patient safety is everyones responsibility.

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• PATIENT SAFETY IS A COMMON GOAL
• Reduce preventable harm to patients
• Provide the safest quality care possible

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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?

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ACTION CHECKLIST(Reality Check)

• Do I
• Communicate in respectful open, honest manner
  daily?
• Communicate regularly with families HC team?
• Provide families with timely health information?
• Use plain language and visual clues when
  discussing the patient with families?
• Regularly ask families to clarify what was
  discussed?

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ACTION CHECKLIST

• DO I
• Encourage families to ask questions?
• Discuss patient safety with families HC team?
• Look for latent safety threats every day?
• Report/disclose any errors or potential errors
  that may impact on patients?
• DO I PROMOTE PATIENT SAFETY??

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BUILDING BLOCKS TOPATIENT SAFETY
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• BUILDING BLOCKS TO PATIENT SAFETY

Communication
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Communication
Patient Safety
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COMMUNICATION

• Why is it important?
• Bridge between HC providers, patients/ families
  rest of HC team to achieve patient safety
  quality care.

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• Communication
• Root cause of 70 of sentinel events reported to
  the Joint Commission, US.

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WHAT TYPE OF COMMUNICATION IS NEEDED ?

• Verbal Non-Verbal
• Respectful
• Honest
• Mutually trusting
• Accepting
• Empathetic

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COMMUNICATION

• Interdisciplinary
• Engage family
• Care planning
• Reporting/disclosing incidents
• Medication safety
• Critical to culture of safety
• Timely shared

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• BUILDING BLOCKS TO PATIENT SAFETY

Action
Communication
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• What can you-Health Care Provider- do?

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ACTIONS OF HEALTH CARE PROVIDERS

• Open two-way communication
• Ongoing involvement
• Ongoing sharing
• Teamwork
• Advocate for Culture of Patient Safety

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• ACTION
• OPEN TWO-WAY COMMUNICATION
• Talk with families/care givers.
• Listen to families/care givers.
• Talk with HC team.
• Listen to HC team.

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• ACTION
• ONGOING INVOLVEMENT
• Families/care givers in health decisions
• Health care team
• Upper management

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• ACTION
• 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

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• ACTION
• TEAMWORK
• Effectively collaborate with others
• Give and receive feedback on performance
• No Blame approach to incident reporting
  analysis

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• ACTION
• 5. ADVOCATE - CULTURE of PATIENT SAFETY
• Be a site champion
• Stay positive
• Involve families in important decisions
• Be persistent

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• BUILDING BLOCKS TO PATIENT SAFETY

Support
Action
Communication
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• SUPPORT
• 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?

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• SUPPORT
• Is there a collaborative environment?
• Blame-free reporting system
• Proactive approach (errors/problems anticipated)
• Share information (3 Cs)
• Accountability - safety is everyones
  responsibility
• Monitoring of situations actions taken

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• SUPPORT
• Are families/care givers involved in process of
  patient safety improvement?
• Is there a clear organizational policy?
• Are there adequate resources to respond to
  identified concerns?

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SUPPORT

• For residents,
• Balance
• Patient Safety Quality of Life/
• Independence

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TOOL for FAMILIES HC PROVIDERS

• Is It Safe to Ask?
• ISTA

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• Its 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

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• Its Safe to Ask (ISTA) Target Groups
• Public Groups in Manitoba (such as elderly, low
  literacy, people with disabilities)
• Health care providers

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• Its Safe to Ask
• What is my health problem?
• What do I need to do?
• Why do I need to do this?

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• What are the values behind in ISTA?
• 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)
• Ask questions.

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• What is MPAC telling families/care givers?
• Communicate with HC providers
• Ask questions
• Learn some medical terminology
• Seek credible resources
• Gain support

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• Material translated into
• Amharic English
• Arabic French
• Chinese Cree
• Ojibway Oji-Cree
• Eritrean German
• Korean Punjabi
• Russian Spanish
• Tagalog 15 languages!

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• PHASE 2, ISTA
• Medication Card

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• Patient Safety is
  achievable!
• Everyone must be willing to

Support
Act
Communicate
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Look for windows of opportunity
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• FAMILY STORIES

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• www.mbips.ca
• www.safetoask.ca

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COMING TOGETHER IS A BEGINNING. KEEPING TOGETHER
IS PROGRESS. WORKING TOGETHER IS
SUCCESS. Henry Ford