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Health literacy is the “capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.” Individuals with limited health literacy skills or those who lack mastery of the English language may require additional or alternative forms of communication in order to ensure care is safely delivered and instructions for care fully understood. Slide 77 Decrease the Risk of Errors Implement safe practices The implementation of safe practices such as promoting and facilitating effective hand hygiene, establishing protocols for communicating critical lab values, standardizing procedures and reconciling medications has solved a number of systemic problems associated with care delivery; however, there is much to be done. Slide 78 RISKY BEHAVIORS At-risk behaviors are those actions performed by healthcare providers which have potential to compromise patient safety At-risk behaviors are those actions performed by healthcare providers which have potential to compromise patient safety. Healthcare personnel may engage in risky behaviors because the risk of patient harm seems remote. They may unknowingly engage in risky behaviors when they become comfortable and competent with a task and lose the perception of risk (NCCMERP, 2007). 47 It's a New Day in Public Health FDOH Medical Errors: A Public Health Perspective Learner Course Guide Slide 79 RISKY BEHAVIORS ‒ “Grab and go” ‒ Failure to educate patients ‒ Using medications without complete knowledge of the medication Continued… Risky behaviors often emerge because of system-based problems in healthcare organizations. The perceived benefits of taking a risky shortcut lead to repeated at-risk behaviors, despite the healthcare provider’s possible knowledge, on some level, that patient safety could be at risk. Slide 80 RISKY BEHAVIORS ‒ Failure to double check high alert medications ‒ Not communicating important information – patient allergies, – diagnosis/co-morbid conditions, – weight, etc. (NCCMERP, 2007) In addition, as one healthcare worker has apparent success with an at-risk behavior, they will likely influence fellow workers until that behavior becomes a standard practice (NCCMERP, 2007). Slide 81 MINIMIZING AT-RISK BEHAVIORS ‒ Eliminate organizational tolerance of risk. ‒ Determine systems-based reasons for risk-taking behavior. Continued… An organizational culture with a high tolerance of at risk behaviors is a system based problem which may lead to medical error and patient harm. Unnecessary complexity in processes provides many opportunities for healthcare providers to take risks when providing care to a patient. The National Coordinating Council on Medication Error Reporting and Prevention (2007) made the presented recommendations to reduce medical errors associated with at-risk behaviors: • Eliminate organizational tolerance of risk. • Determine systems-based reasons for risk-taking behavior. 48 It's a New Day in Public Health FDOH Medical Errors: A Public Health Perspective Learner Course Guide Slide 82 MINIMIZING AT-RISK BEHAVIORS ‒ Increase awareness of at-risk behaviors. ‒ Eliminate system-wide incentives for at-risk behaviors. ‒ Motivate through feedback and rewards. • Increase awareness of at-risk behaviors. • Eliminate system-wide incentives for at-risk behaviors. • Motivate through feedback and rewards. Slide 83 NATIONAL PATIENT SAFETY GOALS (NPSGs) Goal 1 – Improve the accuracy of patient identification - use at least two patient identifiers The National Patient Safety Goals (NPSGs) were established in 2002 to help accredited organizations address specific areas of concern in regards to patient safety. Slide 84 NATIONAL PATIENT SAFETY GOALS (NPSGs) Goal 1 ‒ When administering medications, blood or blood components ‒ When collecting blood samples and other specimens for clinical testing ‒ When providing treatment or procedures Goal 1 - Improve the accuracy of patient identification • When administering medications, blood or blood components, • When collecting blood samples and other specimens for testing, or • When providing treatment or procedures Goal 2 - Improve the effectiveness of communication among and between caregivers. Slide 86 NATIONAL PATIENT SAFETY GOALS (NPSGs) Goal 3 – Improve the safety of using medications To Protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts. Goal 3 - Improve the safety of using medications: • Label all medications and medication containers, • Maintain and communicate accurate patient medication information, • Reduce the likelihood of patient harm associated with the use of anti-coagulate therapy, Slide 87 NATIONAL PATIENT SAFETY GOALS (NPSGs) Goal 3 ‒ Label medications ‒ Maintain accurate medication information ‒ Reduce the likelihood of patient harm ‒ Provide patient education (Continued) • Provide patient education to ensure the patient knows what medicines to take at home, and • Maintain and communicate accurate patient medication information. 50 It's a New Day in Public Health FDOH Medical Errors: A Public Health Perspective Learner Course Guide Slide 88 NATIONAL PATIENT SAFETY GOALS (NPSGs) Goal 7 – Reduce the risk of healthcare associated infections: Goal 7 - Reduce the risk of healthcare associated infections: Slide 89 NATIONAL PATIENT SAFETY GOALS (NPSGs) ‒ Use the hand cleaning guidelines from the CDC or the current WHO hand hygiene guidelines ‒ Set goals for improving hand cleaning ‒ Implement evidence based practices to prevent infections • Use the hand cleaning guidelines from the Centers for Disease Control and Prevention (CDC) or the current World Health Organization (WHO) hand hygiene guidelines, • Set goals for improving hand cleaning, • Implement evidence based practices to prevent central-line associated bloodstream infections (CBI), surgical site infections and catheter associated urinary tract infections (CAUTI) 51 It's a New Day in Public Health FDOH Medical Errors: A Public Health Perspective Learner Course Guide Slide 90 NATIONAL PATIENT SAFETY GOALS (NPSGs) Goal 9 - Prevent residents from falling: ‒ Identify those patients likely to fall and implement precautions Goal 9 - Prevent residents and patients from avoidable falls. Slide 91 NATIONAL PATIENT SAFETY GOALS (NPSGs) Goal 13 – Encourage patients and their families to be actively involved Goal 13 - Communication with residents and families about all aspects of their care, treatment or services is an important characteristic of a culture of safety. When residents know what to expect, they are more aware of possible errors and choices. Residents can be an important source of information about potential adverse events and hazardous conditions (2007). Slide 92 NATIONAL PATIENT SAFETY GOALS (NPSGs) Goal 15 – Identify safety risks inherent in patient populations ‒ Identify at risk for suicide, ‒ Identify risks with home oxygen therapy Goal 15 - Identify safety risks inherent in patient populations: Identify patients at risk for suicide and identify risks associated with patients who are utilizing home oxygen therapy 52 It's a New Day in Public Health FDOH Medical Errors: A Public Health Perspective Learner Course Guide Slide 93 NATIONAL PATIENT SAFETY GOALS (NPSGs) Basic Patient Protections ‒ Proper supply management ‒ Storage ‒ Labeling ‒ Instrument calibration; chart documentation ‒ Ensuring appropriate training ‒ Practicing appropriate hand hygiene ‒ Reconciling medication lists To meet National Patient Safety Goals, primary care practices must implement some basic patient protections, including such activities as proper supply management, storage, labelling, instrument calibration and chart documentation, in addition to more complex efforts like ensuring appropriate training, practicing appropriate hand hygiene and reconciling old, current and new medication lists. 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