Master Ramponi 25.10.08

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Master Ramponi 25.10.08

  1. 1. Errori in Medicina: cosa fare? Master in Malattie Rare Torino 25 Ottobre 2008 © Copyright, Joint Commission Resources Carlo Ramponi, JCI
  2. 2. Cosa é Joint Commission • una organizzazione indipendente, non-governativa, not-for-profit • leader internazionale riconosciuta nel campo dei progetti di miglioramento della qualità in ambito sanitario • pioniere nello sviluppo delle misure di performance © Copyright, Joint Commission Resources e di outcome per le organizzazioni sanitarie Client name/ Presentation Name/ 12pt - 2
  3. 3. Joint Commission International www.jointcommissioninternational.org JCI é una divisione not-for-profit di TJC; la sua mission é quella di migliorare la qualità dell’assistenza sanitaria in ambito internazionale, fornendo servizi connessi con il processo di © Copyright, Joint Commission Resources accreditamento. Client name/ Presentation Name/ 12pt - 3
  4. 4. Il significato di accreditamento JCI un processo volontario attraverso il quale un ente terzo, non governativo, riconosce e afferma che un’organizzazione sanitaria rispetta specifici standard che richiedono un continuo miglioramento nelle strutture © Copyright, Joint Commission Resources nei processi e nei risultati Client name/ Presentation Name/ 12pt - 4
  5. 5. © Copyright, Joint Commission Resources JCI’s 200 accredited organizations are spread over 24 countries Client name/ Presentation Name/ 12pt - 5
  6. 6. Quanto spesso succede? – E’ il piu’ comune Evento Sentinella segnalato a TJC in USA – Dal 1995 sono stati sottoposti a RCA 651 casi (13%) – Lo Stato del Minnesota richiede SE reporting ai propri ospedali e pubblica i risultati – Nel 2007: 35 wrong site surgical procedures – Minnesota conta 1.7% della popolazione USA © Copyright, Joint Commission Resources – Estrapolando questi numeri…. 6 wrong site surgical procedures negli USA ogni giorno---365 giorni all’anno. Client name/ Presentation Name/ 12pt - 6
  7. 7. A proposito di gestione farmaci invece.. – Ci sono sei sottosistemi che compongono il sistema detto “medication management” : – 1) selecting and procuring, – 2) storage of medications, – 3) ordering (prescribing), – 4) preparing and dispensing, © Copyright, Joint Commission Resources – 5) administering, and – 6) monitoring the patient’s response. Client name/ Presentation Name/ 12pt - 7
  8. 8. A proposito di farmaci invece.. – L’incidenza di errori nella gestione dei farmaci e’ stata stimata –nel caso di pazienti adulti ricoverati- pari al 5% di tutti gli ordini scritti – nel caso dei ricoveri pediatrici, l’incidenza e’ stata stimata pari a 1 ogni © Copyright, Joint Commission Resources 6.4 prescrizioni Client name/ Presentation Name/ 12pt - 8
  9. 9. A proposito di farmaci invece.. – In uno studio che ha interessato 1116 ospedali, il 5.07% dei pazienti ricoverati ha sperimentato un errore di terapia farmacologica. Questo valore e’ consistente con tassi di errore dal 3 al 6.9% riportati in altri studi. © Copyright, Joint Commission Resources Client name/ Presentation Name/ 12pt - 9
  10. 10. A proposito di farmaci invece.. © Copyright, Joint Commission Resources IOM Report brief July 2006 Client name/ Presentation Name/ 12pt - 10
  11. 11. Quali proposte? – Agire sulla cultura del rischio, adottare protocolli e procedure evidence-based, insistere, insistere, insistere – Oppure © Copyright, Joint Commission Resources – Agire sul portafoglio: la nuova frontiera! Client name/ Presentation Name/ 12pt - 11
  12. 12. Agire sulla cultura del rischio: un esempio WHO Patient Safety Solutions http://www.ccforpatientsafety.org/30723/ 1. Look-Alike, Sound-Alike Medication Names 2. Patient Identification 3. Communication During Patient Hand-Overs 4. Performance of Correct Procedure at Correct Body Site 5. Control of Concentrated Electrolyte Solutions 6. Assuring Medication Accuracy at Transitions in Care © Copyright, Joint Commission Resources 7. Avoiding Catheter and Tubing Mis-Connections 8. Single Use of Injection Devices 9. Improved Hand Hygiene to Prevent Health Care-Associated Infection (HAI) Client name/ Presentation Name/ 12pt - 12
  13. 13. Agire sulla cultura del rischio: un altro esempio – Guidelines for Implementing the Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery™ http://www.jointcommission.org/PatientSafety/ UniversalProtocol/ © Copyright, Joint Commission Resources Client name/ Presentation Name/ 12pt - 13
  14. 14. Definition A Patient Safety Solution is any system design or intervention that has demonstrated the ability to prevent or mitigate patient harm stemming from the processes of health care. © Copyright, Joint Commission Resources Client name/ Presentation Name/ 12pt - 14
  15. 15. Solutions Template • Solutions Title • Statement of Problem • Background, Issues & Potential Benefits • Solution • Applicability • Patient Involvement © Copyright, Joint Commission Resources • Strength of Evidence • Risk Assessment/Barriers • References/Resources Client name/ Presentation Name/ 12pt - 15
  16. 16. © Copyright, Joint Commission Resources Confusing drug names is one of the most common causes of medication errors and is a worldwide concern. With tens of thousands of drugs currently on the market, the potential for error created by confusing brand or generic drug names and packaging is significant. The recommendations focus on using protocols to reduce risks and ensuring prescription legibility or the use of preprinted orders or electronic name/ Presentation Name/ 12pt - 16 Client prescribing.
  17. 17. The widespread and continuing failures to correctly identify patients © Copyright, Joint Commission Resources often leads to medication, transfusion and testing errors; wrong person procedures; and the discharge of infants to the wrong families. The recommendations place emphasis on methods for verifying patient identity, including patient involvement in this process; standardization of identification methods across hospitals in a health care system; and patient participation in this confirmation; and use of protocols for distinguishing the identity of patients with the same name. 12pt - 17 Client name/ Presentation Name/
  18. 18. Gaps in hand-over (or hand-off) communication between patient care © Copyright, Joint Commission Resources units, and between and among care teams, can cause serious breakdowns in the continuity of care, inappropriate treatment, and potential harm for the patient. The recommendations for improving patient hand-overs include using protocols for communicating critical information; providing opportunities for practitioners to ask and resolve questions during the hand-over; and involving patients and families in the hand-over process. Client name/ Presentation Name/ 12pt - 18
  19. 19. Considered totally preventable, cases of wrong procedure or wrong site surgery are largely the result of miscommunication and unavailable, or © Copyright, Joint Commission Resources incorrect, information. A major contributing factor to these types of errors is the lack of a standardized preoperative process. The recommendations to prevent these types of errors rely on the conduct of a preoperative verification process; marking of the operative site by the practitioner who will do the procedure; and having the team involved in the procedure take a “time out” immediately before starting the procedure to confirm patient identity, procedure, and operative site.- 19 Client name/ Presentation Name/ 12pt
  20. 20. © Copyright, Joint Commission Resources While all drugs, biologics, vaccines and contrast media have a defined risk profile, concentrated electrolyte solutions that are used for injection are especially dangerous. The recommendations address standardization of the dosing, units of measure and terminology; and prevention of mix-ups of specific concentrated electrolyte solutions. Client name/ Presentation Name/ 12pt - 20
  21. 21. © Copyright, Joint Commission Resources Medication errors occur most commonly at transitions. Medication reconciliation is a process designed to prevent medication errors at patient transition points. The recommendations address creation of the most complete and accurate list of all medications the patient is currently taking— also called the “home” medication list; comparison of the list against the admission, transfer and/or discharge orders when writing medication orders; and communication of the list to the next provider of care whenever the - 21 Client name/ Presentation Name/ 12pt patient is transferred or discharged.
  22. 22. The design of tubing, catheters, and syringes currently in use is © Copyright, Joint Commission Resources such that it is possible to inadvertently cause patient harm through connecting the wrong syringes and tubing and then delivering medication or fluids through an unintended wrong route. The recommendations address the need for meticulous attention to detail when administering medications and feedings (i.e., the right route of administration), and when connecting devices to patients (i.e., using the right connection/tubing). Client name/ Presentation Name/ 12pt - 22
  23. 23. One of the biggest global concerns is the spread of Human © Copyright, Joint Commission Resources Immunodeficiency Virus (HIV), the Hepatitis B Virus (HBV), and the Hepatitis C Virus (HCV) because of the reuse of injection needles. The recommendations address the need for prohibitions on the reuse of needles at health care facilities; periodic training of practitioners and other health care workers regarding infection control principles; education of patients and families regarding transmission of blood borne pathogens; and safe needleClient name/ Presentation Name/ 12pt - 23 disposal practices.
  24. 24. One of the biggest global concerns is the spread of Human © Copyright, Joint Commission Resources Immunodeficiency Virus (HIV), the Hepatitis B Virus (HBV), and the Hepatitis C Virus (HCV) because of the reuse of injection needles. The recommendations address the need for prohibitions on the reuse of needles at health care facilities; periodic training of practitioners and other health care workers regarding infection control principles; education of patients and families regarding transmission of blood borne pathogens; and safe needle disposal practices. 12pt - 24 Client name/ Presentation Name/
  25. 25. 2008 Solutions 1. Preventing Pressure Ulcers 2. Responding to the Deteriorating Patient 3. Communicating Critical Test Results 4. Preventing Central Line Infections 5. Preventing Patient Falls in Health © Copyright, Joint Commission Resources Care Organizations Client name/ Presentation Name/ 12pt - 25
  26. 26. Agire sul portafoglio: NOT pay for performance © Copyright, Joint Commission Resources Client name/ Presentation Name/ 12pt - 26
  27. 27. Discutiamone.. © Copyright, Joint Commission Resources Client name/ Presentation Name/ 12pt - 27
  28. 28. Criteri da considerare – Ci sia evidenza che l’insieme degli EA in questione puo’ essere prevenuta con un’ampia adozione di pratiche disponibili e fattibili – Gli EA possono essere accuratamente misurati in un modo verificabile – Gli EA danno origine a danni clinicamente significativi per il paziente – E’ possibile, attraverso la revisione della cartella © Copyright, Joint Commission Resources clinica, differenziare gli EA iniziati in ospedale da quelli gia’ presenti al momento dell’ammissione Client name/ Presentation Name/ 12pt - 28
  29. 29. For more information: The Joint Commission Resources Web Site www.jcrinc.com The Joint Commission International www.jointcommissioninternational.org Joint Commission International Center for Patient Safety © Copyright, Joint Commission Resources www.jcipatientsafety.org cramponi@jcrinc.com Client name/ Presentation Name/ 12pt - 29

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