Modelbit

www.
josieking.
orgJosieKingFoundationintroductiontopatientsafety1Josie'sStory:APatientsafetycurriculumVictoriaS.
Kaprielian,MD,FAAFPDoriT.
Sullivan,PhD,RN,NE-BC,CPHQ,FAANeditorsJosieKingFoundationThestorybehindtheJosieKingPatientSafetyCurriculumInthewinterof2001,eighteen-month-oldJosieKingdiedfromaseriesofpreventablemedicalerrorsatoneofthemostrenownedhospitalsintheworld.
Eightyearslater,GroveAtlanticpublishedJosie'sStory,arecountingofthistragiceventbySorrelKing.
Thebookgainedwidespreadpopularityinmedicalandnursingschoolsalongwithhospitalsaroundthecountryasatooltonotonlyeducatefuturecaregivers,buttoinspirethemaswell.
Asthepowerfulmessageofthisstoryanditsimpactonreadersbecameclear,SorrelandtheJosieKingFoundation(whosemissionitistopreventmedicalerrorsfromharmingpatientsbycreatinganewandbetterculturewithinthehealthcareindustry)reachedouttoKarenFrush,theChiefPatientSafetyOfficeroftheDukeUniversityHealthSystem.
KarenandSorrelsharedthesamefundamentalunderstanding:Factsprovideuswithknowledge–storiesprovideuswithwisdomTogethertheysetouttoformapatientsafetycurriculumthatcombinedthepowerofthestoryandthescienceofsafetywithinteractiveandmeaningfuleducationalmaterial.
Ateamofeducatorswasputinplace,andtheJosieKingPatientSafetyCurriculumwascreated.
Thecurriculumismadeupofsixteensessions,toalignwithatypicalsixteen-weeksemester.
Itisdesignedtobeutilizedinmanydifferentsettings,includingmedicalandnursingschools,alongwitheducatorsinthehospitalenvironmentwhoareinneedofeducationalandinspirationalpatientsafetymaterial.
Itcanbeusedinitsentiretyorasasinglesessiontobuilduponexistingpatientsafety/qualitycontent.
TheJosieKingPatientSafetyCurriculumisforthecaregiversofthefuture.
Wehopethismaterialprovidesknowledgeandwisdomastheygoforthintotheworldofhealing.
SorrelKingPresidentandCo-founderTheJosieKingFoundationKarenFrush,MD,BSNProfessorPediatricsClinicalProfessorofNursingChiefPatientSafetyOfficerDukeUniversityHealthSystem6curriculumsummarytablePATIENTSAFETYCURRICULUMSUMMARYTABLE1#SessionTitleLearningObjectivesSessionFormat1IntroductiontoPatientSafetyeeDiscusshistoricalbackgroundrelatingtopatientsafetyeeDefinehealthcare"quality","medicalerror",and"adverseoutcome"eeDiscussthereasonsforfocusonpatientsafetyeeIntroductorylectureeePossibleunitobservationexercise2Josie'sStory:EngagingPatientsandFamiliesforSafetyeeDiscusstheroleofthepatientandfamilymembersinensuringpatientsafetyeeDescribeamodelPatientAdvocacyCounciloradvisorycommitteeeeCollaboratewithpatientsandfamilymembersinsupportofoptimalpatientcareeeOptional:DescribeConditionHeeVideo-triggeredlargegroupdiscussion,withpatientpanel3AnatomyofanErroreeDiscussmechanismsofhumanerrorandlimitationsofhumanperformanceeeDescribetheepidemiologyofmedicalerrors,includingthemostcommontypesinselecteddisciplinesandsettings(e.
g.
,inpatient,outpatient,surgical).
eeExplaintheSwissCheeseModelofmedicalerrorseeParticipateinaroot-causeanalysisprocess,andsuggestimprovements.
eeGroupproblem-solvingexercise4TheAmericanLegalSystemandPatientSafetyeeStatehowmostmedicalerrorsareclassifiedwithinthelegalsystemeeOutlinelegalconcernsrelatingtomedicalerrorsandtheirdisclosureeeDescribehowpotentiallegalramificationsimpactdisclosureandreportingeeTheorybursteeStructuredsmallgroupworkJosieKingFoundationcurriculumsummarytable71#SessionTitleLearningObjectivesSessionFormat5HealthcareSystemPerspectiveseeDescribeanoverviewoftoday'shealthcaresystemintheU.
S.
eeDiscusstheimpactofmedicalerrorsonhospitalsandhealthcareorganizationseeConsidertherisksandbenefitsofdisclosureatthehospital/healthcaresystemlevelincludingpatients/familyinvolvedinthespecificissue,impactonpotentiallitigationandpublicrelationseeTheorybursteeSmallGroupDiscussions6ReportingMedicalErrorseeReportingmedicalerrorseeDescribeerroridentificationandreportingstrategies,andtheirimpactonqualityeeDiscusstheimportanceofreportingadverseeventsandhowtodosointhelocalsettingeeDiscussthesignificanceofnear-misseseeDemonstratetechniquesforspeakingupaboutaconcerneePresentationeeSmallGroupDiscussioneeQ&A7DisclosureofMedicalErrorseeOutlinekeyfactorsinappropriatedisclosureeeDemonstrateappropriatetechniquefordisclosureofamedicalerroreeTheorybursteeSmallGroupDiscussions8CultureofSafetyeeDescribehoworganizationalculture,blame,andemotionalresponsesimpactdisclosureandreporting.
eeDiscusshoworganizations,institutions,andhealthsystemscancreateandmaintainacultureofsafetyeeOnlinemoduleeePossiblesurveyanddiscussion9JustCultureandSafeChoiceseeDiscusstheconceptsofindividualaccountability,safechoices,and"justculture"andhowtheyrelatetosafetyeeDemonstratesafebehavioralchoicesinpatientcarethroughsmallgroupdiscussionseeTheorybursteeSmallGroupDiscussionsJosieKingFoundation8curriculumsummarytablePATIENTSAFETYCURRICULUMSUMMARYTABLE1#SessionTitleLearningObjectivesSessionFormat10TheSecondVictimeeDiscusstheimpactofmedicalerrorsonhealthcareworkerseeIdentifyresourcesforsupportofhealthprofessionalstrugglingwiththeseissueseeVideoeeTheorybursteePaneldiscussionwithQ&A11RapidResponseTeamsandConditionHelpeeDescribeRapidResponseTeams(RRT)andConditionHeeArticulatetheproandconpositionsofRRTandConditionHeeVideoeePresentationeeTheorybursteePaneldiscussionwithQ&A12CommunicationandHandoffseeDiscusstheroleofcommunicationfailuresinunanticipatedadverseeventseeDescribekeycomponentsofasafeandeffectivepatientcarehandoffeeOptional:Ifpracticesessionisincluded,demonstratesafehandofftechniqueeePresentationeeOptionalsmallgrouppractice13EnhancingTeamworktoImprovePatientSafetyeeDiscusstheroleofteamworkandcommunicationfailuresinunanticipatedadverseevents.
eeDefineandapplyin-teamsituations:SBAR,criticallanguage,check-back,huddles,debriefing,andsituationmonitoringeeRole-playexerciseeeTeamSTEPPStoolscurriculumsummarytable91#SessionTitleLearningObjectivesSessionFormat14MedicationSafetyAppropriateobjectivesforthistopicmaydifferfordifferenthealthprofessions.
Forprescribers:Bytheendofthissession,participantswillbeableto:eeDemonstrateproperprescriptionwritingtechniquetominimizepotentialforerroreeUseonlyapprovedabbreviationswhenwritingprescriptionsororderseeApplysafetechniqueswhendealingwithsound-alikeorlook-alikemedicationseeDiscusstheimportanceoftakingathoroughmedicationhistoryFornon-prescribingprofessions:Bytheendofthissession,participantswillbeableto:eeDiscussessentialcharacteristicsofsafemedicationorderseeApplysafetechniqueswhendealingwithsound-alikeorlook-alikemedicationseeOutlinesafeproceduresfordispensing/administeringmedicationseePresentationeeSmallGroupDiscussion15Mistake-ProofingCareeeDefinethesixmethodsformistake-proofingcareeeDiscusstheimportanceof,andmethodsfor,layeringerror-proofingmethodseeDiscusstheroleofclinicalguidelinesinmistake-proofingcareeeDiscusspatientinvolvementasanecessarypartoferror-proofingeeOnlinemoduleeeApplicationexercise16LifeLessons:ApplicationeeIdentifychosensafepracticesforchosenecareerareaeeDiscussstrategiesforinfluencingsafetycultureinthechosenworksettingeeIdentifyobstaclesthatpresentopportunitieseeChoosepersonalgoalsforthefutureeePresentationeeSmallGroupDiscussionJosieKingFoundationjosie'sstory:engagingpatientsandfamiliesforsafety19JOSIE'SSTORY:ENGAGINGPATIENTSANDFAMILIESFORSAFETYSessionAuthor:VictoriaS.
Kaprielian,MDSessionFormat:Video-triggeredlargegroupdiscussionwithpatientpanelSessionObjectives:Bytheendofthissession,participantswillbeableto:eeDiscusstheroleofthepatientandfamilymembersinensuringpatientsafetyeeDescribeamodelPatientAdvocacyCounciloradvisorycommitteeeeCollaboratewithpatientsandfamilymembersinsupportofoptimalpatientcareeeOptional:DescribeConditionHSuggestedReadingsPriortothissession,learnersshouldpreparebyreadingJosie'sStory:eeProloguethroughChapter4(prologuethroughChapter3mayhavebeenreadearlier)eeReviewResourceGuide,Part1eAdditionalresourcesforthosedesiringfurtherlearning:eeNationalPatientSafetyFoundationtoolsandresourcesforpatients:Factsheetsandothermaterialsforconsumers–bit.
ly/12M6iFueeConsumersAdvancingPatientSafety:Materialstoempowerpatients–bit.
ly/12gakCLeeTheJointCommission:SpeakUpinitiative–bit.
ly/1cHegBheeCentersforDiseaseControlandPrevention:10ThingsYouCanDotobeaSafePatient–e1.
usa.
gov/12gaGJteeSafeCareCampaign:HowtoReceiveSafeCare–bit.
ly/15XYApGeeCampaignZero–bit.
ly/15XYZIveeTheEmpoweredPatientCoalition–bit.
ly/14IKokTeeBaileyE.
ThePatient'sChecklist:10SimpleHospitalCheckliststoKeepyouSafe,Sane,andOrganized.
eNewYork:SterlingPublishing,2011.
eeCurtissK.
SafeandSoundintheHospital:Must-HaveChecklistsandToolsforyourLovedOne'sCare.
eLakeForest,IL:PartnerHealth,2011.
JosieKingFoundation20josie'sstory:engagingpatientsandfamiliesforsafetyAttachmentsDocumentsforthissession:eeFacultyFacilitator'sGuideeeInstructionsforPanelistsPotentialadditionalmaterialseeJosie'sStoryvideo,astoldbySorrelKing,October2002eJosie'sStory(DVD)includedincurriculumbinder.
AdditionalcopiesareavailablebycontactingtheJosieKingFoundation.
JosieKingFoundationjosie'sstory:engagingpatientsandfamiliesforsafety21JOSIE'SSTORY:ENGAGINGPATIENTSANDFAMILIESFORSAFETYFacultyFacilitator'sGuideObjectives:Bytheendofthissession,studentswillbeableto:eeDiscusstheroleofthepatientandfamilymembersinensuringpatientsafetyeeDescribeamodelPatientAdvocacyCounciloradvisorycommitteeeeCollaboratewithpatientsandfamilymembersinsupportofoptimalpatientcareeeOptional:DescribeConditionH1Opening(5min)eeOpenthesession,makingconnectiontoprevioussession(s)eeGiveoverview:ThissessionisabouttheroleofpatientsandfamiliesinhelpingusensuresafecareStartwithashortvideo,followedbydiscussionwithlocalexperts2Video(15min)ee15-minuteclipofSorrelKingtellingJosie'sstoryeeAskstudentstopayattentiontothesequenceofevents,andhowthestaffrespondedtothemotherwheneversheraisedaconcern3TeamCaucus(10min)eeAskstudentstotakeafewminutestodiscussinclusterswhattheyjustsaw(eitherinpreassignedgroupsortrios/smallgroupsseatednearoneanother)WhatproblemscanyouidentifyHowmanywerepickedupbythemomWhathappenedwhenshespokeupWhydoyouthinkthathappens4LargeGroupdiscussion(20min)eeFacilitatediscussionofquestionsWhydohealthprofessionalstendtoresistfamilyrequestsHowdowebringpatientsandfamilymembersintothecoreofcareteamsNeedtobettercollaborateinthebestinterestofpatientseeConsidersequenceofeventsinJosie'sStoryMotherconcerned,askednursetocalldoctor,reassuredJosieKingFoundation22josie'sstory:engagingpatientsandfamiliesforsafetyMotheraskedforanothernursetocheck,reassuredMothermoreconcerned,demandeddoctorstoseeMotherremainedconcerned,askeddoctorstostaynearbyMotherquestionedmedication,reassured,medgiveneeDiscussionmaygeneratequestionsforpanelists5Panel(15-minutesforcomments,thenQ&Adiscussion)eInadvance,recruittwotofourpatientsand/orfamilymemberswithexperienceinthehealthcaresystem.
Ideally,thesearemembersofaPatientAdvocacyCouncilorotheradvisorygroup,butanypatientswhoarewillingtosharetheirstorywithalargegroupmaybeused.
It'sgenerallyworthwhiletospeakwithpanelistsinadvancetoheartheirstoryandguidethemonthedesiredfocus.
Panelistsshouldsitintheroomforthevideoanddiscussiontogivethemasenseofthestudents'perspectivebeforetheyspeak.
eeAllowpaneliststointroducethemselves.
eeAskeachtocommentbrieflyonwhatthey'veheard,andtheirownexperiences(5minuteseacheisappropriate)HaveyouevertriedtospeakupaboutaconcernregardinghealthcareWhathappenedHowwasyourinputreceivedWhatroledoyouthinkpatientsandfamiliescanplayinpatientsafetyWhatdoyouthinkphysicianscandotoimprovecommunicationwithpatientsandfamilieseeQuestionsfromstudentsandresponsesfrompanelists6Optional:ConditionH(5min)eePatients/familieshavetheabilitytocallforhelpiftheyhaveaconcernthatisn'tbeingaddressedtoetheirsatisfactionDiscussstatusinhomesystem–inplaceHowaccessedIsthephonenumberpostedinhospitalroomseeActivatesRapidResponseTeameeAllowbriefdiscussionofpanelists'experienceswithConditionH,iftheyarefamiliarorhaveused.
7Closure(5min)eeGeneratelistoftake-homepointsfrompanelandaudienceTrustinstincts–especiallyamother's"Listen"tothepatient(evenifthey'renottalking);i.
e.
,treatthepatient,notthenumbersJosieKingFoundationjosie'sstory:engagingpatientsandfamiliesforsafety23ee"Notalltheanswersareonclipboardsandcomputers"eeThankpanelistsfortheirtimeandwillingnesstoshareTotalduration:90min-2hours,dependingontimeallowedfordiscussion.
Thedurationcanbeshortenedbyassigningsteps2and3ashomeworkinadvanceofthesession.
JosieKingFoundation