Patient Safety

Over recent years, two national reports published by the Institute of Medicine focus on the need for patient safety programs in hospitals. The reports are entitled "To Err is Human: Building a Safer Healthcare System" and, more recently, "Crossing the Quality Chasm: A New Healthcare System for the 21st Century". Both reports place a spotlight on healthcare errors and identify the need to evaluate and rebuild systems that decrease risk to patients. This involves a need to report errors that occur as well as "near misses" and utilize information to identify risk points and build systems that reduce these risks. Systems is a keyword when talking about patient safety programs. Over many decades healthcare has focused on ensuring that those providing the care are well trained and practice safely. It is important to continually assess the capabilities of those that provide healthcare. However, it is increasingly important to realize that those delivering healthcare are part of complex health delivery systems that need to be retooled and strengthened to support the provision of safe care. The success of such efforts requires us to change the culture in which healthcare is provided. Creating a culture of safety is truly a team effort involving hospitals, caregivers, physicians, and patients. At CVPH, our patient safety program has several functions:

1. We encourage reporting of errors and near-errors by all healthcare providers;
2. We analyze the information provided in reports to identify system weaknesses;
3. We identify root causes (of errors and near-errors) and implement changes to reduce risks;
4. We monitor the results of system changes to evaluate their effectiveness.

We value input from our customers into the patient safety program. Patients and families must be partners in the provision of safe healthcare. Listed below are a few key considerations for consumers of healthcare and opportunities to partner with providers in reducing risks of medical error and assuring positive outcomes for patients:

1. Patient identification. It is important that healthcare is delivered as intended. This means the right treatments and medications provided to the right patient. For example, healthcare workers deal with many patients on a daily basis. In a hospital setting, you will be identified with an armband and it is important that you check the accuracy of the information at the time an armband is applied. It is equally important that you assure that caregivers utilize your armband before providing treatments or medications. We urge patients to remind healthcare workers to check your identification band prior to such procedures.
2. Consents. Persons are asked to sign consents when accessing healthcare and prior to many procedures such as surgery or blood transfusions. It is important that patients discuss the specific consents with their physicians and healthcare providers and understand what they are signing. They should know what the risks and benefits of the procedures or treatments are. They must also check the accuracy of the information written on the consent; for example, "right" or "left".
3. Medication. Patients should be familiar with medications that they take routinely and be informed about new medications that are being prescribed. Medications are intended to benefit patients; however, can have side effects or interactions if multiple medications are taken. Vitamins, herbal preparations, and food supplements should also be thought of as medications. Pharmacies, hospitals, and doctor offices have information about medications and food and drug interactions and are able to provide patients with education related to these medications. Patients should be familiar and able to relate to healthcare providers what drugs they are currently taking. In our community, a form called "Vital Link" can help you keep a current list of medications to bring with you to your doctor's office or the hospital. Patients in healthcare settings should look at medications that they are being given and question providers if, in fact, the medications look different than those that they normally take at home.
4. Infection Prevention. At any time patients undergo procedures or hospitalization, there is risk of infection. We encourage patients to practice good hygiene and handwashing. It is equally important that caregivers utilize handwashing or hand hygiene products as they travel from patient to patient. We encourage patients to speak to their healthcare workers if they do not observe handwashing procedures.
5. Restraints. As older patients are hospitalized, it is understandable that their new surroundings may cause confusion. The use of restraints to prevent patients from falling has been associated with a significant increased risk that patients will be harmed. All hospitals are therefore aware that restraints are only appropriate in extreme circumstances. Family members may be asked to assist in spending time with patients to orient them to their environment, as restraints will not be routinely used.

These are but a few of the many safety measures that patients and providers can share in creating a safer healthcare environment.

Websites

Joint Commission
www.jcipatientsafety.org

Health Care Quality Commission
www.hcqualitycommission.gov/cborr/

National Patient Safety Foundation 
www.npsf.org

We invite you to utilize these web sites to explore more ideas on patient safety. Additionally, we urge you to discuss concerns with your healthcare workers at any point you are receiving care.