Patient Safety

Today’s guest blog comes to us from Vicki Buchda, Director of Care Improvement at the Arizona Hospital and Healthcare Association (AzHHA). Once you have a chance to read it, we would lover to hear your thoughts on how we can continue to make patient safety a top priority. Generating meaningful conversations around the health issues affecting the people of our state is another way we are working toward our long-term goal of one day making Arizona the Healthiest State in the Nation!

hospital_signMost people who enter the healthcare system—whether for a routine check-up or treatment for a traumatic injury—assume that they will be cared for safely. There is an expectation that once we reach a hospital, we are in good hands. We are safe. Unfortunately, that is not always the case.

The statistics are staggering: up to 440,000 people die every year due to preventable medical errors. These errors occur in hospitals and in other healthcare settings. Infections acquired in hospitals, while fewer in number each year, still occur in one of every 25 hospitalized patients. Basic procedures such as handwashing are still not hard-wired, and patients themselves, most likely unknowingly, contribute to the development of organisms (bacteria) that are resistant to antibiotics by insisting on antibiotics when they seek treatment—even when the cause is viral. When these antibiotic resistant organisms infect people they are exceedingly difficult to treat.

According to ECRI, a federally certified Patient Safety Organization, diagnostic errors are the number one patient concern. These diagnostic errors, along with number 2 on the list, opioid safety, can occur anywhere, for example in a hospital, emergency department, outpatient surgery or in a clinic. ECRI states that approximately 1 in 20 adults experiences a diagnostic error. These errors can cause harm from a wrong or missed diagnosis, repeat testing or unnecessary procedures.

The top 10 patient safety concerns are:

  1. Diagnostic errors
  2. Opioid safety across the continuum of care
  3. Care coordination within a setting
  4. Workarounds
  5. Incorporating health IT into patient safety programs
  6. Management of behavioral health needs in acute care settings
  7. All-hazards emergency preparedness
  8. Device cleaning, disinfection, and sterilization
  9. Patient engagement and health literacy
  10. Leadership engagement in Patient safety

Patient safety can be improved, and according to AHRQ, everyone has a role.

  • Patients need to have an empowered voice and see themselves as a part of their own treatment team.
    • One example is Ask Me 3®, an educational program that encourages patients and families to ask three specific questions of their providers to better understand their health conditions and what they need to do to stay healthy.
      • What is my main problem?
      • What do I need to do?
      • Why is it important for me to do this?
    • AHRQ advises patients to:
      • Ask questions to endure they understand their diagnosis, treatment options and plans
      • Speak up about risks and problems they may encounter
      • Express their values and what is important to them
  • Families need to advocate for patients
  • Clinicians (doctors, nurses, and all members of the team) need to have respect for the voice of the patient and each other
  • Health systems set the tone or culture of safety in the organization.   A culture of safety includes lessons learned from high reliable industries, such as teamwork training, and tools, such as checklists. It also includes the concept of “just culture” which focuses on identifying and addressing systems issues, while maintaining accountability and establishing zero tolerance for reckless behavior.

Everyone in the health care process plays a role in delivering safe care. We are all united in the goal of keeping patients and those who care for them free from harm. We are making progress, but there is more work to be done!

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