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error is preventable through improved system design to counteract error including the use of checklists, decreasing interruptions, preventing fatigue, avoiding task saturation and improved environmental conditions. Slide 94 REDUCING DIAGNOSTIC ERRORS ‒ Point-of-care (POC) testing utilizes hand-held medical devices ‒ Devices often not covered by the regulations ‒ Personnel seldom required to undergo training Continued… The use of point-of-care testing utilizes hand-held medical devices which are computerized to perform many diagnostic tests - once performed exclusively by trained healthcare personnel - outside of the laboratory or clinic by people with limited experience and training. The devices used are often not covered by the regulations that govern tests performed in a laboratory setting and the personnel performing point-of-care tests are seldom required to undergo training. 53 It's a New Day in Public Health FDOH Medical Errors: A Public Health Perspective Learner Course Guide Slide 95 REDUCING DIAGNOSTIC ERRORS ‒ Manufacturer’s instructions should be followed carefully to avoid risk of error ‒ Errors can have serious consequences because medication dosages are frequently determined by test results (Wolcott et al., 2008). Although point-of-care tests have a small risk for erroneous results, the manufacturer’s instructions should be followed carefully to avoid risk of error. Errors in point-of-care testing such as glucose and prothrombin time can have serious consequences because medication dosages are frequently determined by POC test results (Wolcott et al., 2008). Slide 96 NPSGs-Reducing Diagnostic Errors ‒ Failing to inform of test results can be a serious error ‒ Failure to inform patients of abnormal outpatient test results are common ‒ Use of simple processes for managing results is associated with lower failure rates (Casalino, Dunham, Chin, Bieland, Kistner, Karrison, Ong, Sarkar, McLaughlin & Meltzer, 2009). (Goal 1, 2, 13) Failing to inform a patient of an abnormal outpatient diagnostic test result can be a serious error. Research indicates failures to inform patients or to document informing patients of abnormal outpatient test results are common; use of simple processes for managing results is associated with lower failure rates. Slide 97 PUBLIC HEALTH PRACTICE & MEDICAL ERRORS Increase of occurrence of medical errors in the outpatient setting offers relevance to the importance of being aware and proactive in the prevention of medical errors in the public health practice arena. The focus of public health is on the safety and well-being of entire populations. A unique aspect of the field is that it strives to provide services that benefit the largest number of people 54 It's a New Day in Public Health FDOH Medical Errors: A Public Health Perspective Learner Course Guide Slide 98 Safety Concepts for PopulationPatient Safety and Public Health Nursing (PHN) Operational Failures Systems Failures PHN Errors of Omission PopulationPatient Safety Preventable Harm by PHN PHN Errors of Commission When providing public health nursing care to the population-patient, structural failures and errors may lead to poor health outcomes and accidental harm. The diagram provided conceptualizes safety as the outcome for population-patients when no errors or failures of practice occur. Slide 99 Population-Patient Safety and Public Health Practice Structures ‒ Operational Failures – Insufficient vaccine supplies – Improper staffing – Insufficient staff training or supervision – Lack of safety culture – Failure to share community referral resources Operational failures are those structural aspects within the organization which make it difficult to avoid making errors. These may be described as problems leading to not having the necessary supplies or information. Disruptions, delays, risks and losses which are costly to the organization frequently occur as a result. Examples may include: insufficient vaccine supplies, improper staffing; insufficient staff training or supervision; lack of safety culture; failure to share community referral resources needed by other staff to efficiently provide care. 55 It's a New Day in Public Health FDOH Medical Errors: A Public Health Perspective Learner Course Guide Slide 100 Population-Patient Safety and Public Health Practice ‒ Systems Failures – Untimely distribution of reports – Inability to obtain or communicate information – Personnel restrictions – Lack of HIPAA agreement Systems failures are those structural aspects of inter-organizational and inter-agency networks that make it difficult to avoid errors. Examples may include: untimely distribution of infectious disease reports among agencies; inability to obtain or communicate information across agency boundaries; personnel restrictions which limit or restrict PHN involvement in community coalitions; lack of HIPAA agreement for patient data sharing and appropriate referrals. Slide 101 Population-Patient Safety and Public Health Practice Processes ‒ Error by omission ‒ Error of commission ‒ Error of communication Error by omission is the failure to engage in an act that would have otherwise prevented illness, distress or harm. Examples may include: inadequate outbreak investigation; failure to conduct a community needs assessment; failure to effectively participate in a community collaborative; failure to conduct outreach to vulnerable populations; failure to identify best practices for population level practices. An example of an error of omission is when the public health nurse falls to fully assess the specific population at risk for missed vaccinations and the underlying reasons for a locally low or declining immunization rate which results in outbreak of communicable disease. Error of commission is engagement in an act that directly leads to or causes illness, distress, or unintentional harm. Examples may include: over-publicized health consequence of an outbreak, implementing a health program shown 56 It's a New Day in Public Health FDOH Medical Errors: A Public Health Perspective Learner Course Guide to be harmful, providing inaccurate data or health information to community groups (Example – A PHN distributes a poorly worded PHA that warns against a health behavior but sparks a widespread panic or anxiety; a patient is having his gallbladder removed but during the surgery, the intestine is nicked and the patient develops a serious infection). Error of communication is the miscommunication or lack of communication which results in preventable harm. The error could occur between a provider and patient or between multiple providers. (Example – A cardiologist, aware the patient was not ready to resume normal activities, failed to warn a 19 year old patient not to run while diagnostics were pending following a syncopal episode; having not been warned, the patient resumed running and suffered sudden death while running.) Slide 102 How Can Errors be Reduced and Patient Safety be Increased???? Create….. A CULTURE OF SAFETY Each of us is responsible for creating a culture of safety. 57 It's a New Day in Public Health FDOH Medical Errors: A Public Health Perspective Learner Course Guide Slide 103 Effective Safety Culture ‒ Shared commitment to safety ‒ Safety-promoting behaviors are encouraged and reinforced by leadership ‒ Near-misses are valued as opportunities for learning and improvement Effective safety cultures have been defined as those in which there is shared commitment to safety, where engaging in safety-promoting behaviors is encouraged and reinforced by leadership and where near misses are valued as opportunities for learning and improvement (Weaver, Dy, Lubomski & Wilson, 2013). Slide 104 Patient Engagement Engaging patients more fully in their care is a primary task toward the creation of a culture of safety. Patient engagement entails involving and informing the patient in choosing treatment options, encouraging the patient to develop healthy habits, and educating and empowering the patient so that the patient feels confident making