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Power point patient saftey final 2010






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  • Freedom from unintended health care errors / injuries due to medical management..
  • without fear of blame or punishment — essential to improving patient safety in any organization
  • 1- that monitors all safety efforts ------ initiative in various areas
  • Having everyone in the same movie ----------------- not having what you need when you need it
  • Regardless of their position ------------ a culture of safety should not only provide safty to patient but should also include staff, visitors, and all individuals interacting with the organization
  • Depending on the safety culture, resources, and issues facing an organization
  • it accomplishes this by generating and implementing a patient safety plan, overseeing initiatives, prioritizing recommendations, and deploying adequate resources.
  • Reports to the governing board should include results and recommendations in a coordinated fashion.
  • Organization leaders should choose relatively simple projects to ease the committee into its work; early wins help to build trust between staff and administrators and enhance the group's ability to tackle larger, more complex issues.
  • Measure and assess leadership contr
  • prevention Reactive = reaction assess and evaluate proactive = to
  • Stat for Emergency Room Nursing Education Department Monthly Infection Control Reports Drug Use and Clinical Adverse Events Patient/Family Questions Specifics Adverse Events Research Studies
  • Educate staff to recognize that a culture of safety should not only provide safety to patient but should also include staff, visitors, and all individuals interacting with the organization. Engage physicians in the effort, to ensure ongoing involvement and buy-in to the culture of safety

Power point patient saftey final 2010 Power point patient saftey final 2010 Presentation Transcript

    • Define patient safety.
    • Understand the development of patient safety structure.
    • Identify culture of safety.
    • List the 6 international goals.
    • Understand leadership focus.
    • Understand Psychological safety.
    • List the library connection.
    • Medical errors have become a leading causes of death, killing more people each year than AIDS or Airplane crashes.
    • These medical errors can be classified into
    • five categories:
    • 1- Poor communication.
    • 2- Poor decision making.
    • 3- Poor patient monitoring.
    • 4- Poor patient identification.
    • 5- Poor patient tracking.
  • Meeting the Joint Commission on accreditation of healthcare Organization (JCAHO) patient safety goals is the current trend in enhancing patient safety.
    • Goal (1) identify patients correctly.
    • Goal (2) improve effective Communication.
    • Goal (3) improve the safety of high-alert medications.
    • Goal (4) ensure correct-site, correct-procedure, correct-patient surgery.
    • Goal (5) reduce the risk of health care–associated infections .
    • Goal (6) reduce the risk of patient harm resulting from falls .
    • Freedom from accidental injury ,ensuring the establishment of operational systems and processes that minimize the likelihood of errors so they won’t occur:
    • Is an atmosphere of mutual trust in which all staff?
    • Members can talk freely about safety problems and how to solve them ---without fear of blame or punishment .
    • 1- Develop a patient safety committee.
    • 2- Integrate the patient safety-related efforts within a coordinating council.
    • 3- Assign one person to coordinate patient safety various areas.
    • 4- Expand the scope of current committee responsibilities and accountability to include patient safety.
    • 1- Not knowing the plan.
    • 2- Communication issues.
    • 3- Surprises.
    • 4- Missing information.
    • 5- Lack of resources.
    • 6- Failure to plan, recognize and rescue others?
    • 1- Support teamwork and respect others.
    • 2- Educate staff.
    • 3- Engage physicians.
    • 4-Share lessons learned.
    • 5- Encourage use of communicating.
    • 6- Assign 1 (one) or 2 (two) clinical staff members.
    • 7-Take a proactive approach to error.
    • 8-Study and learn from near misses.
    • 9- Search for information about how to do things safely.
    • 10-Provide team training to a culture of safety.
    • 11- Encourage patient and family involvement in the care process.
    • 12- Share information about safety with others.
  • Psychological safety is a belief that one will not be punished or humiliated for speaking up with ideas, questions, concerns, or mistakes. A shared sense of psychological safety is a critical input to an effective learning system.  
    • A patient safety committee is a multidisciplinary team that takes a proactive approach to patient safety; It provides coordination and oversight to advance an organizations safety program and implement safety-related policies and procedures .
    • The patient safety committee coordinate the following:
    • 1- The risk management.
    • 2- The environmental safety.
    • 3- The infection control.
    • 4- & the quality improvement.
    • The patient safety committee manage risk in the organization by performing the safety care processes.
    • 1- Should standardize the definitions and categorize medical errors.
    • 2- Establish or enhance an error, near miss reporting mechanism.
    • 3-Identify data collection plan, reporting structure, as well as performing scheduling.
  • Standardized &categorize medical errors Identify data collection plan& reporting structure Establish an error-near miss reporting mechanism Patient safety plan
    • The leadership is to build an environment that recognize the importance of safety.
    • 1- Create & maintain a culture of safety.
    • 2- Encourage decision making.
    • 3- Implement patient safety program throughout the organization.
    • 4- Ensure that the processes are designed well, using available information from internal or external sources about potential risks to patient and successful practices
    • Reactive :
    • Investigate significant patient incidents (sentinel events).
    • Proactive :
    • Monitor patient safety and redesign high-risk processes to prevent a sentinel event from occurring.
    • An inpatient received 2 (two) unit of the incorrect type of blood at the time. The patient’s blood was drawn for a type/cross match, the sample was mislabeled with another patient's name. The transfusion was given to the patient whose name appeared on the type/cross match lab report, not the patient whose blood was in the lab specimen vial.
    • Poorly designed system for labeling laboratory specimen.
    • If this problem continuing uncorrected, for sure it could caused anther incidence that lead to a blind end.
        • 1- Gather the facts.
        • 2- Choose team.
        • 3- Determine sequence of events.
        • 4- Identify contributing factors.
        • 5- Select root causes.
    • 6- Develop corrective actions.
    • 7- & Follow-up plan.
    • How is Your Library
    • Involved in Patient Safety
    • (or how will it be)?
    • With literature searches in Training, Education & in the telling stories; participation creating & sharing information through alert services; supporting & institutional resources & needs. Creating & Sharing Information for patient education on the website information pages:
      • Student Curriculum development
      • CME/ requirements assistance
      • Including patient safety when focusing on computer skills,
      • During orientation classes and introductions
      • On-line tutorials and resources preparation
      • In reference services, with patients and families, health professionals
    • Participation
      • On Patient Safety committees, teams and boards
      • Attending related M&Ms, councils, committees and meetings
      • (Hospitals:) On Rounds, providing RCA support
    • Connect and Educate
      • Safety Officers, Advocates and Directors
      • Executives: CEO, CNO, CME and others
      • Institutional leaders: Directors, Lawyers, Liaisons
        • Recalls, Tables of Contents, Clinical Alerts, Drug Updates, Diseases and Treatments
      • Supporting Institutional Resources and Needs
        • Balanced Score Card, Indicators, Legislation
        • Magnet Status, Joint Commission preparations
        • Policies, Procedures, Employee Handbooks
    • In Summary:
    • All library roles eventually supporting patient’s safety.
    • 1- Staffs are not washing their hands will.
    • 2- Staff does not changing their gloves between patients.
    • 3- Staff does not wearing the appropriate PPE.
    • 4- Given the patients wrong medication.
    • 5- Given the wrong dialyzer.
    • 6- Staff does not performing safe procedure. (catheter care)
    • 7- Staff unskilled in annulations.
    • 8- Staff does not performing appropriate patient assessments .
    • 1-Everyone should know what the plan is.
    • 2-No one is ever hesitant to voice a concern about a patient.
    • 3-There are strong positive perceptions of team work ( trust) & communication .
    • 4-Everyone should be treated with respect .
    • 5-Nursing input is well received.
    • 6-High quality care is delivered safely
    • & efficiency .