NPSF’s Patient Safety Congress and Community Engagement
I look forward each spring to attending the National Patient Safety Foundation’s (NPSF) Patient Safety Congress for great education and networking opportunities. I especially look forward to the pre-conference programs NPSF offers, which this year (May 17–19) added a half-day on medical simulation to the customary full-day sessions on leadership and community engagement. I have enjoyed both full-day offerings in the past. This year, I planned to split my time between simulation and community engagement but found community engagement to be, well, so engaging, that I stayed through the afternoon. I caught up with the medical simulation folks later on in the Exhibit Hall, where they offered structured demonstrations each day; more on that in a future posting.
For now, I want to highlight two topics of lively discussion among those attending the session on community engagement in patient safety.
Following a presentation by session co-chair Kathy Leonhardt, MD, MPH, Jeffrey Johnson, BSN, MBA, patient safety manager for the Tuscaloosa VA Medical Center, Alabama, reported that he recognized something in one of Kathy’s slides. Kathy is patient safety officer and medical director of care management at Aurora Health Care in Wisconsin. She had described a successful program at Aurora that encouraged patients and people in the community to maintain accurate personal medication lists. During that program, small, insulated bags were printed with the program’s logo and distributed throughout the community as an incentive and reminder to patients to bring their medications with them to medical appointments. I’ll let Jeffrey tell the rest of the story.
The Traveling Medicine Bag
Sitting in Orlando in a day-long seminar about engaging the community and family in patient safety efforts, I had no idea that a simple slide presentation would inspire a new meaning for “It’s a small world after all…” The speaker, Dr. Kathy Leonhardt, was covering several community initiatives that had been undertaken to improve medication safety in their patient population. To my surprise, a familiar image appeared on the large screen at the front of the room. It was a picture of a small, blue thermal bag. You know the type – you see them used as kid’s lunchboxes or slung over a mom’s arm with a beach tote while schlepping the kids to the pool. It was not a huge, expensive initiative or high-tech solution. It was a simple bag to help patients remember to bring their medications to their appointments.
How then, did this little blue bag turn out to be such an inspirational talisman? It was the story of that bag that made the “small world” song a reality for me in the patient safety realm. You see, the medication bags had been distributed in Wisconsin in 2006. I truly don’t think that Dr. Leonhardt ever envisioned the bags would inspire the wife of a patient in Alabama to walk into the office of a VA medical center director to request that “all of these veterans” should have one of those little blue bags. The patient’s wife had been given the bag by a primary care provider in Wisconsin. Upon arriving in Alabama, the patient transferred his care to the VA. His wife had become a very vocal patient advocate and took it upon herself to inform our medical center director about the wonderful “bags” that made transport of medications so convenient.
What started as a small awareness campaign in Wisconsin traveled over 800 miles to impact the safety of hundreds of other patients, in other clinics, in other states. The moral of this story is: Don’t underestimate the power of your efforts, no matter what the size. Sure, we measure everything for a recordable outcome, but don’t be surprised when the un-measureable turns out to be immeasurable.
Though Kathy Leonhardt was thrilled to hear how far this medication bag had traveled, she was not completely surprised. Five years after beginning their project in a small rural community, Kathy continues to get requests for presenting their work because it is a rare example of truly engaging a community in patient safety — with measurable success. Using the principles of community-based participatory research, patients and community members participated as leaders of this project, including the design, implementation, and distribution of over 7,300 medication bags. The community became passionate about the use of these bags, as they were vested in the project and the desired outcome of safer medication management.
What’s Holding Us Back?
At the conclusion of the day, Linda Kenney, founder and president of MITSS (Medically Induced Trauma Support Services) and Leonhardt’s co-chair, directed the group of approximately 35 attendees to bring their chairs into a simple circle and asked us each to reflect and report on what we’d heard and learned during the day. We engaged in a lively, hour-long recap and discussion, resulting in the kind of group experience that is difficult to convey after the fact. Many of us revisited an earlier thought that our efforts to improve patient safety, especially with consumers and in our communities, are constrained because the movement lacks a cohesive message. The group consisted of nurses, patient safety officers, patient advocates, and others — self-selected community activists of one sort or another — who asked, “Can we have national impact without a cohesive message?” “What’s needed to transform patient safety into a social movement?” “What’s holding us back?” The intensity of the exchange was characteristic of a small group discussion, but we all wished for the opportunity to engage the larger Congress audience in a similar discussion. At a minimum, it was a great start to this year’s Congress.