Evolution and transformation of Patient Safety in
to the Modern Health Care System-
Tools & Techniques
Presented by Krish ...
Introduction-About me
• Been in healthcare domain for over 24 years.
• Triple Masters degree.
• MS in Patient Safety Leade...
Disclosure
The presenter has nothing to disclose, nor has
any commercial interest with any of those
information's displaye...
About Tawam Hospital
• Tawam is a 466-bed tertiary care facility located in the garden city Al
Ain in the middle of the de...
I will………
Items for discussion
• Ice breaker
– Video: Capt. Chesley "Sully" Sullenberger
• Historical context of Patient Safety
• Le...
Capt. Chesley "Sully" Sullenberger- Video
Hippocratic Oath
5th century BC -Physicians and other healthcare professionals swearing
to practice medicine honestly
Florence Nightingale
The founder of modern nursing
1863-―the very first requirement in a Hospital is that it should do the...
Dr. Ernest Codman
1905 started "end result idea.― Hospital standardization.
Doctors should follow up with all patients to ...
How is it that aviation became safer than
healthcare ???
High Reliability Organizations
Zero compromise to safety
The Annual Toll of Medical Injury
IOM ―To Err is Human‖ (1999)
• 44,000 – 98,000 deaths/year in US due to
medical errors.
...
1
10
100
1,000
10,000
100,000
1 10 100 1,000 10,000 100,000 1,000,000 10,000,000
Number of encounters for each fatality
To...
Why do errors happen in healthcare?
Miscommunication- Video
That killed him- Video
2013-8-23 24
National Quality Forum
List of Never Events-28
• Unintended retention of a foreign body in
a patient after surgery or othe...
The patients saw an average of 17.8 health
professionals during their hospitalization
National Patient Safety Goals
Established in 2003
Established in 2001
Anesthesia Patient Safety Foundation
launched in lat...
What is Patient Safety?- Definition
• The freedom from accidental injury due to medical
care or from medical error.(Instit...
The biggest hurdle!!!!!!
Reported errors
Not reported
We Name, Shame & Blame people
31
“The single greatest impediment to error
prevention in the medical industry is that
we punish people for making mistakes.”...
Second Victim-
Eric Cropp story (Video)
Eric Cropp story (Video)
Common Response After a Medical
Error
The types of suffering are
• Increased anxiety about the future possibility of
error...
Medical error: the second victim..
• The term second victim was initially coined by Wu in
his description of the impact of...
System Failure Vs Individual Fault
―Insanity: doing the same
thing over and over again and
expecting different results‖
Albert Einstein
2013-8-23 38
Avedis Donabedian
1966 –Structure leading to Process and process leading to Outcome
Whether a procedure or intervention ha...
―Every system is perfectly designed to
achieve the results it gets.‖
Donald Berwick, M.D.
President & CEO of Institute for...
Not Bad people - But Bad Systems
2013-8-23 41
Medical Errors related Behavioral
Choices
Reckless
Behavior
Intentional Risk-Taking
Manage through:
• Remedial action
• Di...
How do we prevent errors?
Errors can be prevented by
designing systems that make it
hard for people to do the wrong
thing,...
Critical thinking & System redesign - video
Critical Thinking - Video
System Redesign- Video
System Design- Forcing Function
2013-8-23 47
Steps to Minimize Medical Error
Forcing functions & constraints
Automation & computerization
Standardization & protocol
Ch...
Tools & Techniques
To prevent medical errors &
Improve patient Safety
Accreditation programs
Seeking gold standards
National Accreditation Board for Hospitals
& Healthcare Providers (NABH) is ...
JCIA- Standards
1. International Patient Safety Goals (IPSG)
2. Access to care and continuity of Care (ACC)
3. Patient and...
Patient Safety Goals
1. Identify Patients Correctly
2. Improve Effective Communication
3. Improve the Safe Use of Medicati...
Goal 1
Identify Patients Correctly
Use two identifiers
Patient full name, DOB, Medical Record # etc
• Before giving medica...
Correct Patient Identification
Do Not Use
Patient Room Number or Location
to identify the patient
1343
Use of technology
Goal 2
Improve Effective Communication
• Effective communication, which is
timely, accurate, complete, unambiguo
us, and u...
Miscommunication- Video
The German Coast Guard
Improve Effective Communication
• Verbal & Telephonic order
– Write down and ―Read- Back‖
• Communicate critical test resu...
Verbal & Telephone orders
Daily Goals Check List
Bridging the hierarchy challenges
Goal 3
Improve the Safe Use Of Medications
• Following the Seven Rights
• Storage, labeling and segregation of
High Alert ...
Seven rights to prevent medication
errors
• RIGHT drug
• RIGHT patient (Two Identifiers)
• RIGHT dose
• RIGHT time
• RIGHT...
Improve the Safety of High-Alert
Medications
HIGH ALERT MEDICATIONS :-
Drugs that bear a heightened risk of
causing signif...
Storage, labeling and segregation
• Concentrated Electrolytes are removed
from patient care areas unless clinically
necess...
Storage, labeling and segregation
Independent Double Checking- Video
Independent double check
Medication Reconciliation
• Obtain information on the medications
the patient is currently taking
• Medication orders are ...
The Medication Use System
Selection
&
Procuring
Establish
formulary
Monitoring
Assess patient
response to
drug; report
rea...
Major Areas for Medication Error
Prescribing
Transcribing
Dispensing
Administering
38% 39%
12% 11%
Medication Errors Repor...
Prescribing Errors
Contributing factors:
• Illegible handwriting
• Inaccurate medication history taking
• Confusion with t...
Prescribing Errors….. Example
Name That Drug…
Lipitor 10mg PO QD
Filled Rx: Zyrtec 10mg
Prescribing Errors….. Example
Name That Drug…
6 units of regular insulin now
Filled Rx: 60 units
Prescribing Errors….. Example
Name That Drug…
Tegretol 300mg BID
Filled Rx: Tegretol 1300mg
Dispensing Errors
• Selection of the wrong drug
• Similar appearance or similar
name (look alike sound alike
medication)
Dispensing Errors…..Example
look alike sound alike
Dispensing Errors…..Example
look alike sound alike
Administration Errors
Contributing factors:
• Failure to check the patient’s identity
prior to administration
• Storage of...
Systems & Technology to prevent
medication errors
Tall man lettering to prevent
look alike sound alike drugs
Computerized Physician Order Entry
CPOE- with decision support system
Automated drug dispenser
Barcode Scanner
bedside medication verification
Smart Infusion pumps
Goal 4
Ensure correct-site, correct-procedure, correct- patient
Surgery.
• Use a checklist.
• Verify all documents.
• Chec...
WHO Safe Surgical Checklist- Video
How to perform a ―Time-Out‖
Goal 4
Reduce the Risk of Health Care –Associated Infections
• Strict hand hygiene before and after contact with
each pati...
Five moments of hand hygiene
Technology support
Sharps disposal box
Hand sanitizer dispenser
Antimicrobial Stewardship
• Antibiotic stewardship refers to a set of
coordinated strategies to improve the
use of antimic...
Healthcare Associated Infection-
HAI
• Central line Associated Blood Stream
Infection- CLABSI
• Surgical Site Infection-SS...
HAI
• CLABSI
– Attributable mortality: 9-25%
– Attributable cost: $25,000-$45,000
– Of patients who get a bloodstream infe...
Replicating the same for
CLBASI Free Days
109
NNU CLABSI Free Days
110
PICU CLABSI Free Days
111
ICU CLABSI Free Days
112
CUSP Team with the ICU Executive - COO
Dangerous enviornment
Spread of infection- Video
Goal 6
Reducing the risk of patient resulting from fall
• Falls account for a significant portion of
injuries in hospitali...
Epidemiology of inpatient falls
• 1235 falls by 1082 pts (3.10 falls/1000 pt
days)
• 89% single fall, 11% more than once
•...
Falls risk assessment tools
• Morse, STRATIFY, Hendrich II
Prevention strategies to reduce patient fall-
video
Fall Prevention Strategies
Place fall precautions sign in patient’s room.
Communicate fall risk during hand-off of care
Ma...
Fall prevention protocols
―If you can’t measure it, you
can’t manage it.‖
Peter Drucker
Key Performance Indicators (KPIs)
• Embrace the following :
– People – staff focus
– Service – customer focus
– Quality – ...
Dashboards
• Powerful graphs
communicating both the
financial and nonfinancial
key performance
indicators
• Designed to tr...
Color Coded Dashboard
Discussions- The End Game
Are these initiatives sufficient to prevent &
eliminate Medical Errors and improve Patient
Safety?
If not……then how do we get to the ideal
situation??
Building a Culture of Safety
2013-8-23 131
How to integrate SAFETY in to
the CULTURE of the
organization???
A CUSP Approach
Topic of my next lecture will be
I will………
Resources-websites
• http://www.iom.edu/
• http://www.npsf.org/
• http://www.ihi.org/explore/patientsafety/pages/default.a...
References
• How many health professionals does a patient see during an average
hospital stay? N Whitt, R Harvey, S Child
...
References
• Vincent, C., Young, M., and Philips, A. Why do people sue doctors? A
study of patients and relatives taking l...
• http://www.patientsafetyalliance.in/
Patient Safety Top Priority
Patient Safety Everyone's Responsibility
Contacts:
Email- ksankara@tawamhospital.ae
Mobile- +9...
Evolution and transformation of patient safety in to the modern health care system  tools & techniques
Evolution and transformation of patient safety in to the modern health care system  tools & techniques
Evolution and transformation of patient safety in to the modern health care system  tools & techniques
Evolution and transformation of patient safety in to the modern health care system  tools & techniques
Evolution and transformation of patient safety in to the modern health care system  tools & techniques
Evolution and transformation of patient safety in to the modern health care system  tools & techniques
Evolution and transformation of patient safety in to the modern health care system  tools & techniques
Evolution and transformation of patient safety in to the modern health care system  tools & techniques
Evolution and transformation of patient safety in to the modern health care system  tools & techniques
Evolution and transformation of patient safety in to the modern health care system  tools & techniques
Evolution and transformation of patient safety in to the modern health care system  tools & techniques
Evolution and transformation of patient safety in to the modern health care system  tools & techniques
Evolution and transformation of patient safety in to the modern health care system  tools & techniques
Evolution and transformation of patient safety in to the modern health care system  tools & techniques
Evolution and transformation of patient safety in to the modern health care system  tools & techniques
Evolution and transformation of patient safety in to the modern health care system  tools & techniques
Evolution and transformation of patient safety in to the modern health care system  tools & techniques
Evolution and transformation of patient safety in to the modern health care system  tools & techniques
Evolution and transformation of patient safety in to the modern health care system  tools & techniques
Evolution and transformation of patient safety in to the modern health care system  tools & techniques
Evolution and transformation of patient safety in to the modern health care system  tools & techniques
Evolution and transformation of patient safety in to the modern health care system  tools & techniques
Evolution and transformation of patient safety in to the modern health care system  tools & techniques
Evolution and transformation of patient safety in to the modern health care system  tools & techniques
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Evolution and transformation of patient safety in to the modern health care system tools & techniques

  1. 1. Evolution and transformation of Patient Safety in to the Modern Health Care System- Tools & Techniques Presented by Krish Sankaranarayanan MS, MBA, CPHQ Senior Safety Officer Tawam Hospital. UAE
  2. 2. Introduction-About me • Been in healthcare domain for over 24 years. • Triple Masters degree. • MS in Patient Safety Leadership from UOI- Chicago. • Certified Professional in Healthcare Quality (CPHQ) • Educational consultant- Canadian Healthcare Association- CQI progarm • Membership – Member American College of Healthcare Executives – Member National Association of Healthcare Quality – Member American Society for Healthcare Risk Management – Member American Society of Professionals in Patient Safety – Vice President of the ACHE Middle East and North Africa Group
  3. 3. Disclosure The presenter has nothing to disclose, nor has any commercial interest with any of those information's displayed in this presentation. 2013-8-23 3
  4. 4. About Tawam Hospital • Tawam is a 466-bed tertiary care facility located in the garden city Al Ain in the middle of the desert, and one among the largest healthcare facilities in the United Arab Emirates. • In 2006 the General Authority of Heath Services now called as the Abu Dhabi Health Services Company PJSC (SEHA) entered in to a ten year affiliation contract with Johns Hopkins Medicine. • Tawam Hospital has current status with • Joint Commission International Accreditation (2006; 2009; 2012), • College of American Pathology (CAP; 2011) and • American College of Graduate Medical Education- International (ACGME; Program Accreditation) 2013-8-23 4
  5. 5. I will………
  6. 6. Items for discussion • Ice breaker – Video: Capt. Chesley "Sully" Sullenberger • Historical context of Patient Safety • Lessons from high reliability organization • Patient Safety definitions • Patient Safety Organizations • Why do errors happen? • Second Victim • Tools & techniques to improve patient safety 2013-8-23 6
  7. 7. Capt. Chesley "Sully" Sullenberger- Video
  8. 8. Hippocratic Oath 5th century BC -Physicians and other healthcare professionals swearing to practice medicine honestly
  9. 9. Florence Nightingale The founder of modern nursing 1863-―the very first requirement in a Hospital is that it should do the sick no harm
  10. 10. Dr. Ernest Codman 1905 started "end result idea.― Hospital standardization. Doctors should follow up with all patients to assess the results of their treatment and that the outcomes actively be made public.
  11. 11. How is it that aviation became safer than healthcare ???
  12. 12. High Reliability Organizations Zero compromise to safety
  13. 13. The Annual Toll of Medical Injury IOM ―To Err is Human‖ (1999) • 44,000 – 98,000 deaths/year in US due to medical errors. • $ 50 billion in total costs. • 7% of patients suffer a medication error. • Every patient admitted to ICU suffers an adverse event. 1 in 3 people say that they or a family member has experienced a medical error at some point in their lives 180,000 people die each year due to iatrogenic injury in US. This is equivalent to three fully loaded jumbo- jet crashing every two days. Most of it where preventable !!!!
  14. 14. 1 10 100 1,000 10,000 100,000 1 10 100 1,000 10,000 100,000 1,000,000 10,000,000 Number of encounters for each fatality Totalliveslostperyear REGULATEDDANGEROUS (>1/1000) ULTRA-SAFE (<1/100K) Health Care Mountain Climbing Driving Chemical Manufacturing Chartered Flights Scheduled Airlines European Railroads Nuclear Power
  15. 15. Why do errors happen in healthcare?
  16. 16. Miscommunication- Video
  17. 17. That killed him- Video
  18. 18. 2013-8-23 24
  19. 19. National Quality Forum List of Never Events-28 • Unintended retention of a foreign body in a patient after surgery or other procedure • Surgery performed on the wrong body part • Surgery performed on the wrong patient • Wrong surgical procedure performed on a patient • Infant discharged to the wrong person • Stage 3 or 4 pressure ulcers acquired after admission to a healthcare facility
  20. 20. The patients saw an average of 17.8 health professionals during their hospitalization
  21. 21. National Patient Safety Goals Established in 2003 Established in 2001 Anesthesia Patient Safety Foundation launched in late 1985 APSF was incorporated as an association in July 1989 World Alliance for Patient Safety was launched in 2004 Canadian Patient Safety Institute Established in 2003 National Patient Safety Foundation Established in 1997
  22. 22. What is Patient Safety?- Definition • The freedom from accidental injury due to medical care or from medical error.(Institute Of Medicine) • The prevention of healthcare errors, and the elimination or mitigation of patient injury caused by healthcare errors. (National Patient Safety Foundation) • The absence of the potential for or occurrence of health care associated injury to patients. Created by avoiding medical errors as well as taking action to prevent errors from causing injury. (Agency for Healthcare Research and Quality)
  23. 23. The biggest hurdle!!!!!! Reported errors Not reported
  24. 24. We Name, Shame & Blame people 31
  25. 25. “The single greatest impediment to error prevention in the medical industry is that we punish people for making mistakes.” (Leape 2009) Dr. Lucian Leape is a professor at Harvard School of Public Health, he is a health policy analyst whose research has focused on patient safety and quality of care
  26. 26. Second Victim- Eric Cropp story (Video)
  27. 27. Eric Cropp story (Video)
  28. 28. Common Response After a Medical Error The types of suffering are • Increased anxiety about the future possibility of errors. • Loss of confidence in the work they do. • Some face difficulty sleeping. • Concern about their reputation as a care giver • Reduction in their sense of job satisfaction. • Excellent clinicians may leave the profession prematurely when involved in a preventable error.
  29. 29. Medical error: the second victim.. • The term second victim was initially coined by Wu in his description of the impact of errors on professionals. The doctor who makes the mistake needs help too. • In the aftermath of a mistake, it's important the doctor seek support to deal with the consequences. Albert W Wu associate professor School of Hygiene and Public Health and School of Medicine, Johns Hopkins University, Baltimore, MD 2013-8-23 36
  30. 30. System Failure Vs Individual Fault
  31. 31. ―Insanity: doing the same thing over and over again and expecting different results‖ Albert Einstein 2013-8-23 38
  32. 32. Avedis Donabedian 1966 –Structure leading to Process and process leading to Outcome Whether a procedure or intervention has made a favorable difference. Structure Process Outcome Paradigm
  33. 33. ―Every system is perfectly designed to achieve the results it gets.‖ Donald Berwick, M.D. President & CEO of Institute for Healthcare Improvement 2013-8-23 40
  34. 34. Not Bad people - But Bad Systems 2013-8-23 41
  35. 35. Medical Errors related Behavioral Choices Reckless Behavior Intentional Risk-Taking Manage through: • Remedial action • Disciplinary action At-Risk Behavior Unintentional Risk-Taking Human Error Product of our current system design Manage through changes in: • Processes • Procedures • Training • Design • Environment Console Coach Punish Manage through: • Removing incentives for at-risk behaviors • Creating incentives for healthy behaviors • Increasing situational awareness
  36. 36. How do we prevent errors? Errors can be prevented by designing systems that make it hard for people to do the wrong thing, and easy for people to do the right thing. 2013-8-23 43
  37. 37. Critical thinking & System redesign - video
  38. 38. Critical Thinking - Video
  39. 39. System Redesign- Video
  40. 40. System Design- Forcing Function 2013-8-23 47
  41. 41. Steps to Minimize Medical Error Forcing functions & constraints Automation & computerization Standardization & protocol Checklist & double check system Rules & policies Education/ Information Be more careful, be vigilant Most effective Least effective
  42. 42. Tools & Techniques To prevent medical errors & Improve patient Safety
  43. 43. Accreditation programs Seeking gold standards National Accreditation Board for Hospitals & Healthcare Providers (NABH) is a constituent board of Quality Council of India
  44. 44. JCIA- Standards 1. International Patient Safety Goals (IPSG) 2. Access to care and continuity of Care (ACC) 3. Patient and Family Rights (PFR) 4. Assessment of patients (AOP) 5. Care of patients (COP) 6. Anesthesia and Surgical care (ASC) 7. Medication management and use (MMU) 8. Patient and Family Education (PFR) 9. Quality Improvements and patient Safety(QPS) 10.Prevention and Control of Infections (PCI) 11.Governance Leadership and Direction (GLD) 12.Facility Management and Safety (FMS) 13.Staff Qualification and Education (SQE) 14.Management of communication and Information (MCI)
  45. 45. Patient Safety Goals 1. Identify Patients Correctly 2. Improve Effective Communication 3. Improve the Safe Use of Medications 4. Ensure correct-site, correct- procedure, correct- patient Surgery 5. Reduce the Risk of Health Care –Associated Infections 6. Reduce the Risk of Patient Harm Resulting from Falls
  46. 46. Goal 1 Identify Patients Correctly Use two identifiers Patient full name, DOB, Medical Record # etc • Before giving medication • Before administering blood or blood products • Before taking blood samples & specimens • Before doing clinical testing • Before providing any treatment or procedures
  47. 47. Correct Patient Identification
  48. 48. Do Not Use Patient Room Number or Location to identify the patient 1343
  49. 49. Use of technology
  50. 50. Goal 2 Improve Effective Communication • Effective communication, which is timely, accurate, complete, unambiguo us, and understood by the recipient, reduces errors and results in improved patient safety.
  51. 51. Miscommunication- Video
  52. 52. The German Coast Guard
  53. 53. Improve Effective Communication • Verbal & Telephonic order – Write down and ―Read- Back‖ • Communicate critical test results – Write down and ―Read- Back‖ • Use of SBAR, I PASS BATON- structured form of communication • Daily Goals Checklist
  54. 54. Verbal & Telephone orders
  55. 55. Daily Goals Check List
  56. 56. Bridging the hierarchy challenges
  57. 57. Goal 3 Improve the Safe Use Of Medications • Following the Seven Rights • Storage, labeling and segregation of High Alert Medication • Do Not Use dangerous abbreviation List • Medication Reconciliation
  58. 58. Seven rights to prevent medication errors • RIGHT drug • RIGHT patient (Two Identifiers) • RIGHT dose • RIGHT time • RIGHT route • RIGHT reason • RIGHT documentation
  59. 59. Improve the Safety of High-Alert Medications HIGH ALERT MEDICATIONS :- Drugs that bear a heightened risk of causing significant patient harm when they are used in error. Although mistakes may or may not be more common with these drugs, the consequences of an error with these medications are clearly more devastating to patients. (Institute for Safe Medication Practice)
  60. 60. Storage, labeling and segregation • Concentrated Electrolytes are removed from patient care areas unless clinically necessary • Segregated from other medications and Labeled as "High Alert Concentrated electrolytes are: Magnesium sulfate injection Potassium Acetate injection Potassium chloride for injection concentrate Potassium phosphates injection Sodium Acetate injection Sodium bicarbonate 8.4% injection Sodium Chloride for injection, hypertonic (greater than 0.9% concentration) Sodium Phosphate injection
  61. 61. Storage, labeling and segregation
  62. 62. Independent Double Checking- Video
  63. 63. Independent double check
  64. 64. Medication Reconciliation • Obtain information on the medications the patient is currently taking • Medication orders are compared to the list of medications taken prior to admission
  65. 65. The Medication Use System Selection & Procuring Establish formulary Monitoring Assess patient response to drug; report reactions & errors Administering Review dispensed drug order; assess patient & administer Preparing & Dispensing Purchase & store drug; review & confirm order; distribute to patient location Prescribing Assess patient; determine need for drug therapy; select & order drug Clinician & administrators Physician/ prescriber Pharmacist Nurse/other health professionals All practitioners, plus patient &/or family Joint Commission. 1998
  66. 66. Major Areas for Medication Error Prescribing Transcribing Dispensing Administering 38% 39% 12% 11% Medication Errors Reporting Program US
  67. 67. Prescribing Errors Contributing factors: • Illegible handwriting • Inaccurate medication history taking • Confusion with the drug name • Inappropriate use of decimal points • Use of abbreviations • Use of verbal order Williams DJ. 2007
  68. 68. Prescribing Errors….. Example Name That Drug… Lipitor 10mg PO QD Filled Rx: Zyrtec 10mg
  69. 69. Prescribing Errors….. Example Name That Drug… 6 units of regular insulin now Filled Rx: 60 units
  70. 70. Prescribing Errors….. Example Name That Drug… Tegretol 300mg BID Filled Rx: Tegretol 1300mg
  71. 71. Dispensing Errors • Selection of the wrong drug • Similar appearance or similar name (look alike sound alike medication)
  72. 72. Dispensing Errors…..Example look alike sound alike
  73. 73. Dispensing Errors…..Example look alike sound alike
  74. 74. Administration Errors Contributing factors: • Failure to check the patient’s identity prior to administration • Storage of similar preparations in similar areas • Noise, interruptions, & poor lighting Williams DJ. 2007
  75. 75. Systems & Technology to prevent medication errors
  76. 76. Tall man lettering to prevent look alike sound alike drugs
  77. 77. Computerized Physician Order Entry CPOE- with decision support system
  78. 78. Automated drug dispenser Barcode Scanner bedside medication verification
  79. 79. Smart Infusion pumps
  80. 80. Goal 4 Ensure correct-site, correct-procedure, correct- patient Surgery. • Use a checklist. • Verify all documents. • Check equipment needed for surgery. • Mark the precise site ( involve the patient ). • Use "time-out" just before starting a surgical / invasive procedure.
  81. 81. WHO Safe Surgical Checklist- Video
  82. 82. How to perform a ―Time-Out‖
  83. 83. Goal 4 Reduce the Risk of Health Care –Associated Infections • Strict hand hygiene before and after contact with each patient or their environment • Adequate hand hygiene facilities for staff and patients • A clean hospital environment and good hygiene practice • Isolation of patients in single rooms, when necessary, to reduce the risk of infection • Careful prescription of antimicrobial drugs • Training on infection prevention and control for all staff
  84. 84. Five moments of hand hygiene
  85. 85. Technology support Sharps disposal box Hand sanitizer dispenser
  86. 86. Antimicrobial Stewardship • Antibiotic stewardship refers to a set of coordinated strategies to improve the use of antimicrobial medications with the goal of enhancing patient health outcomes, reducing resistance to antibiotics, and decreasing unnecessary costs. • The Infectious Diseases Society of America (IDSA)
  87. 87. Healthcare Associated Infection- HAI • Central line Associated Blood Stream Infection- CLABSI • Surgical Site Infection-SSI • Cather Associated Urinary Tract Infection-CAUTI • Ventilator Associated Pneumonia -VAP
  88. 88. HAI • CLABSI – Attributable mortality: 9-25% – Attributable cost: $25,000-$45,000 – Of patients who get a bloodstream infection from having a central line, up to 1 in 4 die. • CMS Medicare and Medicaid no longer pays hospital for CLABSI • CLABSI – Remove Unnecessary Lines – Wash Hands Prior to Procedure – Use Maximal Barrier Precautions – Clean Skin with Chlorhexidine – Avoid Femoral Lines
  89. 89. Replicating the same for CLBASI Free Days 109
  90. 90. NNU CLABSI Free Days 110
  91. 91. PICU CLABSI Free Days 111
  92. 92. ICU CLABSI Free Days 112 CUSP Team with the ICU Executive - COO
  93. 93. Dangerous enviornment Spread of infection- Video
  94. 94. Goal 6 Reducing the risk of patient resulting from fall • Falls account for a significant portion of injuries in hospitalized patients. • Establish fall-risk reduction program – Initial assessment of patients for fall risk during admission – Reassessment of patients when indicated by a change in condition or medications – Implemented fall reduction strategies – Monitor intended and unintended consequences of fall risk measures
  95. 95. Epidemiology of inpatient falls • 1235 falls by 1082 pts (3.10 falls/1000 pt days) • 89% single fall, 11% more than once • 40% related to toileting • Serious injury (laceration requiring sutures, loss of consciousness, fracture, SDH) – 6% • Death – 0.2% (both in patient with more than 1 fall) Source: Inf Control Hosp Epidem 2005;26:822
  96. 96. Falls risk assessment tools • Morse, STRATIFY, Hendrich II
  97. 97. Prevention strategies to reduce patient fall- video
  98. 98. Fall Prevention Strategies Place fall precautions sign in patient’s room. Communicate fall risk during hand-off of care Maintain bed in low position, and put bed rails up. Assess hourly patient’s need for toileting. Actively engage patient and family Lock all moveable equipment before transferring patients. Do not leave patient unattended for transfers/toileting. Place patient care articles within reach (call bell, urinal, phone, water). Provide physically safe environment (adequate lighting, eliminate spills, clutter, electrical cords, and unnecessary equipment). Evaluate medication profile for fall risk. Move patient closer to the nursing station for those at High Risk
  99. 99. Fall prevention protocols
  100. 100. ―If you can’t measure it, you can’t manage it.‖ Peter Drucker
  101. 101. Key Performance Indicators (KPIs) • Embrace the following : – People – staff focus – Service – customer focus – Quality – excellence in clinical outcomes and service – Finance – Growth – expansion of services
  102. 102. Dashboards • Powerful graphs communicating both the financial and nonfinancial key performance indicators • Designed to translate vision & strategy into objectives • Employees can: – embrace, achieve, measure & celebrate. – focus on annual goals & long term strategic goals.
  103. 103. Color Coded Dashboard
  104. 104. Discussions- The End Game
  105. 105. Are these initiatives sufficient to prevent & eliminate Medical Errors and improve Patient Safety?
  106. 106. If not……then how do we get to the ideal situation??
  107. 107. Building a Culture of Safety 2013-8-23 131
  108. 108. How to integrate SAFETY in to the CULTURE of the organization??? A CUSP Approach Topic of my next lecture will be
  109. 109. I will………
  110. 110. Resources-websites • http://www.iom.edu/ • http://www.npsf.org/ • http://www.ihi.org/explore/patientsafety/pages/default.aspx • http://www.hopkinsmedicine.org/armstrong_institute/ • http://www.josieking.org/ • https://www.patientsafetygroup.org/main/index.cfm • http://www.pso.ahrq.gov/ • http://www.patientsafety.gov/ • http://www.safetyleaders.org/
  111. 111. References • How many health professionals does a patient see during an average hospital stay? N Whitt, R Harvey, S Child • Waterman AD, Garbutt J, Hazel E, et al. The emotional impact of medical errors on practicing physicians in the United States and Canada. Jt Comm J Qual Patient Saf 2007;33:467–76. • Rossheim J. To err is human—even for medical workers. Healthcare monster. http://healthcare.monster.ca/8099_en-CA_pf.asp (accessed 21 Jan 2009). • Green, M.J., Farber, N.J., and Ubel, P.A. Lying to each other. Archives of Internal Medicine, 2000;160:2317-23. • Mizrahi, T. Managing medical mistakes: ideology, insularity and accountability among internists-in-training. Social Science & Medicine, 1984;19(2):135-46 • Hickson, G. B., Clayton, E. W., Githens, P. B., et al. Factors that prompted families to file medical malpractice claims following perinatal injuries. JAMA, 1992;267:1359-63.
  112. 112. References • Vincent, C., Young, M., and Philips, A. Why do people sue doctors? A study of patients and relatives taking legal action. Lancet, 1994;343:1609-13. • Witman, A. B., Park, D. M., and Hardin, s. B. How do patients want physicians to handel mistakes? A survey of internal medicince patients in an academic setting, Archives of Internal Medicine, 1996;156(22):2565-69.
  113. 113. • http://www.patientsafetyalliance.in/
  114. 114. Patient Safety Top Priority Patient Safety Everyone's Responsibility Contacts: Email- ksankara@tawamhospital.ae Mobile- +971 50 9211649 2013-8-23 138 Thank You
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