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NATIONAL PATIENT SAFETY DAY
June 25, 2011
THEME:
“ Working Together Towards Patient Safety”
Slogan:
“Kaligtasan ng Pasyent...
What is Patient Safety?
Patient Safety is the avoidance,
prevention and amelioration of
adverse outcomes/ injuries stemmin...
Date: July 30, 2008
Administrative Order No. 2008-0023
National policy on Patient Safety
Goal: To ensure that the patient ...
The Veterans Regional
Hospital Administrative
Manual Patient Safety
Plan
I. PURPOSE
OBJECTIVE:
To provide a planned, ongoing, comprehensive,
coordinated and integrated Hospital-
wide mechanism to...
The essential elements of the program include:
• The integrated Patient Safety
Committee, supported by the COH, have
the a...
•Responsibility for Patient Safety
activities are shared by the Medical Staff
Departments, Patient Care Services, the
Clin...
•Department Chiefs of all hospital
departments are responsible for the
ongoing education, monitoring, and
evaluation in pr...
•The information collected
addresses the requirements of DOH
and PHIC for a Patient Safety
Program.
•Appropriate actions are taken to
resolve identified problems and/or
identified opportunities to improve
patient care and ...
•The information derived from each
department’s monitoring, evaluation
and improvement activities is shared
with other dep...
•The Patient Safety program is
reviewed annually to assure the
program’s objectives are attained
and that improvement to p...
II. DEFINITIONS OF TERMS
The following definitions are
uniformly used in the hospital’s
Incident Report, Sentinel Event
an...
•Sentinel Event
Unexpected incident involving death
or serious physical or psychological
injury, or the risk thereof.
The ...
•Near Miss or “close call”
An event or situation that could have
resulted in an accident, injury, or illness,
but did not,...
•Latent Failure
An error precipitated as a consequence of
management and organizational processes
that poses the greatest ...
•No Blame Culture
A non-punitive encouraging voluntary
reporting of adverse events.
•Risk
Is any exposure to a harmful
event. It is directly related to hazard
and vulnerability and, inversely, to
capacity.
•Adverse Drug Reaction
Any undesirable or unexpected
medication related event that requires
discontinuing a medication or ...
•Medication Error
Any preventable event that may
cause or lead to inappropriate
medication use or patient harm while
the m...
Such events may be related to
1.professional practice
2.health care products
3.procedures and systems, including
prescribi...
•Unexpected Event
Any situation that is not
consistent with the routine operation of
the affiliate or routine care and saf...
Policy on Patient Safety
Safety standard policies:
•Access to care and continuity of care (ACC)
Policies: Admission
Networ...
Policy on Patient Safety
Safety standard policies:
•Patient and family rights
Policies: Information
Patient care
Autopsy
C...
Policy on Patient Safety
Safety standard policies:
•Assessment of care
Policies: Referral
Credentialing and hiring
Others
Policy on Patient Safety
Safety standard policies:
• Care of patients
Policies: Clinical pathways. Dse related
groups, cli...
Policy on Patient Safety
Safety standard policies:
•Anesthesia and surgical care
Policies: pre-anesthetic evaluation
Surgi...
Policy on Patient Safety
Safety standard policies:
•Medication Management and use
Policies: Procurement
Storage/dispensing...
Policy on Patient Safety
Safety standard policies:
•Medication Management and use
Policies: Procurement
Storage/dispensing...
Policy on Patient Safety
Safety standard policies:
•Patient and family education
Policies: Training and education
Particip...
Policy on Patient Safety
Safety standard policies:
•Quality improvement and patient safety
Policies: Sentinel event report...
Policy on Patient Safety
Safety standard policies:
•Prevention and control of infection
Policies: Hand washing
Disinfectio...
Policy on Patient Safety
Safety standard policies:
•Governance, Leadership and direction
Policies: Organizational mission
...
Policy on Patient Safety
Safety standard policies:
•Facility Management and safety
Policies: Safe Environment
Equipment ma...
Policy on Patient Safety
Safety standard policies:
•Staff qualification and education
Policies: Hiring
Training needs anal...
Role:
To take the lead role in
planning, implementing,
managing,, and evaluating
safety initiatives and programs
Committee...
7 STEPS TO PATIENT SAFETY
1. Build a safety culture
2. Lead and support your staff
3. Integrate your risk
management activ...
Committee on Patient Safety
MEDICAL TEAM
1. Safe Surgery Team
2. Medication Safety Team
3. Blood Transfusion Safety Team
4...
Lecture patient safety
Lecture patient safety
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Lecture patient safety

  1. 1. NATIONAL PATIENT SAFETY DAY June 25, 2011 THEME: “ Working Together Towards Patient Safety” Slogan: “Kaligtasan ng Pasyente, Una Lagi”
  2. 2. What is Patient Safety? Patient Safety is the avoidance, prevention and amelioration of adverse outcomes/ injuries stemming from the process of health care
  3. 3. Date: July 30, 2008 Administrative Order No. 2008-0023 National policy on Patient Safety Goal: To ensure that the patient safety is institutionalized as a fundamental principle of the health care delivery system in improving health outcomes.
  4. 4. The Veterans Regional Hospital Administrative Manual Patient Safety Plan
  5. 5. I. PURPOSE OBJECTIVE: To provide a planned, ongoing, comprehensive, coordinated and integrated Hospital- wide mechanism to objectively and systematically monitor and evaluate the safety of patient care, promptly identify and resolve problems, plan education to improve patient safety and to reduce medical errors throughout the organization.
  6. 6. The essential elements of the program include: • The integrated Patient Safety Committee, supported by the COH, have the authority to recommend changes and take necessary actions in order to make improvements to patient care services provided.
  7. 7. •Responsibility for Patient Safety activities are shared by the Medical Staff Departments, Patient Care Services, the Clinical Support Services and all other hospital departments.
  8. 8. •Department Chiefs of all hospital departments are responsible for the ongoing education, monitoring, and evaluation in preventing, detecting and correcting medical errors within their departments.
  9. 9. •The information collected addresses the requirements of DOH and PHIC for a Patient Safety Program.
  10. 10. •Appropriate actions are taken to resolve identified problems and/or identified opportunities to improve patient care and non-clinical services rendered.
  11. 11. •The information derived from each department’s monitoring, evaluation and improvement activities is shared with other departments as deemed necessary by the Department Chief and is integrated with information obtained from other hospital-wide patient safety activities as appropriate.
  12. 12. •The Patient Safety program is reviewed annually to assure the program’s objectives are attained and that improvement to patient care and service delivery is made.
  13. 13. II. DEFINITIONS OF TERMS The following definitions are uniformly used in the hospital’s Incident Report, Sentinel Event and other relevant environment of care and medication use policies.
  14. 14. •Sentinel Event Unexpected incident involving death or serious physical or psychological injury, or the risk thereof. The fundamental objective of sentinel event reporting is corrective in nature and the identification of appropriate actions to prevent recurrence.
  15. 15. •Near Miss or “close call” An event or situation that could have resulted in an accident, injury, or illness, but did not, either by chance or timely intervention. It is a serious error or mishap that has the potential to cause as adverse event but fails to do so because of chance or because it is intercepted.
  16. 16. •Latent Failure An error precipitated as a consequence of management and organizational processes that poses the greatest danger to complex systems. Latent failures cannot be foreseen but, if detected, they can be corrected before they contribute to mishaps.
  17. 17. •No Blame Culture A non-punitive encouraging voluntary reporting of adverse events.
  18. 18. •Risk Is any exposure to a harmful event. It is directly related to hazard and vulnerability and, inversely, to capacity.
  19. 19. •Adverse Drug Reaction Any undesirable or unexpected medication related event that requires discontinuing a medication or modifying the dose, requires or prolongs hospitalization, results in disability, requires supportive treatment, is life threatening or results in death, results in congenital anomalies, or occurs following vaccination.
  20. 20. •Medication Error Any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in control of the health care professional, patient or consumer.
  21. 21. Such events may be related to 1.professional practice 2.health care products 3.procedures and systems, including prescribing; order communication; product labeling; packaging, and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use.
  22. 22. •Unexpected Event Any situation that is not consistent with the routine operation of the affiliate or routine care and safety of a patient. All events identified should be reported following the Patient Incident Report Policy utilizing the patient incident report.
  23. 23. Policy on Patient Safety Safety standard policies: •Access to care and continuity of care (ACC) Policies: Admission Networking Transport Discharge Others
  24. 24. Policy on Patient Safety Safety standard policies: •Patient and family rights Policies: Information Patient care Autopsy Confidentiality Security Others
  25. 25. Policy on Patient Safety Safety standard policies: •Assessment of care Policies: Referral Credentialing and hiring Others
  26. 26. Policy on Patient Safety Safety standard policies: • Care of patients Policies: Clinical pathways. Dse related groups, clinical practice Medication preparation, storage Periodic clinical monitoring and evaluation Special care/Intensive care Others
  27. 27. Policy on Patient Safety Safety standard policies: •Anesthesia and surgical care Policies: pre-anesthetic evaluation Surgical site preparation Post –anesthetic care Credentialing Others
  28. 28. Policy on Patient Safety Safety standard policies: •Medication Management and use Policies: Procurement Storage/dispensing Preparation Medication errors/near misses Adverse drug reaction Others
  29. 29. Policy on Patient Safety Safety standard policies: •Medication Management and use Policies: Procurement Storage/dispensing Preparation Medication errors/near misses Adverse drug reaction Others
  30. 30. Policy on Patient Safety Safety standard policies: •Patient and family education Policies: Training and education Participative care Others
  31. 31. Policy on Patient Safety Safety standard policies: •Quality improvement and patient safety Policies: Sentinel event reporting and handling or processing Others
  32. 32. Policy on Patient Safety Safety standard policies: •Prevention and control of infection Policies: Hand washing Disinfection Handling of infectious waste, sharps, specimens Personal protective equipment (PPE) Rational use of antibiotics (3rd gen and above) Others
  33. 33. Policy on Patient Safety Safety standard policies: •Governance, Leadership and direction Policies: Organizational mission Monitoring and evaluation Periodic review of policies and procedures Handling of complain Patient survey Accountability Others
  34. 34. Policy on Patient Safety Safety standard policies: •Facility Management and safety Policies: Safe Environment Equipment maintenance Building and environment maintenance Patient transport maintenance Other facility maintenance such as electricity, generator, water, gas management Waste segregation and disposal Others
  35. 35. Policy on Patient Safety Safety standard policies: •Staff qualification and education Policies: Hiring Training needs analysis Continuing professional training Others
  36. 36. Role: To take the lead role in planning, implementing, managing,, and evaluating safety initiatives and programs Committee on Patient Safety
  37. 37. 7 STEPS TO PATIENT SAFETY 1. Build a safety culture 2. Lead and support your staff 3. Integrate your risk management activity 4. Promote reporting 5. Involve and communicate with patients and the public 6. Learn and share safety lessons 7. Implement solutions to prevent harm
  38. 38. Committee on Patient Safety MEDICAL TEAM 1. Safe Surgery Team 2. Medication Safety Team 3. Blood Transfusion Safety Team 4. Fall Prevention Team 5. Adverse Event Team 6. Infection Control Team ENVIRONMENTAL SAFETY TEAM
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Getting started with patient safety

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