In November of 1999, the Institute of Medicine (IOM) released its landmark report, “To Err is Human.” The realization that tens of thousands of Americans were dying every year because of medical errors brought the concept of patient safety to the forefront of medical organizations and public/private policymakers across the country.

This article series will deliver essential information on this critical issue in the following areas:
• Risk Assessment
• Physician Practice Patient Safety Assessment (PPPSA)
• Pathways for Patient Safety
• The Joint Commission’s National Patient Safety Goals
• TeamSTEPPS
• Examples of Successful Patient Safety Initiatives
• Advances in Patient Safety

What is Hurting Our Patients?
Whether patients are treated in the hospital, in the physician’s office, at a radiology suite, or at a surgical center, one of the biggest areas at risk for patient safety relates to medications. According to the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), more than 7,000 people die each year as a result of medication errors. Another half million Americans are injured in some way by mistakes made when administering various medicines. Patients and families are suffering at an incredibly high rate as even one error is one too many (Neuenschwander, 2009).

Another huge area of risk is patient identification. How are patients identified at your organization when they present for treatment – by name, by wristband, by family member? If you are with an outpatient facility, do you require the patient to show you photo identification? In the hospital setting, do you have a barcoding system that allows you to scan the patient’s wristband to confirm identification? What about children? What about patients with the same or similar sounding names? Do you confirm identification on every patient that comes through your door or your unit or your testing facility?

The Status Quo
Many organizations believe they are giving the best care available in the safest way they know how to give it. Consider Johns Hopkins Medicine in Baltimore, Maryland, which includes the Johns Hopkins School of Medicine, Bayview Medical Center, Howard County General Hospital, and Johns Hopkins Hospital. Their combined organization has 1,714 full-time attending physicians, 1,089 residents and fellows, and 1,017 beds.

Being a nationally renowned, $4.1 billion health system, Johns Hopkins believed they were the best of the best. What they discovered during a patient safety survey is that they had serious work to do to create the safety culture they believed was already in place. Executives created CUSP – the Comprehensive Unit Safety Program – as senior management began adopting units so they could observe what was actually occurring in the clinical setting. This first-hand knowledge allowed executives to better understand what was occurring at the point of service, create teams, and take direct action to improve various work flows and ultimately patient safety. As a result of these overall efforts, Healthcare Informatics honored Johns Hopkins Medicine with one of its 2009 HCI Innovator Awards (Gamble, 2008).

How Do We Assess Safety?
The Commonwealth Fund committed grant funding to the Institute for Safe Medical Practices (ISMP), the Health Research and Education Trust (HRET), and the Medical Group Management Association (MGMA) Center for Research to develop a self-assessment tool specifically focused on ambulatory care practices. The result of this effort is the Physician Practice Patient Safety Assessment or PPPSA, which consists of six domains:
• Medications
• Handoffs and Transitions among Providers and Settings
• Sedation and Invasive Procedures
• Personnel Qualifications and Competencies
• Practice Management and Culture
• Patient Education and Communication

So, you download the tool, print it out, and read it (available at www.Physiciansafetytool.org). What you do next is very important. Many medical practice executives and administrators feel that they do not have the time to use this process with all of the staff and physicians throughout their organization. Common excuses include, “It takes too long to complete,” “My physicians will NEVER fill out this stuff,” and “We already know that we give safe care.” Do you KNOW you give safe care, or do you THINK you give safe care? Has your staff ever given the wrong vaccine to a child? Do you reconcile medication lists at every visit? If you perform invasive procedures in the office, how do you ensure the right procedure is done on the right patient with the right equipment and the right staff? How do you measure these parameters? What do you do with any of the data that you collect? How is information communicated to the staff? Do you have a group of physicians that reviews “never events” and outcomes? What types of continuing education do you offer to the staff regarding safety? Unless you feel 100 percent comfortable with the answers to all of these questions, you cannot afford NOT to take the time to perform a safety assessment!

In 2007, Emily Callaway, Director of Morton Plant Mease Primary Care (MPMPC) in Tampa, Florida, chose to make patient safety a priority at her organization. With the support of her physician leaders, she administered the PPPSA at 31 practice sites at which time staff and 80 physicians voluntarily completed the assessment tool. MPMPC used the information gathered during the first assessment to make some changes throughout the offices. When Ms. Callaway repeated the assessment in 2008, it gave them an opportunity to see what things had changed throughout the organization and what areas for improvement still existed. Last month, Ms. Callaway presented her findings at the Institute for Healthcare Improvement’s (IHI) 10th Annual International Summit on Redesigning the Office Practice.

“We have found the PPPSA to be a valuable tool to improve quality and reduce patient harm. We now have over 40 offices with 80 physicians and plan to continue our patient safety journey by constantly trying to find opportunities for improvement. The physicians have really engaged the staff so that we now have a practice culture of continual self-improvement.” (Callaway, Nath, Gans, & Stokes, 2009)

What Next?
Many healthcare leaders and executives believe that their organizations are providing safe care. How many of them, however, will dare to assess their efforts objectively to discover what really happens inside the healthcare walls? Accept the challenge and be accountable for the results. Assess your organization now.
The next article will discuss the National Patient Safety Goals developed by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). Future articles will continue to address ongoing issues that can help create or destroy a culture of patient safety in the medical community.
Meanwhile, if you have any questions, would like assistance in assessing the safety of your organization, or desire a presentation on patient safety, contact Elizabeth Evans at eevans@cokergroup.com.

Additional Information
For more information, visit any of the web sites listed below. Search the site for “patient safety” if specific details are not immediately found.
• Agency for Healthcare Research and Quality at www.ahrq.org
• Institute for Healthcare Improvement at www.ihi.org
• Joint Commission on Accreditation of Healthcare Organizations at http://www.jointcommission.org/patientsafety/nationalpatientsafetygoals/
• Medical Group Management Association at www.mgma.com
• Morton Plant Mease Primary Care (MPMPC) at www.mpmprimarycare.com
• National Patient Safety Foundation at www.npsf.org
• National Institute for Children’s Health Quality at www.nichq.org
• World Alliance for Patient Safety at www.who.int/patientsafety
Other articles of interest include:

• Hohenhaus, S. M. and Frush, K.S. (2004). Pediatric patient safety: Common problems in the use of resuscitative aids for simplifying pediatric emergency care. Journal of Emergency Nursing, (30), 1, pp. 49-51.

• Jessee, W.F. (February, 2008). Taking a stand for patient safety: Reduce risk – and save money – by building patient safety into your systems. MGMA Connexion, pp. 38-41.

• Mendez, J. (September, 2008). Removing barriers so patients understand their care. MGMA Connexion, pp. 38-42.

• Murphy, J. (2009). Technology and nursing – A love/hate relationship. Journal of Healthcare Information Management, (23), 2, pp. 9-11.

• Pawola, L.M. (2008). Leadership establishes culture. Patient Safety & Quality Healthcare, (6), 4, pp 56-57.

• Schneck, L. H. (September, 2007). The good, the bad, and the equitable – Patient safety and the just culture. MGMA Connexion, pp. 27-28.

NOTE: Elizabeth Evans, RN, BSN, MPM, FACMPE, is a founding member of MGMA’s Patient Safety and Quality Advisory Committee, chairperson of MGMA’s Ethics Committee, and a member of the Executive Committee of the MGMA Board of Directors. Contact her at emevans@panda-llc.com.

References:
Callaway, E., Gans, D.N., Nath, M. R., and Stokes, C. D. (2009). Putting patient safety front and center in the medical practice – Enhancing patient safety using the PPPSA. Presented at the 10th annual international summit on redesigning the office practice sponsored by the Institute for Healthcare Improvement, March 24, 2009.

Gamble, K.H. (2009). The long mile. Healthcare Informatics, (26), 4, pp. 34-40.

Neuenschwander, M. (2008). National safety goals and barcoding. Patient Safety & Quality Healthcare, (6), 2, pp 16-17.