The document outlines the policies and procedures of a hospital's patient safety plan. It establishes a patient safety committee to identify risks, prevent medical errors, and improve safety. It defines key terms like adverse events, near misses, and medication errors. It also lists the standard safety policies the hospital has implemented covering areas like clinical care, medication management, infection control, and facility maintenance. The goal is to institutionalize patient safety as a fundamental part of healthcare delivery.

2. NATIONAL PATIENT SAFETY DAY
June 25, 2011
THEME:
“ Working Together Towards Patient Safety”
Slogan:
“Kaligtasan ng Pasyente, Una Lagi”

3. What is Patient Safety?
Patient Safety is the avoidance,
prevention and amelioration of
adverse outcomes/ injuries stemming
from the process of health care

4. 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.

5. The Veterans Regional
Hospital Administrative
Manual Patient Safety
Plan

6. 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.

7. 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.

8. •Responsibility for Patient Safety
activities are shared by the Medical Staff
Departments, Patient Care Services, the
Clinical Support Services and all other
hospital departments.

9. •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.

10. •The information collected
addresses the requirements of DOH
and PHIC for a Patient Safety
Program.

11. •Appropriate actions are taken to
resolve identified problems and/or
identified opportunities to improve
patient care and non-clinical
services rendered.

12. •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.

13. •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.

14. 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.

15. •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.

17. •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.

18. •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.

19. •No Blame Culture
A non-punitive encouraging voluntary
reporting of adverse events.

20. •Risk
Is any exposure to a harmful
event. It is directly related to hazard
and vulnerability and, inversely, to
capacity.

21. •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.

22. •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.

23. 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.

24. •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.

25. Policy on Patient Safety
Safety standard policies:
•Access to care and continuity of care (ACC)
Policies: Admission
Networking
Transport
Discharge
Others

26. Policy on Patient Safety
Safety standard policies:
•Patient and family rights
Policies: Information
Patient care
Autopsy
Confidentiality
Security
Others

27. Policy on Patient Safety
Safety standard policies:
•Assessment of care
Policies: Referral
Credentialing and hiring
Others

28. 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

29. Policy on Patient Safety
Safety standard policies:
•Anesthesia and surgical care
Policies: pre-anesthetic evaluation
Surgical site preparation
Post –anesthetic care
Credentialing
Others

30. Policy on Patient Safety
Safety standard policies:
•Medication Management and use
Policies: Procurement
Storage/dispensing
Preparation
Medication errors/near misses
Adverse drug reaction
Others

31. Policy on Patient Safety
Safety standard policies:
•Medication Management and use
Policies: Procurement
Storage/dispensing
Preparation
Medication errors/near misses
Adverse drug reaction
Others

32. Policy on Patient Safety
Safety standard policies:
•Patient and family education
Policies: Training and education
Participative care
Others

33. Policy on Patient Safety
Safety standard policies:
•Quality improvement and patient safety
Policies: Sentinel event reporting and
handling or processing
Others

34. 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

35. 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

36. 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

37. Policy on Patient Safety
Safety standard policies:
•Staff qualification and education
Policies: Hiring
Training needs analysis
Continuing professional training
Others

38. Role:
To take the lead role in
planning, implementing,
managing,, and evaluating
safety initiatives and programs
Committee on Patient Safety

39. 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

40. 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