15 patient safety11

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Lecture By Dr.Moh'd Ramzi

Published in: Education

15 patient safety11

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  2. 2. Patient Safety DefinitionThe working to avoid, manage and treatunsafe acts within the health-care system, through the use of best practices lead to optimal patient outcomes.
  3. 3. First do no harm now do it safe "Safety is the most basic dimension of performance necessary for the improvement of healthcare quality. Safety is the underlying reason for risk management, infection control It is the reason we insist on qualified clinical practitioners and support staff, validating education, expertise, and other credentials; providing appropriate orientation and continuing education; and performing periodic appraisal. 3
  4. 4. Patient Safety Terms
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  6. 6. Some Reasons Why Errors Occur ‫تناغم‬
  7. 7. Not Who caused the accident but What caused the accident? “ We cannot change the human condition, but we can change the conditions under which human works.” (Reason 2000)
  8. 8. What is a culture of safety?Components of a safety culture include: Commitment to safety as the primary priority Availability of the necessary resources ‫التحفيز‬ Incentives, and rewards for safety Openness about errors and problems Commitment to organizational learning ‫اخل ص‬ Unity, loyalty, and teamwork among staff Non Punitive Environment (culture of safe reporting) leads to increase number of reported errors 8
  9. 9. Just culture 3 basics: ‫مسؤولية‬ ‫النضباط‬1. It doesn’t reduce the personal accountability and discipline. It emphasizes the learning from the errors and near misses to reduce errors in the future.2. The greatest error not to report a mistake. Thereby prevent learning. ‫محامى‬3. All in the organization to serve as safety advocates. Both providers and consumers will feel safe and supported when they report medical errors, near misses and voice concerns about patient safety.‫اهمال‬ ‫مسموح‬ It has zero tolerance for reckless behavior.
  10. 10. Behaviors Human error – inadvertent action: doing other than what should have been done. ‫غفلة-غير مقصود‬ Manage through change in processes, procedures and training. At risk behavior: behavioral choice that increase risk , where risk is not recognized or is believed to be justified. Manage through increase awareness, and providing incentives for healthy behaviors and disincentives for risky behaviors. Reckless behavior: consciously disregard substantial and unjustifiable risk. ‫اجراء عقابى علجى‬ Manage through Remedial and punitive action.
  11. 11. ‫قلعة قايتباى‬‫الـســــــــــكندري‬ ‫ة‬ ‫11‬
  12. 12. Related Safety Programs A. Environment and equipment A written environmental management plan and designated leader to coordinate activities and respond to immediate threats; components include management! coordination of:-  Safety-- Security–  Staff education  Hazardous materials and waste—  Emergency power: maintenance, testing, and inspection—  Fire safety: drills, equipment, building features—  Medical equipment: maintenance, testing, and inspection–  Utilities: maintenance, testing, and inspection– 12
  13. 13. Related Safety Programs B. Employees Staff, licensed practitioners, students, and volunteers should be able to describe their roles and responsibilities relative to safety, based on their specific job responsibilities and education received. The most common cause of medical errors is miscommunications 13
  14. 14. Definitions Miscommunication: Breakdowns in communication can result in the wrong treatment, a lack of treatment, or incorrect self-care by the patient.
  15. 15. Patient Safety Goals6 15 2 4 3
  16. 16. International Patient Safety Goals IPSG IPSG.1 Identify Patients Correctly IPSG.2 Improve Effective Communication IPSG.3 Improve the Safety of High-Alert Medications IPSG.4 Ensure Correct-Site, Correct-Procedure, Correct- Patient Surgery IPSG.5 Reduce the Risk of Health Care–Associated Infections IPSG.6 Reduce the Risk of Patient Harm Resulting from Falls
  17. 17. Patient Safety Goals 1Identify patient correctly by two identifiers before: Providing treatments Administering and procedures medications,Taking blood and other specimens blood, or its products
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  19. 19. International Patient Safety Goals IPSG IPSG.1 Identify Patients Correctly IPSG.2 Improve Effective Communication IPSG.3 Improve the Safety of High-Alert Medications IPSG.4 Ensure Correct-Site, Correct-Procedure, Correct- Patient Surgery IPSG.5 Reduce the Risk of Health Care–Associated Infections IPSG.6 Reduce the Risk of Patient Harm Resulting from Falls
  20. 20. Patient Safety Goals con.. 2Improve effective communication through: The most common cause of medical errors is miscommunications
  21. 21. SBAR A structured communication technique designed to convey a great deal of information in an organized & brief manner. This is important as we all have different styles of communicating, varying by profession, culture, and gender.
  22. 22. SBARSSituationA concise statement of the problemWhat is going on nowBBackgroundPertinent and brief information related to the situationWhat has happenedAAssessmentAnalysis and considerations of optionsWhat you found/think is going onRRecommendationRequest/recommend actionWhat you want done
  23. 23. Example SBAR briefingSituation: Dr. Jones, I have a 55 Y/O Man who looks pale, sweaty and is complaining of chest pressure.• Background: He has a history of HTN, admitted for GI Bleed received 2 units, last crit two hours ago was 31 vital signs are: BP 90/50, Pulse 120• Assessment: I think he’s got an active bleed and we can’t rule out an MI but we don’t have a troponin or a recent H&H.• Recommendation: I’d like to get an EKG and labs and I need for you to evaluate him in right away.
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  25. 25. International Patient Safety Goals IPSG IPSG.1 Identify Patients Correctly IPSG.2 Improve Effective Communication IPSG.3 Improve the Safety of High-Alert Medications IPSG.4 Ensure Correct-Site, Correct-Procedure, Correct- Patient Surgery IPSG.5 Reduce the Risk of Health Care–Associated Infections IPSG.6 Reduce the Risk of Patient Harm Resulting from Falls
  26. 26. Patient Safety Goals con.. 3Improve the safety of high alert medication Double check Labeling? Why ? To prevent medication errors
  27. 27. Medication reconciliation(Medication Reconciliation is a formal process in which healthcare providers partner with patientsand their families to ensure accurate and complete medication information transfer at interfaces of care i.e at discharge ) 27
  28. 28. International Patient Safety Goals IPSG IPSG.1 Identify Patients Correctly IPSG.2 Improve Effective Communication IPSG.3 Improve the Safety of High-Alert Medications IPSG.4 Ensure Correct-Site, Correct-Procedure, Correct- Patient Surgery IPSG.5 Reduce the Risk of Health Care–Associated Infections IPSG.6 Reduce the Risk of Patient Harm Resulting from Falls
  29. 29. Patient Safety Goalscon..  ENSURE 4
  30. 30. International Patient Safety Goals IPSG IPSG.1 Identify Patients Correctly IPSG.2 Improve Effective Communication IPSG.3 Improve the Safety of High-Alert Medications IPSG.4 Ensure Correct-Site, Correct-Procedure, Correct- Patient Surgery IPSG.5 Reduce the Risk of Health Care–Associated Infections IPSG.6 Reduce the Risk of Patient Harm Resulting from Falls
  31. 31. Patient Safety Goalscon.. B 5 ef or e Reduce the risk of health care pa tie associated infections by Hand hygiene nt coBe nt for ac e a t n a se After exposure to body fluid pti c t as k act Af t ter c on co nta e nt ct ati wi r p th pa A fte tie nt su rro un din g
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  33. 33. International Patient Safety Goals IPSG IPSG.1 Identify Patients Correctly IPSG.2 Improve Effective Communication IPSG.3 Improve the Safety of High-Alert Medications IPSG.4 Ensure Correct-Site, Correct-Procedure, Correct- Patient Surgery IPSG.5 Reduce the Risk of Health Care–Associated Infections IPSG.6 Reduce the Risk of Patient Harm Resulting from Falls
  34. 34. Patient Safety Goalscon.. 6Reduce the risk of patientharm resulting from falls by:  Initial assessment for fall risk at the time of admission  Reassessment when change in patient condition, medication , etc.  Implement fall prevention measures
  35. 35. Thank you 35

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