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&apos;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
• Define patient safety.
• Understand the development
of patient safety structure.
• Identify culture of safety.
• List the 6 international goals.
• Understand leadership
• Understand Psychological
• List the library connection.
Medical errors have become a leading causes of
death, killing more people each year than AIDS or
These medical errors can be classified into
2-Poor decision making.
3-Poor patient monitoring.
4-Poor patient identification.
5-Poor patient tracking.
Meeting the Joint
(JCAHO) patient safety
goals is the current trend
in enhancing patient
Goal (1) identify patients correctly.
Goal (2) improve effective Communication.
Goal (3) improve the safety of high-alert
Goal (4) ensure correct-site, correct-procedure,
Goal (5) reduce the risk of health care–
Goal (6) reduce the risk of patient harm
resulting from falls.
.Freedom from accidental
injury ,ensuring the
operational systems and
processes that minimize the
likelihood of errors so they
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.
5-Lack of resources.
6-Failure to plan, recognize and
1-Support teamwork and respect others.
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
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
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 manage
risk in the organization by performing
the safety care processes.
1-Should standardize the
definitions and categorize
2-Establish or enhance an error,
near miss reporting mechanism.
3-Identify data collection plan,
reporting structure, as well as
Patient safety plan
Establish an error-
near miss reporting
The leadership is to build an
environment that recognize the
importance of safety.
1-Create & maintain a culture of
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
Investigate significant patient incidents
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
4- Identify contributing factors.
5- Select root causes.
6-Develop corrective actions.
7- &Follow-up plan.
LIBRARY CONNECTIONS &
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:
All library roles eventually
supporting patient’s safety.
1- Staffs are not washing their hands will.
2-Staff does not changing their gloves between
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.
7-Staff unskilled in annulations.
8-Staff does not performing appropriate patient
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