Patient safety staff education

Significant deficiencies in the security and control of samples have been well documented. " " In fact, it has been estimated that just over half of samples actually reach patients. Samples may be used by prescribers and staff, or they may be diverted. Personal use of drug samples by physicians and other healthcare providers raises ethical concerns and is not without risk." Limaye and Paauw described three medical residents who self-prescribed antimicrobials and were subsequently diagnosed with Clostridium difficile infection." Tong and Lien reported self-medication with samples and distribution of samples to nonphysicians by almost 60% of pharmaceutical representatives surveyed at a Canadian family practice office. A contributing factor to some of these issues is that institutional or facility sample policy and procedures are often absent, or compliance is poor. One institution found only 10% compliance when the inventory of samples was compared with the required written documentation. Even after an educational program in which the policy was explained to the house staff, a second audit found only 26% compliance. " Poor compliance with policy and procedure may jeopardize patient safety, as well as put the institution at risk for JCAHO recommendations or Board of Pharmacy penalties. 

The National Fire Protection Association (NFPA), headquartered in Quincy, Massachusetts, is an international nonprofit (tax-exempt) membership organization foimded in 1896. The mission of NFPA is to reduce the worldwide burden of fire and other hazards on the quality of life by developing and advocating scientifically based consensus codes and standards, research, training, and education. NFPA activities generally fall into two broad, interrelated areas technical and educational. NFPA s technical activity involves development, publication, and dissemination of more than 300 codes and standards. NFPA codes and standards are developed by nearly 230 technical committees. The Health Care Sectirm of NFPA is comprised of individuals with a focus on die protection of patients, visitors, staff, property, and the environment from fire, disaster, and related safety issues. 

Hospital work areas and staff asked to complete the survey When the Hospital SOPS was developed, it was not specifically designed and tested for use with non-clinical staff like those in honsekeeping, facilities, or human resources. Yet once the snrvey was released, it became very clear that hospitals wanted to survey all staff from all units and departments, with the understanding that every staff member plays an important role in ensuring patient safety. By being attentive and aware of patient safety risks, in an environment that encourages open communication and learning, even non-clinical staff can help prevent medication errors, patient identification errors and many other types of errors. Since one of the uses of the survey is as an education and awareness tool, it makes sense for hospitals to conduct the survey in a broad way across units and staff positions. 

Held educational/patient safety fair for staff 47%... 

Feedback and error communication Feedback of incident reporting communication of specific patient safety issues (e.g. hemovigilance) mandatory education of new staff on patient safety discussion of feedback incident reports with units on regular basis in order to implement improvements patient safety column in hospital magazine patient safety dashboard via intranet designation of incident administrator... 

Build quality improvement and patient safety policies into staff orientation and continuing education offerings. 

Protection of Staff Who Report. Staff members who appropriately report a patient safety event to the Office of Patient Safety will not be subject to retaliation for reporting. This does not remove The Health Care Organization s obligations to take appropriate educational or performance actions to protect patients, nor does it require The Health Care Organization to protect staff members who engage in acts of malfeasance that compromise patient safety. 

Review facility historical accident and injury records to assist in identifying slip, trip, and fall hazards. Establish written housekeeping procedures and reqnire everyone including patient care staff to immediately report spills and other floor hazards. Incorporate slip, trip, and fall prevention education into recurring safety training. Conduct awareness campaigns to educate employees about the risk of slips, trips, and falls. Provide feedback on the actions taken to prevent slip, trip, and fall injuries. 

The patient safety program should include an annual survey of patients, their families, and staff about their perceptions of risks to patients. The survey should solicit opinions and suggestions for improvement. It is important to make sure that patients and, when appropriate, their families are informed about the outcomes of care brief patients about unanticipated outcomes or when the outcomes differ significantly from the anticipated outcomes. When a healthcare error leads to injury, the patient and family should receive a truthful and compassionate explanation about the error, including remedies available to the patient. They should be informed that the factors involved in the injury are being investigated so steps can be taken to reduce the likelihood of similar injury to other patients. Staff should educate patients and their families about their role in helping to facilitate the safe delivery of care. 

Fig. 2. Education posters for staff and patients may heip to improve patient safety.

The patient safety aspect in the daily business of health care professionals is interconnected with the health care system, educational behaviors of staff and patients and finally efforts in research. The latter is on one hand extremely important to show the evidence of a treatment strategy or to evaluate the efficacy of new devices. On the other hand research is by itself a very sensitive domain in which unexpected adverse events can become a major issue for patients with end-stage renal disease (ESRD) under investigation. 

Patient safety research needs further progress especially related to dialysis access patients. In the implementation of the results, staff and patient education is key. With regard to clinical research questions, more RCTs are mandatory, and therefore multicenter studies are important, and international collaboration like the Kidney Health Initiative (www.asn-online.org/khi) should be established [22]. 

Educate staff about sleep hygiene and the effects of fatigue on patient safety Provide opportunities for staff to express concerns about fatigue... 

A cancer patient may encounter many different health care professionals phlebotomists, pathologists, surgeons, medical and radiation oncologists, physician assistants, pharmacists, nurses, counselors, dieticians, social workers, and chaplains all may be involved with a single patient. Each one plays an important role in care of the cancer patient. The pharmacist s role may include education of patients and family members, education of staff about new agents and safety issues, preparation of therapies, resolution of reimbursement issues, development of order sets, and participation in clinical trials. Each patient should have access to an interdisciplinary team to assist him or her during treatment. 

Advisory council members are participants in staff project teams and in several standing hospital committees, such as those involved with care improvement, clinical quality and safety, and facilities. Council members initiate projects to educate the Dana-Farber community about patients viewpoints, and they participate in problem resolution when patients have concerns. The following list describes some of the advisory council s initiatives (Ponte and others, 2003) ... 

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