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Ppt patient safety final


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Ppt patient safety final

  1. 1. PATIENT SAFETY<br />Group 14<br />
  2. 2. Patient Safety<br /><ul><li>Patient safety is a fundamental principle of health care. Every point in the process of care-giving contains a certain degree of inherent unsafety.
  3. 3. Adverse events may result from problems in practice, products, procedures or systems. Patient safety improvements demand a complex system-wide effort, involving a wide range of actions in performance improvement, environmental safety and risk management, including infection control, safe use of medicines, equipment safety, safe clinical practice and safe environment of care.</li></li></ul><li>10 FACTS ON PATIENT SAFETY<br />FACT 1<br />Patient safety is a serious global public health issue. In recent years, countries have increasingly recognized the importance of improving patient safety. In 2002, WHO Member States agreed on a World Health Assembly resolution on patient safety.<br />FACT 2<br />Estimates show that in developed countries as many as one in 10 patients is harmed while receiving hospital care. The harm can be caused by a range of errors or adverse events.<br />FACT 3<br />In developing countries, the probability of patients being harmed in hospitals is higher than in industrialized nations. The risk of health care-associated infection in some developing countries is as much as 20 times higher than in developed countries.<br />FACT 4<br />At any given time, 1.4 million people worldwide suffer from infections acquired in hospitals. Hand hygiene is the most essential measure for reducing health care-associated infection and the development of antimicrobial resistance.<br />FACT 5<br />At least 50% of medical equipment in developing countries is unusable or only partly usable. Often the equipment is not used due to lack of skills or commodities. As a result, diagnostic procedures or treatments cannot be performed. This leads to substandard or hazardous diagnosis or treatment that can pose a threat to the safety of patients and may result in serious injury or death.<br />
  4. 4. 10 FACTS ON PATIENT SAFETY<br />FACT 6<br />In some countries, the proportion of injections given with syringes or needles reused without sterilization is as high as 70%. This exposes millions of people to infections. Each year, unsafe injections cause 1.3 million deaths, primarily due to transmission of blood-borne pathogens such as hepatitis B virus, hepatitis C virus and HIV.<br />FACT 7<br />Surgery is one of the most complex health interventions to deliver. More than 100 million people require surgical treatment every year for different medical reasons. Problems associated with surgical safety in developed countries account for half of the avoidable adverse events that result in death or disability.<br />FACT 8<br />The economic benefits of improving patient safety are compelling. Studies show that additional hospitalization, litigation costs, infections acquired in hospitals, lost income, disability and medical expenses have cost some countries between US$ 6 billion and US$ 29 billion a year.<br />FACT 9<br />Industries with a perceived higher risk such as aviation and nuclear plants have a much better safety record than health care. There is a one in 1 000 000 chance of a traveller being harmed while in an aircraft. In comparison, there is a one in 300 chance of a patient being harmed during health care.<br />FACT 10<br />Patients' experience and their health are at the heart of the patient safety movement. The World Alliance for Patient Safety is working with 40 champions – who have in the past suffered due to lack of patient safety measures – to help make health care safer worldwide.<br />
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  6. 6. FIRST GLOBAL PATIENT SAFETY CHALLENGE<br />CLEAN CARE IS SAFER CARE<br /> The goal of Clean Care is Safer Care is to ensure that infection control is acknowledged universally as a solid and essential basis towards patient safety and supports the reduction of health care-associated infections and their consequences.<br /> <br /> SAVE LIVES: Clean Your Hands is a major component of Clean Care is Safer Care. <br />
  7. 7. SAFE SURGERY SAVES LIVES<br />THE SECOND GLOBAL PATIENT SAFETY CHALLENGE<br /> <br />The goal of the Safe Surgery Saves Lives Challenge is to improve the safety of surgical care around the world by ensuring adherence to proven standards of care in all countries. <br /> The WHO Surgical Safety Checklist has improved compliance with standards and decreased complications from surgery in eight pilot hospitals where it was evaluated.<br />
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  9. 9. Equity and excellence: The role of patient safety<br />The Department of Health puts increased safety at the heart of its proposals, emphasizing that the NHS should refuse to tolerate unsafe and substandard care. The supporting consultation document on the development of an outcomes framework also has patient safety as a key focus.<br />
  10. 10. Improving Patient Safety<br />Involves assessing how patients may be harmed, preventing or managing risks, reporting and analysing incidents, learning from such incidents and implementing solutions to minimize the likelihood of them reoccurring. <br />
  11. 11. <ul><li>McFadden et al. (2006), found that the most widespread error reducing method being used in health care organizations to date is the development of blame free error reporting systems.
  12. 12. Blame free reporting systems allow hospital employees to report errors for the purpose of correcting hospital policy and procedures.</li></li></ul><li><ul><li>National Patient Safety Center should be formed to ensure patient safety within health care settings. This organization would be committed to research, tracking, and goal setting.
  13. 13. This organization would also work with health care organizations to implement corrections in protocols that have already been identified as problem areas through the use of blame free error reporting systems.
  14. 14. This organization would also work with health care organizations to implement corrections in protocols that have already been identified as problem areas through the use of blame free error reporting systems.
  15. 15. A main goal of the Center for Patient Safety would be reducing medical errors by 50%within 5 years</li></li></ul><li>The patient safety system shall address the following:<br />1. detection of safety issues<br />2. preventive and corrective action<br />3. processes to reduce risks<br />4. implementation of corrective action plans<br />5. on-going measurement to ensure action effectiveness<br />
  16. 16. Patient Safety Guidelines <br />Better lighting and less clutter in work areas where medications are prepared, keeping distractions to a minimum, and keeping noise levels down.<br />Drug companies and health care facilities are also standardizing medication labels and packaging.<br />Medications that can have a particularly dangerous effect are being marked as “high alert”.<br />Many hospitals are investing in technology to minimize errors, such as machines that dispense medications for just one patient at a time.<br />Patients are given identification bracelets showing their names and allergies.<br />All medical personnel are required to wear name tags showing their level of training.<br />
  17. 17. Unacceptable abbreviations are not used in documentation and the medical record.<br />Two identifiers are checked prior to procedures and medication administration.<br />Physician's verbal or telephone orders are read back to the physician.<br />Medication is labelled appropriately.<br />Hand washing guidelines are utilized.<br />Medications are reconciled by the physician on discharge.<br />Fall prevention.<br />Encourage patient involvement in their own care. <br />Pressure ulcer prevention.<br />Time out procedure prior to procedures requiring anesthesia or conscious sedation.<br />Blood components checked by two registered nurses at the bedside of the patient.<br />
  18. 18. Hygiene and Cleanliness<br />"Hand washing" - nurses should wash their hands or use a hand sanitizer before and after each patient interaction.<br />
  20. 20. Promoting Safety<br />Measures to ensure the safety of people of all ages focus on:<br /><ul><li>observation or prediction of potentially harmful situations so that harm can be avoided.
  21. 21. client education that empowers clients to protect themselves and their families from injury. Safety measures covering the life from infancy to elders are listed in the accompanying Client Teaching.</li></li></ul><li>Postoperative clients<br />Nursing during the postoperative phase is especially important for the client’s recovery because anesthesia impairs the ability of clients to respond to environmental stimuli and to help themselves, although the degree of consciousness of clients will vary/ Moreover, surgery itself traumatizes the body by disrupting protective mechanisms and homeostasis.<br />
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  26. 26. DRUG SAFETY<br />
  27. 27. INTRODUCTION<br />Over-the-counter (OTC) drugs are those available without a prescription. <br />OTC drugs enable people to relieve many annoying symptoms and to cure some diseases simply and without the cost of seeing a doctor. However, safe use of these drugs requires knowledge, common sense, and responsibility.<br />
  28. 28. SAFETY CONSIDERATIONS<br />Safety is a major concern when the FDA considers reclassifying a prescription drug as OTC. <br />Most OTC drugs—unlike health foods, dietary supplements (including medicinal herbs) and complementary therapies have been studied scientifically and extensively. <br />However, all drugs have benefits and risks, and some degree of risk has to be tolerated if people are to receive a drug's benefits. <br />Defining an acceptable degree of risk is a judgment call. <br />Safety depends on using a drug properly. <br />For OTC drugs, proper use often relies on consumer self-diagnosis, which leaves room for error.<br />
  29. 29. CONSIDERATIONS IN RECLASSIFYING A DRUG AS OVER-THE-COUNTER<br />SAFETY<br />Has the drug been used for a long enough time so that any harmful effects are fully understood?<br />What harmful effects (including those from misuse) may the drug produce?<br />Is the drug habit forming?<br />Do the benefits of OTC status outweigh the risks?<br />
  30. 30. EASE OF DIAGNOSIS AND TREATMENTCan the average person self-diagnose the condition that calls for the drug?Can the average person treat the condition without the help of a doctor or other health care practitioner?LABELINGCan adequate directions for use be written?Can warnings against unsafe use be written?Can the average person understand the information on the label?<br />
  31. 31. READING A DRUG LABEL<br /><ul><li>Nonprescription drugs are required to have labels that explain what a drug's benefits and risks are and how to use the drug correctly. The label is entitled “Drug Facts.”</li></li></ul><li>Active ingredient: The drug itself is the active ingredient. Combination products have more than one active ingredient. <br />Uses: Symptoms or disorders.<br />Warnings: When the drug should not be used, when a doctor or pharmacist should be consulted (and after how long), and which factors can alter the expected response to the drug are listed, usually in four sections.<br /><ul><li>“Ask a doctor before use if you have”
  32. 32. “Ask a doctor or a pharmacist before use if you are taking”
  33. 33. “When using this product”
  34. 34. The last section lists special warnings for women who are pregnant or breastfeeding and for children, with instructions about what to do in case of an overdose.
  35. 35. Directions: How much of the drug and how often to take the drug are given for different age groups
  36. 36. Other information: Special instructions
  37. 37. Inactive ingredients: In addition to the drug, drug products—the tablets, capsules, or other formulations that consumers buy—contain substances added to facilitate the administration of the drug
  38. 38. Inactive ingredients are usually harmless, but some of them cause an allergic reaction in a few people, who should look for products made without those ingredients.</li></li></ul><li>INJECTION SAFETY<br /> WHO estimates that in developing and transitional Member States, 16 billion health care injections are administered each year – an average of 3.4 injections per person per year. This figure, along with reports indicating inappropriate use of injections, suggests that injections are overused as a means of administering medications. In addition to being overused, injections may also be administered through unsafe procedures and cause infections.<br />
  39. 39. Causes of harm from injections<br />Injections may harm the patient when injection devices are reused in the absence of sterilization.<br />Reuse of injection devices in the absence of sterilization is of greatest concern, since it leads to the heaviest burden of disease. A mathematical model developed by WHO suggests that in 2000, in developing and transitional Member States, reuse of injection devices accounted for an estimated 22 million new infections with Hepatitis B virus (one-third of all such infections), 2 million new infections with hepatitis C virus (40% of all such infections) and 260 000 new HIV infections (5% of all such infections). The infections acquired in 2000 alone are expected to lead to an estimated 9 million years of life lost (adjusted for disability) between 2000 and 2030.<br />Injections may harm health-care workers when dirty needles are not collected in safety boxes. <br />Injections may also harm the community at large when health-care facilities are surrounded by sharp health-care waste – mostly dirty syringes and needles.<br />
  40. 40. Evidence shows that death and disability associated with unsafe injections are highly preventable. <br /><ul><li>First, interventions that aim at improving communication between patients and doctors and at improving prescriptions through monitoring of providers have effectively decreased injection overuse.
  41. 41. Second, interventions to make single-use syringes regularly available in each health care facility effectively prevent reuse of injection devices.</li></li></ul><li>Four Key Strategies:<br />increasing population awareness regarding the risk of HIV and other infections associated with unsafe injections;<br />making sure there are sufficient quantities of single-use injection devices and safety boxes in every health-care facility where injections are administered;<br />ensuring that donors and lenders supporting the supply of injectable substances in developing and transitional Member States also support the provision of injection devices with reuse-prevention features and safety boxes;<br />managing the waste associated with dirty syringes and needles in a safe and appropriate way.<br />
  42. 42. BLOOD<br />SAFETY<br />
  43. 43. Mission of BT Safety<br /><ul><li>Promote the formation of national blood programmes ensuring the safety, quality and adequacy of blood and blood products to meet the needs of all patients, on the understanding that patients will receive blood transfusions only when they need them.
  44. 44. Blood and blood products are provided as part of a sustainable blood programme within the health care system.</li></li></ul><li>Integrated strategy for blood safety<br />establishment of a nationally coordinated blood transfusion service that can ensure adequate and timely availability of safe blood for all patients in need;<br />collection of blood from voluntary, non-remunerated blood donors from low-risk populations;<br />testing of all donated blood for transfusion-transmissible infections, blood grouping and compatibility testing;<br />appropriate clinical use of blood and blood products.<br /> The strategy addresses all the steps in collecting, testing, processing, storage and use of blood and blood products that could directly or indirectly influence the safety of patients. It can be effective only if quality systems cover all aspects of transfusion, from recruitment and selection of blood donors to transfusion of blood and blood products.<br />
  46. 46. The devices group in WHO carries out activities to ensure the safety of patients, health-care workers and the community with regard to medical devices and equipment.<br />
  47. 47. Four Strategic Areas<br /><ul><li>Development of national policy: tools to assess and strengthen national regulatory authorities, including the recent medical device regulations: global overview and guiding principles, in order to promote national coordination and management of equipment.
  48. 48. Quality and safety: elements such as the elaboration of new ISO standards and WHO performance specifications, the pre-qualification of suppliers, the development of standardized procedures for alerts and recalls, and tools to assess safety and performance of products, in order to reduce risks linked to substandard products and procedures.
  49. 49. Access: quality management systems covering identification of equipment needs, and the selection, procurement and distribution process. Tools include the development of a model list of essential equipment, the WHO Essential Healthcare Technology Package, guidelines for good donation practices and increased collaboration with industry.
  50. 50. Appropriate use of equipment in order to reduce risks: elaboration and diffusion of materials on information, education and communication and of training manuals for managers and users of equipment, particularly as regards preventive maintenance.</li></li></ul><li>“Don't play for safety - it's the most dangerous thing in the world.” -Hugh Walpole <br />