Ephemeris Project and Patient Safety

 "Humanism is important to patient safety. Understanding a patient’s needs and exhibiting care and nurturing can help to reduce the incidence of medical errors. In addition, humanism enhances safety by emphasizing the needs of caregivers."
Ellen W. Kramer Lambert, Esq.,
Putting Patient Safety Into Practice
October, 2002
Washington, D.C

"Patient safety has been described as “freedom from accidental injury” or “the prevention of harm to patients”. Not only does this focus on establishing health care systems and processes which minimise errors and adverse events, but it also centres on the professionalism of individual practitioners. Medical professionalism has been defined as effective communication, ethics and clinical competence, upon which other attributes like humanism are built. This broad theme includes research on student learning of patient safety and professionalism within formal (taught), informal (learnt), and hidden curricula, and includes the exploration of professional identity formation amongst healthcare students.

"The Patient Safety portfolio includes educating medical students and health professionals about the context of health care and the role of complexity. Understanding how poorly designed systems can lead to inadequate care and the role the system plays in minimising error is necessary if health care professionals are to reduce adverse events suffered by patients."

"Medicine is practiced in a complex environment, so there are usually many factors contributing to poor outcomes for patients. Most of these errors are not caused by people acting recklessly but by badly designed systems of health care. We know that people are reluctant to talk about adverse events, but if there is no acknowledgement of them, it is impossible for improvements to be made and learning to occur."

"Professionalism and ethical conduct are important components in patient safety. In the health care setting, the term professionalism covers those attitudes and behaviors that serve to promote and maintain the patient’s best interests. Ethical behaviour is a mandatory component required by all health professions and employers and covers a range of attitudes and behaviors. All our patient safety work includes teaching students and health care professionals about their professional obligations and responsibilities to patients, their colleagues and the wider community."  Associate Professor Merrilyn Walton, Director of Patient Safety.

Mindfulness (a calm, purposeful, and reflective presence).  “Through humility and continual self-evaluation, mindful individuals (physicians) become tacitly aware of their own limitations and continually address these deficiencies through everyday actions-with patients, families, and other professionals”
Ryff CD, and Singer B. (1996).

"I've come to the realization that life is not designed for our comfort, or pleasure, but for us to discover our gifts and contribute what we can to make life better for others."
Dr. Robert Paeglow

"…to know and understand, obviously, is a dimension of being scientific… to be known and understood is a dimension of caring and being cared for."
George Engel


National Patient Safety Foundation

The mission of the National Patient Safety Foundation (NPSF) is to improve measurably patient safety in the delivery of health care by its efforts to:

  • identify and create a core body of knowledge;
  • identify pathways to apply the knowledge;
  • develop and enhance the culture of receptivity to patient safety;
  • raise public awareness and foster communications about patient safety; and
  • improve the status of the Foundation and its ability to meet its goals.

Visit the NPSF Web site for more information about the Foundation, educational opportunities, patient safety literature, and much more.

You may contact the NPSF at 1120 MASS MoCA Way North Adams, MA, 01247; phone, (413) 663-8900; fax, (413) 663-8905; or E-mail, info@npsf.org.


Joint Commission Program on Patient Safety 2009

 

Summary
In 2009, changes in the Joint Commission’s Leadership standards become effective with a greater emphasis on patient safety.  The new Leadership standards are organized according to four pillars which support effective performance: Leadership Structure, Leadership Relationships, Organization Culture, and Performance and Operations. 

This program will focus on the four pillars, providing specific content for each, including: getting the board actively involved in quality and safety activities, organizational structures for patient safety, communicating leadership’s vision for safety, managing conflict, developing a culture of safety, and using quality and safety data.

A "Culture" of Patient Safety

Culture (from the Latin cultura stemming from colere, meaning "to cultivate,")[1] generally refers to patterns of human activity and the symbolic structures that give such activities significance and importance. Cultures can be "understood as systems of symbols and meanings that even their creators contest, that lack fixed boundaries, that are constantly in flux, and that interact and compete with one another"[2] Different definitions of "culture" reflect different theoretical bases for understanding, or criteria for evaluating, human activity.

Culture is manifested in music, literature, lifestyle, painting and sculpture, theater and film and similar things.[3] Although some people identify culture in terms of consumption and consumer goods (as in high culture, low culture, folk culture, or popular culture),[4] anthropologists understand "culture" to refer not only to consumption goods, but to the general processes which produce such goods and give them meaning, and to the social relationships and practices in which such objects and processes become embedded. For them, culture thus includes art, science, as well as moral systems. Wikipedia

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Copyright 2008  Michael R. Berman, M.D. All rights reserved
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