National Patient Safety Awareness Week 2024

National Patient Safety Awareness Week is being celebrated on March 10-16, 2024.  The week is a way to highlight and improve patient safety in all healthcare settings by bringing awareness of best practices and improving access to resources to improve patient safety. 

History of National Patient Safety Awareness Week

National Patient Safety Awareness Week was initiated by the National Patient Safety foundation in 2002.  Using increased awareness and education, the week has highlighted the changes that have occurred to improve the safety of patients in all healthcare settings.  In 1994 Dr. Lucian Leape presented a framework for error analysis and prevention to help to decrease adverse outcomes in healthcare settings.  In 1999 “To Err is Human” report was published to help build a safer health system.  According to the report at the time there were between 44,000 and 98,000 preventable error deaths in US hospitals.  The Awareness and education opportunities have progressed to include “preventable harm” and incorporate all types of healthcare settings. Unfortunately, there are estimated to be 210,00 deaths with the most recent data from 2013 demonstrating a significant need for continued focus and profound systematic changes made in our healthcare system.

Establishment of System Changes in Healthcare

Some significant developments in the establishment of systemic changes can be seen such as “Safe Surgery Saves Lives”, “Crew Resource Management”, and TeamSTEPPS.  By looking at the contributions these programs have made to patient safety we can see how good team effort and collaboration can improve safety.

Safe Surgery Saves Lives

This program was established by the World Health Organization.  It had consisted of a method of empowering the team to decrease the chance of errors during surgery.  Some of the aspects that had been established by the checklist was the establishment of the Surgeon being the leader of the group and marking the surgical site prior to surgery, establishing the “Speak Up” initiative where every team member has a voice, and a Pre-operative “time out” to establish the communication and role establishment for each surgery.

Crew Resource Management

This program was established by the aviation industry and has been modified to reduce communication barriers and solve immediate problems effectively.  It establishes a framework of leadership, communication, and decision making when quick life or death decisions might need to be made.

TeamSTEPPS

This program was established by the Department of Health and Human Services and stands for “Team Strategies and Tools to Enhance Performance and Patient Safety.”  This program includes training for healthcare personnel to utilize communication and collaboration while utilizing checklists, debriefs, huddles and check-backs to enhance patient safety.

Patient Safety Awareness in Nursing Homes

Through increasing knowledge and awareness of improving patient safety there have been multiple changes system wide in nursing homes to enhance patient safety.  Some the most effective have been the change to electronic medical records, utilizing multiple checkpoints for medication and procedure safety by asking for names, date of birth, and utilizing photos uploaded on the EMR, and different protocols using data to monitor health status.  These protocols include scheduled vitals checks, scheduled weigh ins, monitoring of meal consumption, and monitoring of bowel movements and urine output.

There has also been the establishment of increased multi-disciplinary collaboration of any incidents in a nursing home to initiate an intervention to attempt to prevent a repeat of an incident.  These collaborations include utilizing medication management, Therapy services, and environmental changes to maximize safety.

Importance of Rehabilitation services for patient safety

One significant aspect of improved patient safety in the Nursing home is utilization of Rehabilitation services.  By interventions using Physical Therapy and Occupational Therapy we can possibly prevent a reoccurrence of an accident or possibly prevent an accident from happening.  Through use of therapy interventions, Therapists can increase overall strength and range of motion to allow for easier movement and decreased assistance needed by staff.  Through improving balance and functional mobility we can directly affect the body by improving functional mobility while decreasing the risk of falling.  For those that are unable to functionally move Independently we can directly improve positioning in wheelchairs and bed to decrease risks of falls, contracture development, and decrease risks of skin breakdown and wounds.  Rehabilitation services can improve patient safety, decrease adverse outcomes, and improve the quality of life of residents of nursing homes.

We all have a hand to play in making progress.

Through education and awareness all parties involved need to be involved in improving patient safety.  We all have a role to play.  This role needs to not only be from the professional healthcare worker, but along the entire chain of possibilities.  It needs to involve professional and nonprofessional staff, as well as the patient and the family to be advocates for each other.  We all need to maintain accountability and not be afraid to make system wide changes for the betterment of our population.  We also need to never feel afraid or ashamed to speak up when something is just not right.

“Wisdom stems from personal accountability.  We all make mistakes; own them…learn from them. Don’t throw away the lesson by blaming others.” – Steve Maraboli

 

Jonathan Roberto PTA

Director of Rehab Services

Continuum Therapy Partners