a simple guide to patient safety

1. Patient Safety
Dr. Nilly Shams
CPHQ, TQM, Public Health Specialist
President of the Egyptian Nutrition and Health Coaching
Association
Certified Health Coach, IIN. USA

2. MAP
• Patient safety guidelines.
• Some definitions related to patient safety.
• How to create the culture of patient safety?
• What are the national patient safety goals?
• Comprehensive patient safety program.

3. Patient safety guidelines
• AHRAQ : Agency for Healthcare
Research and Quality
• NQF: National Forum for Quality
Measurement and Reporting
• NHS: National health and Safety
• NPSA: National Patient Safety Agency
• WHO: World Health Organization

4. Did you hear about this study?
• The Institute of Medicine (IOM)
study “To Err is Human; Building a
Safer Healthcare System”
• Adverse events occur in 2.9 to 3.7%
of all hospitalizations

5. Medical errors
• At least 44,000 people, and perhaps as many as
98,000 people, die in hospitals each year as a
result of medical errors that
could have been prevented.
• Medical errors:
the failure of a planned action to be completed
as intended or the use of a wrong plan to
achieve an aim.

7. Why do we care?

8. Why do we care?
• Errors…are costly in terms of loss
of trust in the health care system
by patients and diminished
satisfaction by both patients and
health professionals.

9. Patient Safety

10. What is Patient Safety ?
• Freedom from injury or illness resulting from
the processes of care
National Forum for Quality Measurement and Reporting
• Safety is the avoidance and prevention of
patient injuries or adverse events resulting
from the processes of healthcare delivery
Agency for Healthcare Research and Quality

11. HOW of CARE
• Human beings make mistakes because the
systems, tasks and processes they work in are
poorly designed.”
Dr Lucian Leape, testifying to the US President’s Commission on
Consumer Protection and Quality in Health

12. Patient safety???
• First, do no harm – Safety is the most
basic dimension of performance necessary for
the improvement of healthcare quality.

13. Organizational culture
(how work gets done)
• It’s the habitual/behavior that
characterize the organization, reflects
the beliefs, attitudes and priorities of
its members, and influences the
effectiveness of performance.
• Culture of safety and quality exists when
ALL who work in the organization are
focused on excellent performance
(personal responsibility).

14. Organizational culture
(how work gets done)

15. Just culture
• one that support the discussion of errors so
that lessons can be learned from them
• one in which frontline staff feel comfortable in
disclosing errors including their own while
maintaining professional accountability
AHRQ

16. Just culture

17. Just Culture recognizes the difference
between :
it is important to note that the response is not based on the
severity of the event

18. Just Culture Algorithm

19. Do you have a just culture
organization ?

20. The organization adopting safety culture
• Committed to ongoing learning & flexible to
accommodate changes
• Encourage team work
• Encourage & reward reporting
• Focus on system & process rather than individual
• Respect people working in the organization
regardless of their position.
• No blame culture
• Proactive

21. The organization adopting safety culture

22. A scenario………….:
• Person low in hierarchy (unit coordinator)
• Something seems not quite right in preparation for a patient’s
procedure and the patient is first on a full schedule. Clarifying
requires calling the head nursing who was not available in the
theater . The coordinator stopped the process and said
“I need clarity”
• The case is delayed 45 minutes and it turns out that there is
no problem at all regarding the safety of the patient
What happens to her?

23. Safety cultured organizations ….
• She gets thanked by the physician.
• The manager thanks her and makes
sure the CEO, CNO, or CMO come by
later in the day to congratulate her.
• Her action becomes a story told in
the organization.

24. Not a Safety Culture organizations……..
• People whisper about her.
• She gets grief from the charge nurse in the
procedure area for messing up the entire
schedule.
• The physician demands that a unit
secretary cannot delay a case again.
• She says to colleagues: “Never doing that
again.”

25. 2nd Scenario ………..
work group

26. International Patient Safety
Goals (IPSG)
• promote specific improvements in patient
safety
• Highlight problematic areas in healthcare
• Describe evidence- and expert-based
consensus solutions to these problems

27. 2015 National Patient Safety Goals - Pg. 27
©Copyright,TheJointCommission
 The National Patient Safety Goals (NPSGs)
were established in 2002 to help accredited
organizations address specific areas of concern
in regards to patient safety
 The first set of NPSGs was effective January 1,
2003
 The Patient Safety Advisory Group advises The
Joint Commission on the development and
updating of NPSGs

28. 2015 National Patient Safety Goals - Pg. 28
©Copyright,TheJointCommission
Patient Safety Advisory Group
 Panel of widely recognized patient safety experts
– Nurses, physicians, pharmacists, risk managers, clinical
engineers, other professionals
 Hands-on experience in addressing patient safety
issues in wide variety of health care settings
 Advises The Joint Commission how to address
emerging patient safety issues
– NPSGs, Sentinel Event Alerts, standards and survey
processes, performance measures, educational
materials, Center for Transforming Healthcare projects

29. National patient safety goals
• Identify patients
correctly
• Improve staff
communication
• Use medication safely
• Prevent infection
• Check patient
medicines
• Prevent patient from
falling
• Help patients to be
involved in their care
• Identify patient safety
risks
• Watch patient closely
• Prevent errors in
surgery

32. 2015 National Patient Safety Goals - Pg. 32
©Copyright,TheJointCommission
The National Patient Safety Goals for
each program and more information are
available on The Joint Commission
website at www.jointcommission.org
Questions can be sent to the Standards
Interpretation Group at 630-792-5900 or
via the Standards Online Question Form
For more information…

33. Comprehensive patient safety program
• Infrastructure
• Policies & procedure
• Education
• Occurrence/event reporting system
• Proactive activities
• Process for immediate response

34. Mention the steps that you will do to create
the safety culture in your organization ?
• Leadership commitments
• Communication among care givers
• Environment of Care ( safe design)
• Simple and standardized system
• Assigned roles and responsibilities
• Incident Reporting system
• Team work

35. Role of leaders in creating culture
• Commitment
• Taking actions by creating
structures, processes, and
programs that allow a culture
of safety and quality to
flourish
• Focus plan on improving
patient safety
• Provide accurate and usable
information related to safety
• Use data
• Education that focuses on
safety
• Team approach
• Openly discuss issues of
safety and quality.
• Include patients
• Creating and implementing
a process for managing
disruptive and
inappropriate behaviors.
A Safety Culture is one in which the senior leaders hear
bad news

36. Communication and Safety

37. Communication and Safety

38. Teach back/ Ask me 3:
• Self care on return
home
• How/who to contact
for help
• Medication uses and
doses
• What is my main
problem? (Diagnosis)
• What do I need to
do? (Treatment)
• Why is it important
for me to do this?
(Context)

39. Environment of Care ( safe design)
We don’t need this……

40. Or this…….

41. Structure
Assigned roles and responsibilities
• Patient safety officers
• Patient safety committee
• Safety action teams

42. Role of a PSO
• Import new ideas and best practices and
oversees their local application.
• Teach, mentor, and reinforce good practices
within the organization.
• Considers and recommends organizational
policies to advance patient safety.
• Report to the CEO, COO, Chief Medical Officer

44. Patient Safety Committee
• Is a comprehensive leadership-level action
committee that reviews all safety issues
across the organization through regular
meetings.

45. Safety Action Teams:
• These are small cross-functional groups of people
within units who meet periodically (perhaps
monthly) to discuss safety issues.
Role of safety Action Teams:
• Discuss information from the safety reporting system
• Identify solutions and corrective action planning .
• Provide direct feedback to senior leader about the
impact of their changes

46. Incident report review
Occurrence/event incident
reporting system
• One documentation
mechanism
• Early warning system
Circumstances examples:
• Death
• Medical incident requiring
emergency/intervention
• Unplanned admission
• Attempted suicide
• Injury requiring medical
treatment
• Medication error

47. Sentinel event review
• Event: occurrence that is either deemed to be or
result in a significant adverse event or sentinel event.
• Adverse event: unintended injury to a patient
resulting from a medical intervention.
• Near miss: any process variation that didn’t affect an
outcome but a recurrence carries a significant chance
of a serious adverse outcome.
• Sentinel event: unexpected occurrence involving
death or serious physical or psychological injury.

48. Sentinel event
100% analysis
0% acceptance
• Suicide within 72 hours of discharge
• Unanticipated death of full term
infant
• Abduction
• Discharge if an infant to wrong
family
• Rape
• Hemolytic transfusion

49. What should you do?
• Identify & respond
• RCA, action plan, improvement

50. RCA
• A systematic process to identify the most basic
or casual factors that underlies variation in the
process. An intensive, in depth analysis of a
problem event. Focus on system & process.

51. What should we do with
Near Miss?

52. Work Group
Mention the steps that u will do to
create the safety culture in your
organization ?

53. THANK YOU
Nilly Shams