Patients for Patient Safety

1. In honour of • those who have died, • those who have been left disabled, • our loved ones today, • we will strive for excellence, • so that all people receiving healthcare • are as safe as possible, • as soon as possible. • This is our pledge of partnership Patients for Patient Safety Margaret Murphy, Patient Advocate External Lead Advisor Patients for Patient Safety WHO Patient Safety THE PATIENT EXPERIENCE AS A CATALYST FOR MEDICATION OPTIMIZATION PRIMM LONDON 23 January 2015 Philadelphia August, 2009

2. INTRODUCTION • The patient as a collaborative partner • Patient Autonomy • Patient Centred Care • WHO Patients for Patient Safety • Patient and Family as a constant in the continuum of care. • The Report Safety First 2006

3. Yesteryear vs Today • The patient expectation • Mystique vs blind faith • Patient responsibility and understanding of complexity of care • Report of Irish Commission Knowledgeable Patients receiving safe & effective care from skilled professionals in appropriate environments with assessed outcomes • Compliance, adherence, education of patients • Equipping and training professionals

4. THE PROCESS • The need for robust diagnosis • Deficits in consultation process • Patient Centred Care • The elderly patient – a personal experience • The elderly patient – a community experience. • Errors of commission and omission

5. FURTHER CONSIDERATIONS • Risks / Benefits • Supporting the patient • Written instructions and alerts • Reflective listening • Transition points and perceived discrepancies • Medication Reconciliation – a role for the patient? • Clinician role at transition points

6. AREAS FOR SPECIAL ATTENTION • The high-risk patient • When administering high-risk drugs • Patient Centred Care • Medication safety in psychiatry • Ethical issues – patient autonomy vs patient competence to decide • Untrained or inadequately trained personnel • Empowering/reassuring patient & family

7. CAUSES OF MEDICATION ERRORLeape, Bates, Cullen, et al JAMA 1995 • Lack of knowledge about the drug • Lack of information about the patient • Violation of rules • Slips and memory lapses • Errors of transcription • Faulty checking of patient identity • Faulty interaction with other services (communication) • Faulty dose checking • Infusion pump problems • Inadequate patient monitoring • Drug stocking & delivery problems • Preparation errors • Lack of standardisation

8. CHALLENGES, INITIATIVES (Global and Local) • Responsibility and Accountability • Cultural shift • WHO – PS Curriculum & 3rd Global Challenge • JCI and Medication Safety • Encouraging and Educating Patients • The role of the community pharmacist • A Danish example - An Irish example

9. ‘Let’s Talk Medication Safety’ • The Basics: Why, Name, Dose, How often, How long, Side effects, Storage • Understanding your Medicine: Prescription, Over-the-counter, complementary, herbal, alternative • Names: Brand and Generic • Useful tips for safe use of medicine • Do and Don’t list • Following instructions • Storing • Tips for when admitted to hospital & questions to ask • Tips for when discharged & questions to ask • Keeping a medication list and what to include on that list.

10. - A Resolution Going Forward - More than anything, what distinguishes the great from the mediocre, is not so much that they fail less, it is that they rescue more. - AtulGawande

11. THE ACID TEST DISCLOSURE and the LIVED EXPERIENCE • Disclosure = ? • Blame vs Integrity and Professionalism • Learning? • Preventing recurrence? • The burden of error • Respectful Management of Serious Clinical Events - IHI

12. Patients for Patient SafetyThe London Declaration - a vision statement for Patients for Patient Safety, written at 1st PFPS workshop by patients and families from every region of WHO • In honour of • those who have died, • those who have been left disabled, • our loved ones today, • we will strive for excellence, • so that all people receiving healthcare • are as safe as possible, • as soon as possible. • This is our pledge of partnership • margaretmurphyireland@gmail.com “To err is human, to cover up is unforgivable but to fail to learn is inexcusable.” • Sir Liam Donaldson,Chair, WHO Patient Safety