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Lecture patient safety


Patient safety

In the presentation, a summary of initiatives to be taken by hospitals in different areas for patient safety have been described for the knowledge, practices and implementation of patient safety initiative by hospital managers/Administrators.

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Patient safety

  2. 2. WHAT IS SAFETYS – Sense the errorA – Act to prevent itF – Follow Safety GuidelinesE – Enquire into accidents/DeathsT – Take appropriate remedial measureY – Your responsibility
  3. 3. WHY SAFETY IN THE HOSPITAL• Hospital is a people intensive place• Provide services to sick people round the clock24 hours daily 365 days a year.• People have a free access to enter any part ofthe hospital any time for advice and treatment• The hospital atmosphere is filled with emotions, excitement, life & happiness, death & sorrow• Since hospital operates under continuousstrain, it gives rise to irritation, confrontation,conflicts & aggression, threatening the life ofhospital staff & hospital properties
  4. 4. WHO’S SAFETY
  8. 8. PATIENT SAFETYPatient safety is the absence of preventableharm to a patient during the process of healthcare.The discipline of patient safety is thecoordinated efforts to prevent harm to patients,caused by the process of health care itself. It is generally agreed upon that the meaningof patient safety is…“Please do no harm”
  9. 9. ORIGIN OF PATIENT SAFETY CONCEPT HIPPOCRATIC OATH I will prescribe regimens for the good of my patients according to my ability and my judgment and ”never do harm” to anyone. Improving Patient Safety means reducing patient harm. Hospitals were founded to give care to those who need it and to keep patients safe is their moral duty
  10. 10. CURRENT ENVIRONMENT• Errors and system failures repeated• Action on known risks is very slow• Detection systems in their infancy• Many events not reported• Understanding of causes limited• Few examples of successful scale up• Limited measurement of impact• Blame culture alive and well• Defensiveness and secrecy
  11. 11. M E D IC A L E R R O R S•1 in 10 patients admitted to hospital suffersan adverse event•The Institute of Medicine in their study foundout that in USA.•Medical Error injures 1 in 25 hospitalpatients.•Kills about 44000 to 98,000 patients everyyear.•Medical errors cost the United States billionsof dollars each year.
  12. 12. HOW DANGEROUS IS HEALTH CARE • Less than one death per 100 000 encounters – Nuclear power – European railroads – Scheduled airlines • One death in less than 100 000 but more than 1000 encounters – Driving – Chemical manufacturing • More than one death per 1000 encounters – Bungee jumping ( Tying rope on leg) – Mountain climbing – Health care SOURCE: Internate
  13. 13. WHO’S ERROR B A 16% 66% C D 14% 4%66% - Accidents caused entirely by patient.16% - Accidents due to error by hospital staff.14% - Accidents staff and patient both equallyresponsible.4% - Accidents due to physical, mechanical orelectrical errors. SOURCE: Internate
  14. 14. WHY ERROR-In most cases fault is not willful negligence,but systemic flaws, inadequatecommunication and wide-spread processvariation and patient ignorance.-People responsible are the doctors, nurses,pharmacists , technicians and Patient.
  15. 15. TYPES OF ERRORSi. Adverse Health Care Event – event or omission arising during clinical careand causing physical or psychological injury to a patientii. Error – failure to complete a planned action as intended, or the use of anincorrect plan of action to achieve a given planiii. Health Care Near Miss – situation in which an event or omission (orsequence) arising during clinical care fails to develop further, whether or notas the result of compensating action, thus preventing injury.iv. Adverse Drug Reaction – any response to a drug which is noxious,unintended and occurs at doses used for prophylaxis, diagnosis or therapy1 Predictable Unpredictablev. Medication Error – any preventable event that may cause or lead toinappropriate medication use or patient harm while the medication is in thecontrol of health professional, patient or consumer vi. Sentinel error- Surgery on the w r o n g b o d y p a r t Surgery on the w r o n g p a t i e n t Patients receiving the w r o n g m e d i c a t i o n
  16. 16. FOCUS ON NEAR MISSES• No patient harm, therefore no blame• No guilt• No fear of litigation• Focus on future prevention
  17. 17. HUMANE ERROR “ To Err Is HUMANE” “Human beings make mistakes because the systems, tasks and processes they work in are poorly designed.” (Professor Lucian Leape, testifying to the US President’s Commission on Consumer Protection and Quality in Health) Every Error has a root cause and every cause has a solution. One Un willful Error is a miss Repeated Error is a Crime. Errors can be prevented with Every one’s Initiative in the system.“HERE COMES THE ROLE OF PATIENT SAFETY”
  18. 18. “WHA” INITIATIVE• Jan 2002 – Executive Board discuss patient safety• May 2002 – resolution adopted by 55th World Health Assembly• May 2004 – WHA support establishing World Alliance for Patient Safety• October 2004 – launch of the World Alliance and Forward Programme by DG of WHO• December 2005 – first progress report of the Alliance
  19. 19. WHO/WORLD ALLIANCE FOR PATIENT SAFETY Co-ordinate, spread and accelerate improvements in patient safety worldwide WHO Patient Safety was created to facilitate the development of patient safety policy and practice across all WHO Member States and to act as a major force for patient safety improvement across the world. Our mission The mission of WHO Patient Safety is to coordinate, facilitate and accelerate patient safety improvements around the world by: •being a leader and advocating for change; •generating and sharing knowledge and expertise; •supporting Member States in their implementation of patient safety actions. Our vision •Every patient receives safe health care, every time, everywhere.
  20. 20. WORLD ALLIANCE FOR PATIENT SAFETY: TEN ACTION AREASGlobal Patient Safety Challenges : Solutions to improve1. Clean Care is Safer Care patient safety2. Safe Surgery Saves Lives High 5s WHO Project Patients for Patient Safety Catalyse Technology for Patient Safety Research for Patient Safety countries’ action to achieve Knowledge Management International safety of care Special projects: Classification for - Education Patient Safety (ICPS) - Radiotherapy - Rewarding excellence - When things go wrong Reporting & - Vincristine sulphate Learning
  21. 21. HIGH 5s WHO PROJECTA High 5s Steering Group was established in 2006 to determine the overallarchitecture of the initiative. The project is being implemented in three phases.The first phase (2006-2008), initiated in late 2006, has involved theidentification of five evidence-based solutions for patient safety and thedevelopment of a Standard Operating Protocol (SOP) for each solution.The solutions are:Managing Concentrated Injectable Medicines;Assuring Medication Accuracy at Transitions in Care;Communication During Patient Care Handovers;Improved Hand Hygiene to Prevent Health Care-Associated Infections; andPerformance of Correct Procedure at Correct Body SitesThe second phase (2008 -2010) identify a lead technical agency in eachparticipating country to coordinate the High 5s initiative at the country level.Impact will be measured using the following tools:Root cause analyses of indicator events and other adverse eventsPatient safety indicatorsCultural assessmentsEconomic impact indices.The third phase (2010-2011) Over time, the project will encourage participatingcountries to use their established relationships with other countries
  22. 22. PATIENT SAFETY INITITIVE•Patients know that their ailments may not always be cured, but theydon’t expect to be inadvertently harmed during their medical care.• The “blame and train” approach to medical errors and close callsdoesn’t work well.• human factors engineering techniques tease out root causes ofmedical errors and close calls.• Playing the Blame Game: An Ineffective strategy for improvingpatient safety• Preventing inadvertent harm to patients requires use of humanfactors engineering principles.• In other high hazard jobs such as airplane flying and running nuclearreactors, systems have been developed to minimize risks based on thescience of human factors engineering. There fore concept of Patient safety has been derived from Aviation industry.
  23. 23. Summary SHARED SAFETY BEHAVIORS AVIATION & MEDICINE• Broaden dimensions • human factors engineering • fatigue & stress management • effective communication • shared awareness • teamwork• Countermeasures • briefings, debriefings • workload distribution • cross-monitoring • graded assertiveness • checklists
  24. 24. LESSONS FOR HEALTH FROM THE AIRLINE INDUSTRY • Statutory reporting of procedures • A voluntary (without jeopardy) reporting culture • Recurring statutory examinations • Systems development • Safety analysis of data • Acceptance that staff make mistakes • Role of teamwork
  25. 25. PATIENT SAFETY GOALImprove the accuracy of patient identification.Improve the effectiveness of communication amongcaregivers.Improve the safety of using medications.Reduce the risk of healthcare associated infections.Accurately and completely reconcile medications acrossthe continuum of care.Reduce the risk of patient harm resulting from falls.Special emphasis on ,Dangerous abbreviations, infectioncontrol, “Look alike and sound-alike” medications, time outs.
  29. 29. WORK ENVIRONMENT SAFETY There is a direct link between work environment and patient safety Therefore, if not addressing work environment, we are not addressing patient safety Healthy work environments do not just happen Therefore, if we do not have a formal program in place addressing work environment issues, little will change Creating healthy work environments requires changing long-standing cultures, traditions and hierarchies Therefore, though everyone must be involved in the creation of healthy work environments, the onus is on organizational, departmental and unit leaders to ensure that it happens
  30. 30. ENVIRONMENTAL SAFETY• Adequate light• Adequate ventilation, exhaust fan• Stairs with hand rails• Window-door-closer• Slip preventing floors• Fire extinguishers and fire alarms• Prevent noise pollution• Heavy and fixed beds• Safe wheel chairs and trolleys• No water logging in bathrooms• Call bell system for patients• Adequate no. of bed screens to maintain privacy of the patient.
  31. 31. MEDICAL SAFETY1. Illegible Writing prescription by doctors.2. Wrong medicines or wrong does or wrong patient.3. Wrong injection, wrong does or wrong patient, wrong route of administration.4. Drip sets, air bubbles, over hydration, drip speed.5. Oxygen flow check empty gas cylinders.6. Clear, written medication guidelines.7. Identification of each patient with Similar patient names8. Proper handing taking over during change of shift.9. Look alike and Sound Alike “LASA”
  32. 32. A- Medication orders should be written legibly in ink and should include:• Patient’s name and location (ward, room No, and bed No) .• Medication Generic Name.• Dosage, frequency and route of administration.• Signature of the physician.• Date and hour the order was written.B- Any abbreviations used in medication orders should be agreed to andjointly adopted by the medical, nursing, pharmacy, and medical records staffof the institution. Lately, in the interest of patient safety, “Do Not Abbreviate”is the new practice nowadays.C- Before dispensing the drug The pharmacist must receive the physician’soriginal order or a direct copy of the order (except in emergency situations).This permits the pharmacist to:•Resolve questions or problems with drug orders before the drug is dispensedand administered.• Eliminate errors which may arise when drug orders are transcribed intoanother form for use by the pharmacy.D- to check at least two patient identifiers before providing care, treatmentsor services.• Patient name and medical record numberE- Discourage Telephonic orders , Do not accept verbal orderF- Examine safety Code
  33. 33. Methods of sending the Physician’s orders to the pharmacy are:1. Self-copying order forms: This method provides the pharmacistwith a duplicate copy of the order and does not require specialequipment. There are two basic formats:a. Orders for medications included among treatment orders.b. Medication orders separated from other treatment orders on theorder form.`2. Electromechanical: Copying machines or similar devices may beused to produce an exact copy of the physician’s order. Provisionshould be made to transmit physicians’ orders to the pharmacy in theevent of mechanical failure.3. Computerized: Computer systems, in which the physician entersorders into a computer which then stores and prints out the orders inthe pharmacy or elsewhere.
  34. 34. SURGICAL SAFETY1. Consent of the patient/ relative in writing2. Proper identification of patient, name wrist band3. Proper identification mark of parts to be operated4. Pre- anesthetic check-up5. Anesthetic Safety6. Ensure no foreign body left inside7. Safety measures from ward to OT & coming back (Safety check list)8. Prevention of surgical wound infections9. Use of Surgical safety proforma in all operations10. Check Safety code if available DNR Purple Falls Risk Yellow Allergies Red (Red for Allergy Alert, yellow for Fall Risk, and Purple for Do Not Resuscitate).
  35. 35. SummaryWHO SURGICAL SAFETY CHECKLIST • The primary benefit of the checklist may be to engage the medical team. • By using the checklist, we may be gaining the ability to open communication by the medical team, to encourage teamwork behaviors, & to develop discipline in the team. • Reducing sentinel error 35
  36. 36. INSTALLATION HAZZARDS1. Regular checking of equipments2. Proper earthling to avoid shock3. Regular maintenance & repair4. Training of nurses & technical staff5. How do you control hazards?• Preventing inadvertent harm to patients requires use of human factors engineering principles.6. The “hierarchy of hazard control:”• Eliminate hazard• Guard against hazard• Train to avoid hazards• Warn against hazards
  37. 37. NEW DEVICES• Acceptance, safety inspection, compatibility, education, procedures, and appropriate purchasing documents (including loan agreements).• When in doubt, have CE (Certified Equipment)check, supply chain management .(SCM),
  38. 38. WHY REPORTING MEDICAL DEVICE PROBLEMS• Prevent future problems and protect patients, staff, families, and visitors• Achieve performance improvement goals• Assist Risk Management with claims or litigation• Provide information to manufacturers and/or Food and Drug Administration• Publicize report for the general good of patients and health care providers• Effect changes in policies and procedures of procurement
  39. 39. WHEN TO REPORT• When you think a device has or may have caused or contributed to any of the following outcomes (for a patient, staff member or visitor): – Death – Serious injury – Minor injury – Close calls or other potential for harm
  40. 40. INDIVIDUAL’s ROLE• Identify actual and potential problems, adverse events, close calls with medical devices• Report the problem or adverse event to your supervisor, according to policy and procedure• Make sure your report includes details• Remove the device, keep all affected items, save the packaging
  41. 41. ELECTRICAL SAFETY1. Safety fuses with each equipment2. No loose wires or connection3. Properly plugged and fixed4. If short circuit call electrician5. Electricity back up battery/ generator6. Use of CVT/UPS
  42. 42. FIRE SAFETYUse Fire proof material for construction.Have Fire Exit in all Buildings.Smoke detectors and water sprinklerson the roof of all Floors. Fire Extinguishers in all areas. Fire Hydrants in all buildings.Training in Fire management
  43. 43. BLOOD SAFETY1. Proper grouping & cross matching2. Tests of HIV, Inf. hepatitis & VDRL3. Proper leveling of group, name of the patient4. Control of mismatch reaction5. Standard operating procedure6. Screening against HIV, Hepatitis. VD, Malaria.7. Inform adverse reaction to BB
  44. 44. SANITATION- INFECTION CONTROL- BMW DISPOSAL Sanitation BMW HAI Disposal• Proper segregation & transportation of biomedical wastes• Sanitation & hygiene of different parts of hospital to avoid infection• Use of sterile procedures• Safety in use of incinerator, autoclave, shredder, needle destroyers and proper disposal of biomedical waste.• Formation of hospital infection control committee• Investigation of all hospital infections• Use of proper antibiotics in right doses in right time• Reorientation of Resident doctors & Nursing staff
  45. 45. LABORATORY SAFETY•Avoid needle prick & spilling of blood• Safety measures in Radiology & Radiotherapydepartments• Safety norm guide lines for different areas ofhospitals.• Regular pest control measures• Care in handling acids, reagents, inflammablesubstances.• BMW segregation and disposal
  47. 47. PATIENT INVOLVEMENT• Individual Advocacy – In doctor & hospital visits – Share information • Create lists of health problems, previous operations, etc. • List or bring all medications, supplements, and vitamins – Get information • Ask questions about treatments, medications, etc. • Research illnesses and treatments – Bring an Advocate – Know what to do before leaving • Ask about medications and future appointments
  48. 48. PREVENT MEDICAL ERRORS BY PATIENTA. MEDICINES1. Make sure that all of your doctors know aboutevery medicine you are taking. This includesprescription and over-the-counter medicines anddietary supplements, such as vitamins and herbs.2. Bring all of your medicines and supplements toyour doctor visits. Your medicines can help you andyour doctor talk about them and find out if there areany problems.3. Make sure your doctor knows about anyallergies and adverse reactions you have had tomedicines.
  49. 49. ERRORS BY PATIENT4. When your doctor writes a prescription for you,make sure you can read it.5. Ask for information about your medicines interms you can understand—both when yourmedicines are prescribed and when you get them:•What is the medicine for?•How am I supposed to take it and for how long?•What side effects are likely? What do I do if theyoccur?•Is this medicine safe to take with other medicines ordietary supplements I am taking?•What food, drink, or activities should I avoid whiletaking this medicine?
  50. 50. 6. When you pick up your medicine from thepharmacy, ask: Is this the medicine that my doctorprescribed?7. If you have any questions about the directions onyour medicine labels, ask if "four times daily" meanstaking a dose every 6 hours around the clock or justduring regular waking hours.8. Ask your pharmacist for the best device tomeasure your liquid medicine. Special devices, likemarked syringes, help people measure the right dose.9. Ask for written information about the side effectsyour medicine could cause. If you know what mighthappen, you will be better prepared if it does or ifsomething unexpected happens.
  51. 51. B. HOSPITAL STAYS10. If you are in a hospital, consider asking all healthcare workers who will touch you whether they havewashed their hands. Hand washing can prevent thespread of infections in hospitals.11. When you are being discharged from the hospital,ask your doctor to explain the treatment plan you willfollow at home.•About your new medicines,•When you can get back to your regular activities.•Continuing old medicines before your hospital stay.•When to come back to the hospital for check up
  52. 52. C. SURGERY12. If you are having surgery, make sure that you,your doctor, and your surgeon all agree onexactly what will be done.Surgeons are expected to sign their initials directlyon the site to be operated on before the surgery.13. If you have a choice, choose a hospital wheremany patients have had the procedure or surgeryyou need. Research shows that patients tend tohave better results when they are treated in hospitalsthat have a great deal of experience with theircondition.
  53. 53. D. OTHER STEPS14. Speak up if you have questions orconcerns.15. Make sure that someone, such as yourprimary care doctor, coordinates yourcare.16. Make sure that all your doctors haveyour important health information.20. Learn about your condition andtreatments by asking your doctor and nurseand by using other reliable sources.
  54. 54. PATIENT INVOLVEMENT• Patient Representative – In health care organizations – Work to improve safety at the organization and individual unit level – Serve on committees and boards – Assist on rounds and here patient greivences – Support staff and families
  55. 55. PATIENT INVOLVEMENT• Patient Participant/Activist – Participate on state and regional coalitions and organizations and/or – Serve nationally – Advocate for public reporting and accountability of hospital and health system performance – Volunteer, make donations, work with fund- raising – Be aware of state and national legislation, contact legislators
  56. 56. PATIENT INVOLVEMENT• Patient Advocate – For friends and family – Willingness to go with the patient to appointments, be with them in the hospital and clinics – Listening and taking notes – Speak up when necessary to clarify an issue and to ask a question – Question when something does not seem right in the hospital, nursing homes, clinics, etc.
  57. 57. PREVENT MEDICAL ERRORS BY MEDICAL STAFFCommunication & coordination deficits driveerrorsApplication of Aviation Safety concepts & skills arebeing introduced in healthcareStrong Correlation between Teamwork results in: •Improved Patient Outcomes •Patient Satisfaction •Staff Satisfaction •Reduced Errors •Reduce malpractice claims •Reduce ‘Blame culture’
  58. 58. TWO-CHALLENGE RULE :It is your responsibility to assertively voice yourconcern at least two times to ensure that it hasbeen heardThe member being challenged mustacknowledgeProvide supporting information with secondchallengeIf the outcome is still not acceptable use ‘CUS’Concern, Un comfortable , Stop Take a stronger course of action “Empower any member of the team to “stop the line” if he or she senses or discovers an essential safety breach.”
  59. 59. EFFECTIVE COMMUNICATIONCommunication Breakdowns Contributing Factor in43% of adverse surgical eventsPivotal Factor in 65% of Sentinel Events (3,000events 1995-2005) (Joint Commission on Accreditation of Healthcare Organizations. (2006)Primary contributing factor in adverse events 70-80%of root cause analysis (National Center for Patient Safety(2006). Root Cause Analysis Database) Common in: •Medical errors •Medical malpractice cases •Adverse surgical events •Adverse medical events •Sentinel events
  60. 60. ADVERSE INCIDENT REPORTING• Complete and submit• Notify Risk Management• Drug controller notification if Medical Device or Medication• Begin Root Cause/Intensive analysis to examine process changes that may prevent future events• Take preventing measures for future near miss.
  61. 61. PEER REVIEWMonitor and improve physician care ofpatientsAccomplish by: •Open, non-punitive discussion •Review and discuss alternatives •Disseminate to ALL physicians •Monthly review scheduleMove towards: review previous 48 hour record (Code Blue) •Could this event have been prevented? •Were signs of deterioration missed? Elevated BP, dropping BP Elevated HR, dropping HR Elevated RR
  62. 62. HEALTH EXECUTIVE’S ROLE  Set Culture Accountability Measures High Reliability/Redesign Communication and Teamwork Professional Development  Reliability principles:  simplification  standardization  relation of humans to the work  environment
  64. 64. PRATICE OF PATIENT SAFETY ( WHO )1. Be aware of Look-Alike, Sound-Alike Medication Names.2. Proper Patient Identification.3. Explain in Detail During Patient Hand/Take- Overs.4. Performance of Correct Procedure at Correct Body Site.5. Careful About Electrolyte Imbalance.6. Assuring Proper Treatment During Shifting.7. Avoid Catheter and Tubing, Wrong Connections .8. Single Use of Injection Syringes.9. Improved Hand Hygiene to Prevent Health Care- Associated Infections .10. Proper Disposal of BMW and Good House Keeping.11 Practice Surgical Safety Guide Lines.
  65. 65. TIPS FOR IMPROVING PATIENT SAFETY1. Constitution of Patient Safety Committee.2. Develop clear policies and protocols for patient safety.3. Discuss regularly patient safety initiative within hospital staff.4. Orientation, Re-orientation hospital staff on patient safety5. Encourage transparency in the regular death review.6. Non- punitive incident reporting by staff.7. Each department to devise their own patient safety protocols.8. Investigate each accident/ incident reported and take remedial measures.9. Review, monitor & evaluate. safety procedures regularly.
  66. 66. hospiad Hospital Administration Made Easy http//hospiad.blogspot.com An effort solely to help students and aspirants in their attempt to become a successful Hospital Administrator. DR. N. C. DAS
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In the presentation, a summary of initiatives to be taken by hospitals in different areas for patient safety have been described for the knowledge, practices and implementation of patient safety initiative by hospital managers/Administrators.


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