This is how our presentations will be structured today Patient safety, a general overview of patient safety, quality issues &introduce main issues Infection control Medication errorsDocumentation, pertaining to surgical error How we worked towards and decided on the selection on areas of focus for the presentations, will be discussed towards the end of this presentation.
Patient safety is a term we hear often, in relation to health care provision and delivery. It’s quite plausible to say that people involved in the health care system and areas that constitute the system (ie. wards) will have an idea of what patient safety is.. In this case, if we were to ask the question “What does the term ‘patient safety’ mean?” There would be a variance in answers..So in describing what patient safety is, we can look to a quote from the World Health Organization.. “Patient safety is the absence of preventable harm to a patient during the process of health care.”WHO (2012) also states that..“The discipline of patient safety is the coordinated efforts to prevent harm, caused by the process of health care itself, from occurring to patients...patient safety has been increasingly recognized as an issue of global importance...”----------------------------------------------Information adapted from:World Health Organization [WHO]. (2012). Patient safety. Retrieved January 1, 2012, from World Health Organization: http://www.who.int/patientsafety/en/
Why do we need to focus on, research into & monitor the quality of patient safety?..Because there is evidence of unsafe care.. Which is based upon the findings of research & subsequently data collection in the area.The World Health Organization summarized the current research of patient safety and published the findings in a report which identified some key findings.The available data suggest that harmas a direct outcome of health care provided to patients, poses a significant burden to people and their families, globally.Much of the evidence base has been created in the developed countries. There is some epidemiological evidence of poor clinical outcomes due to unsafe health care in developing countries, but the information on contributing factors to unsafecare is derived almost entirely from a number of developed countries. Although some of the means for reducing harm are known, large gaps in knowledge need to be filled before comprehensive solutions can be found.--------------------------------------------------------Information adapted from:World Health Organization [WHO]. (2012). Evidence of unsafe care. Retrieved January 1, 2012, from World Health Organistaion: http://www.who.int/patientsafety/research/country_studies/en/index.htmlArticle:Patient safety research: an overview of the global evidenceJha A K, Prasopa-Plaizier N, Larizgoitia I, Bates D W. Patient safety research: an overview of the global evidence. Qual Saf Health Care 2010;19:42-47 doi:10.1136/qshc.2008.029165
The primary areas for concern/research/quality improvement in regards to patient safety were identified through an orientation to the literature available, (primarily articles and web pages from the WHO).. Then a brief literature review, to identify which areas were occurring most frequently when the term ‘patient safety’ was entered into the database engines...-------------------------------------Image sourced from:http://www.med.uottawa.ca/sim/data/Patient_Safety_Measures_e.htm&docid=saz1LRPSQOAWsM&imgurl=http://www.med.uottawa.ca/sim/data/Images/Infection_hospital_cartoon.jpg&w=299&h=296&ei=LI4BT4a0O4WLswbZttgS&zoom=1&iact=rc&dur=2&sig=108125072540068073160&page=1&tbnh=111&tbnw=112&start=0&ndsp=22&ved=1t:429,r:19,s:0&tx=65&ty=-9***Screen print & highlight results that coincide with the topics chosen
Google scholar article search --------------------------------------Screen print:http://scholar.google.com/scholar?hl=en&q=patient+safety+issues&as_sdt=0%2C5&as_ylo=&as_vis=1
WHO patient safety webpage----------------------------------****** Jess, I was thinking it would be best just to read what is highlighted in this screen & if it’s not COMPLETELY obvious how it fits in with our topics, just say “So-and-so, is relative to medication errors” etc etc (:Screen print:http://www.who.int/topics/patient_safety/en/
Who High 5’s project..Point 1 & 2 – Ties into the topic of Medication errorsPoint 3 – Ties into the field of documentation to prevent surgical error????Point 4 – Although we’re not addressing it directly, handover & communication is relevant to all 3 topics, as there needs to be information passed for all aspects to be sustained & subsequent patient safety quality to be improvedPoint 5 – Part of infection control is to identify and minimise risks for hospital and health-care acquired infections..Screen print:http://www.who.int/patientsafety/implementation/solutions/high5s/ps_high5s_project_overview_fs_2010_en.pdf
Hospital and community acquired infections: Hospital patients may develop infections making their illnesses and treatment more difficult. Including those with compromised immune systems, such as those with an open wound from injury or surgery, those who require catheters for drainage or drug delivery, or the elderly.Drug errors: Including badhandwriting on a prescription, mistakes at the pharmacy, dosage errors, time frames and route of administrationSurgical errors: Wrong site surgeries and procedures, or patient misidentification comprise the bulk of surgical errors.----------------------------------------------Information adapted from:National Quality Forum (2008). Serious Reportable Events (SREs): Transparency & Accountability are Critical to Reducing Medical Errors. Retrieved January 2, 2012: http://www.qualityforum.org/Publications/2008/10/Serious_Reportable_Events.aspx.Torrey, T. (2008). Issues in patient safety. Retrieved January 2, 2012, from Patient empowerment: http://patients.about.com/od/empowermentbasics/a/patientsafety.htm
Information adapted from:World Health Organization. (2009). Welcome to the high 5's project website. Retrieved January 2, 2012, from High 5's: https://www.high5s.org/bin/view/Main/WebHomeImage sourced form:http://www.who.int/patientsafety/events/media/h5-p1.jpg
Qi project patient safety- jade
Patient safetyOverview of patient safety, qualityissues & primary areas of concern
Patient safetyInfection Medication Documentation control errors > surgical error
Patient safety?“Patient safety is the absence of preventable harm to a patient during the process of health care.” WHO 2012 Health Prevent Patients care harm
Why?Evidence of unsafe care!WHO summarized the current research into patient safety and published the findings in a report which identified some key findings. Developed Harm Gaps Countries Patient safety research: an overview of the global evidence Jha A K, Prasopa-Plaizier N, Larizgoitia I, Bates D W
Primary areas of focus; patient safetyAfter orientatingourselves to theliterature, we started tonote and identifyrelevant topics thatrecurred in oursearches...
The National Quality Forum in 2006 published a list of ‘errors’ pertaining to patient safety and called them "never events”.Among the errors cited, were; Hospital & community Drug errors Surgical errors acquired infectionsOther sources of patient safety problems resulted in compromised patient protection, adverse events involving devices/equipment and criminal events.
“The Mission of the High 5s Project is to facilitate implementation and evaluation of standardised patient safety solutions within a global learning community to achieve measurable, significant, and sustained reductions in highly important patient safety problems.” -WHO (2012)WHO (2012) is implementing the high 5’s project multi-nationally, focusing on similar areas to those we found to be of most importance through their predominance in the literature surrounding Patient Safety..