HM 2012 session-VIII patient safety


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Hospital Manaement Course Session VIII

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  • Level 1: Compliance with 100% of critical standards and any number of core and developmental standardsLevel 2: Compliance with 100% critical standards and 60% to 89% core standards, and any number of developmental standardsLevel 3: Compliance with 100% critical standards and at least 90% core standards, and any number of developmental standardsLevel 4: Compliance with 100% critical standards and at least 90% core standards, and at least 80% of developmental standards.
  • HM 2012 session-VIII patient safety

    1. 1. Hospital Management Session VIIIPatient Safety Friendly Hospital Initiative (PSFHI) DR. ASHFAQ AHMED BHUTTO MBBS, MBA, MAS, DCPS, MRCGP, (PhD) SUNDAY, FEBRUARY 19, 2012
    2. 2. Acknowledgement 2 The slide depicted here are taken from WHO resource CD provided by WHO EMRO region with permission.
    3. 3. 3
    4. 4. The risk of Dying is: 4 If some one is admitted to a Hospital in USA for one day onlyIt is equal to travel 8800 hour in an Air plane or 460 trip from Pakistan to USA
    5. 5. Adverse Events in Health Care 5■ 10% of hospital patients suffer an adverse event■ 16.6% of hospital patients suffer an adverse event (Australia)■ ≈100,000 hospital deaths/year through medical error (USA)■ Unsafe Surgery: o 234m case globally/year: 7 m complications, 1 m death■ Patient Handovers o 15% of adverse events or errors (USA study)
    6. 6. Common Types of Error 6 A nurse gives a patient a 4 X overdose of methotrexate; the patient dies A physician removes the wrong kidney A patient receives a 10 X overdose of insulin, goes into shock, is resuscitated, but has persistent brain damage.
    7. 7. Case 7 64 year old woman is admitted to hospital with fevers. Presumed diagnosis of pneumonia, treated for that with penicillin. On day 2, she develops a severe rash, felt to be caused by her infection. Involves entire body. Service is very busy. No senior doctor available. Penicillin continued. Rash progresses. On day 4 she is confused, gets out of bed at night, floor is wet, and she slips and falls, fracturing hip. Dies on day 7. What happened?
    8. 8. Causation 8 Individuals made errors Junior doctor didn’t know what was causing rash Senior doctor wasn’t available Nurse wasn’t there when patient got out of bed However, the system also allowed errors to slip through No good approach for dealing with very busy period Insufficient nurse staffing at night Operating room was too full and no surgeon available
    9. 9. The Burden of Unsafe Care 9 Adverse events due to medical devices & medications:  Good data from developed nations  Very little data from developing / transitional nations Surgical errors, health-care associated infections  Common sources of harm in all nations  Preliminary data from developing / transitional nations Unsafe blood products  Likely major cause of harm in some developing nations  Reasonably good data from select nations (WHO) Patients safety among pregnant women and newborns  Better data needed from developing / transitional nations
    10. 10. The Burden of Unsafe Care: Developing Countries 10 Mothers and newbornsMaternal mortality rates:North America: 1 in 3700Asia (some countries): 1 in 65Africa (some countries): 1 in 16Afghanistan 1 in 6 % deliveries in developing countries attended by health professional: 53%
    11. 11. The Burden of Unsafe Care: Unsafe Injections 11 16 billion injections a year in developing countries 39.6% with syringes and needles reused non sterilized (70% in some countries) Unsafe disposal can lead to re-sale of used equipment on the black market. The extent of harm caused by unsafe injections is unknown
    12. 12. Unsafe Blood, Counterfeit Drugs 12 5–15% of HIV infections in developing countries are due to unsafe blood Unsafe blood risks transmission of: hepatitis B & C syphilis, malaria, Chagas disease and West Nile fever Counterfeit drugs account for up to 30% of medicines consumed in developing countriesThe extent of harm causedby unsafe blood andmedications are unknown
    13. 13. Deficit of Qualified Health-care Providers 13 The deficit in 57 countries is estimated to be 2.4 million doctors, nurses and midwives Fatigue, production pressures cause high risk of mistakes
    14. 14. Medical Record Review StudyResults 14 Study Adverse No. of Permanent Percent Percent AE event rate records disability deaths preventable EMR 8.1% 15,548 0.9% 1.86% 83% (2.5-18%) Australia 16.6% 14,210 2.2% 0.79% 50% Canada 7.5% 3,745 0.4% 1.2% 37% New York 3.7% 30,195 0.24% 0.51% NA Wilson RM. Unpublished data, Regional Patient Safety Research Meeting, Amman, Jordan, August 2008
    15. 15. THE SWISS CHEESE MODELSUCCESSIVE LAYERS OF DEFENCES Physical barriers Procedures Information Decisions Adapted from Professor James Reason 15
    16. 16. THE SWISS CHEESE MODEL 16 DEFENCES Procedures Physical barriers Information THE Decisions HOLES Poor protocols Faulty equipment Missing informationPatientharmed Inadequate supervision Adapted from Professor James Reason
    17. 17. Regional Strategy for Patient Safety5 Axes to enhance the safety of patients I Awareness II Assess Scope EMR V Organizing & Patient Safety Strategy III Understanding the Running Causes of Error PS programs IV Developing & Testing Methods For Prevention 17
    18. 18. Patient Safety FriendlyHospital Initiative (PSFHI) – (1) 18 Promote safe practices in hospitals by assessing adherence to PS guidelines developed - EMRO/WAPS/IIRO Develop standards for assessing patient safety and guidelines for implementation  Patient safety assessment manual  7 hospitals identified as pilot sites for PSFHI – EGY, JOR, MOR, PAK, SUD, TUN, YEM
    19. 19. Patient Safety FriendlyHospital Initiative (PSFHI) – (2) 19 PS Assessment manual developed  Review of literature  Internally reviewed  Externally reviewed  Pre-piloted  Piloted Baseline Assessment of 7 hospitals completed between July-October 2009
    20. 20. Five Domains for Measurement of Performance of a PSF Hospital 20
    21. 21. PSFHI Assessment Manual Domains Critical Core DevelopmentalLeadership and 9 20 7ManagementPatient 2 16 10CenterednessEvidence based 7 29 8PracticeEnvironment 2 19 0Lifelong learning 0 6 5Total score 20 90 30 21 21
    22. 22. Baseline assessment of pilot hospitals in 7 countriesStandards EGY JOR MOR PAK SUD TUN YEMCritical (20) 15.5 12 10.5 13 8 11 5Core (90) 41 34 25.5 34 22 32.5 16.5Developmen 0.5 4 1 3.5 1 3 1tal (30)Total 57.5 50 37.5 50.5 32.5 47.5 22.5 22 22
    23. 23. Domains Patient Safety Subdomain Critical Core Developmental Standards Standards StandardsA. Leadership and A.1. The leadership and governance 3 3 2Management Domain are committed to patient safety A.2. The hospital has a patient 2 5 2 safety program. A.3. The hospital uses data to 0 2 2 improve safety performance. A.4. The hospital has essential 3 3 1 functioning equipment and supplies to deliver its services. A.5. The hospital ensures staff 1 5 0 safety for safer patients and availability of staff round the clock to deliver safe care. A.6. Hospital has policies, 0 2 0 guidelines, and standard operating procedures (SOP) for all departments and supporting services. 23 9 20 7
    24. 24. Examples of Critical Standards: 24 The hospital has Patient Safety as a strategic priority. This strategy is being implemented through a detailed action plan. All patients are identified and verified with at least 2 identifiers including full name and date of birth. The hospital maintains clear channels of communication for urgent critical results. The hospital conforms to guidelines on management of sharps waste.
    25. 25. Examples of Core Standards : 25 The hospital has a set of process and output measures that assess performance with a special focus on patient safety. The patient rights statement exists in the hospital and is visible to patients. The hospital ensures that each and every patient has a single completed medical record with a unique identifier.
    26. 26. LEVELS OF COMPLIANCE WITH PATIENT SAFETY STANDARDS 26Hospital level Critical Core Developmental Standards Standards StandardsLevel 1 100% Any AnyLevel 2 100% 60-89% AnyLevel 3 100% ≥ 90% AnyLevel 4 100% ≥ 90% ≥ 80%
    27. 27. How to Develop a PS Programin your Hospital?
    28. 28. 1-Leadership Commitment 28 Embrace a blame free Culture Strategic plan Accountability Leadership PS walk rounds
    29. 29. 2-Establish a PS Organizational Structure 29 Human Resources:  PS leader  PS Coordinator  PS Departmental focal points PS Council PS Sub committees:  Infection prevention and control  Environment safety  Medication safety  Research and ethics  Patient and public involvement
    30. 30. 3-Adopt PSFH Standards 30 Start learning about PSFH standards and how to comply with them Self assessment on ongoing basis Action plan : develop and monitor its implementation
    31. 31. 4- Train , Train, Train 31Involve as many as possible: PS Concepts PS assessment PS reporting PS SOPs , plans Risk Management
    32. 32. 5- Work to Overcome Resistance 32 What are they going to gain? Let them compete and be proud of their accomplishments Communicate to all staff
    33. 33. 6- Develop Systems, Procedures that support PS 33 Risk Management ADE Reporting Clinical Auditing PS Performance Management Patient Safety Tour
    34. 34. 34Thank You