Transcript Document

PATIENT SAFETY
through
COMMUNICATION
March 11, 2008
BACKGROUND on MIPS:
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Independent, non-profit corporation
Created in May 2004
Governed by 12 member board:
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Majority (7) elected by our membership and 5
appointed by Minister of Health
 Board – 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 COMMITTEE
“MPAC”
MPAC
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Provide a voice for patients/families interested in
patient safety & its promotion in healthcare settings
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Do activities to promote MIPS mission & objectives
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Create long-term strategies for patient & family
involvement in MB Health care system
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:
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7. 5% (185,000) of adult hospital admissions (acute
care) resulted in an adverse event
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Of these, 37% (70,000) were considered preventable,
and
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9000-24000 died.
FACTS
Safety in Long-Term Care Settings (2008)
Wagner & Rust
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Accidental injury - most common adverse event among
nursing home residents with dementia & psychosis
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Falls - most frequently reported adverse event in LTC
settings
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Medications- 42% of all adverse drug events preventable
“Patient safety is everyone’s responsibility.”
PATIENT SAFETY IS A COMMON GOAL
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Reduce preventable harm to patients
Provide the safest quality care possible
DO I PROMOTE PATIENT SAFETY?
Ask yourself:
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Do I value resident safety?
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Do I communicate effectively with residents &
their families?
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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
Communication
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.
WHAT TYPE OF COMMUNICATION IS NEEDED ?
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Verbal & Non-Verbal
Respectful
Honest
Mutually trusting
Accepting
Empathetic
COMMUNICATION
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Interdisciplinary
Engage family
Care planning
Reporting/disclosing incidents
Medication safety
Critical to culture of safety
Timely shared
BUILDING BLOCKS TO PATIENT SAFETY
Action
Communication
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
OPEN TWO-WAY COMMUNICATION:
1.
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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
ONGOING SHARING of:
3.
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Patient information
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Importance of patient safety
•
Latent threats to patient safety
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Reporting/disclosure of adverse events
With:
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Families/care givers
Rest of HC team
ACTION
4.
TEAMWORK:
• Effectively collaborate with others
• Give and receive feedback on
performance
• “No Blame” approach to incident
reporting & analysis
ACTION
5. ADVOCATE - CULTURE of PATIENT SAFETY
• Be a site “champion”
• Stay positive
• Involve families in important decisions
• Be persistent
BUILDING BLOCKS TO PATIENT SAFETY
Support
Action
Communication
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?
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“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
Arabic
Chinese
Ojibway
Eritrean
Korean
Russian
Tagalog
English
French
Cree
Oji-Cree
German
Punjabi
Spanish
15 languages!
PHASE 2, ISTA
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Medication Card
Patient Safety is achievable!
Everyone must be willing to:
Support
Act
Communicate
Look for
windows of
opportunity
FAMILY STORIES
www.mbips.ca
www.safetoask.ca
COMING TOGETHER IS A BEGINNING.
KEEPING TOGETHER IS PROGRESS.
WORKING TOGETHER IS SUCCESS.
Henry Ford