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PATIENT SAFETY
       DR. N. C. DAS
WHAT IS SAFETY

S – Sense the error
A – Act to prevent it
F – Follow Safety Guidelines
E – Enquire into accidents/Deaths
T – Take appropriate remedial measure
Y – Your responsibility
WHY SAFETY IN THE HOSPITAL
• Hospital is a people intensive place
• Provide services to sick people round the clock
24 hours daily 365 days a year.
• People have a free access to enter any part of
the hospital any time for advice and treatment
• The hospital atmosphere is filled with emotions,
    excitement, life & happiness, death & sorrow
• Since hospital operates under continuous
strain, it gives rise to irritation, confrontation,
conflicts & aggression, threatening the life of
hospital staff & hospital properties
WHO’S SAFETY
SAFETY OF PLACE
SAFETY OF PROPERTY
SAFETY OF PEOPLE
PATIENT SAFETY

Patient safety is the absence of preventable
harm to a patient during the process of health
care.
The discipline of patient safety is the
coordinated efforts to prevent harm to patients,
caused by the process of health care itself.
 It is generally agreed upon that the meaning
of patient safety is…“Please do no harm”
ORIGIN OF PATIENT SAFETY
              CONCEPT

   HIPPOCRATIC OATH
    I will prescribe regimens for the good of my
    patients according to my ability and my
    judgment and ”never do harm” to anyone.
   Improving Patient Safety means reducing
    patient harm.
   Hospitals were founded to give care to those
    who need it and to keep patients safe is their
    moral duty
CURRENT ENVIRONMENT
•   Errors and system failures repeated
•   Action on known risks is very slow
•   Detection systems in their infancy
•   Many events not reported
•   Understanding of causes limited
•   Few examples of successful scale up
•   Limited measurement of impact
•   Blame culture 'alive and well'
•   Defensiveness and secrecy
M E D IC A L E R R O R S

•1 in 10 patients admitted to hospital suffers
an adverse event
•The Institute of Medicine in their study found
out that in USA.
•Medical Error injures 1 in 25 hospital
patients.
•Kills about 44000 to 98,000 patients every
year.
•Medical errors cost the United States billions
of dollars each year.
HOW DANGEROUS IS HEALTH CARE
 • Less than one death per 100 000 encounters
    – Nuclear power
    – European railroads
    – Scheduled airlines
 • One death in less than 100 000 but more than 1000
   encounters
    – Driving
    – Chemical manufacturing
 • More than one death per 1000 encounters
    – Bungee jumping ( Tying rope on leg)
    – Mountain climbing
    – Health care                     SOURCE: Internate
WHO’S ERROR
                      B
          A           16%
          66%
                      C
                 D    14%
                 4%


66% - Accidents caused entirely by patient.
16% - Accidents due to error by hospital staff.
14% - Accidents staff and patient both equally
responsible.
4% - Accidents due to physical, mechanical or
electrical errors.
                                 SOURCE: Internate
WHY ERROR


-In most cases fault is not willful negligence,
but systemic flaws, inadequate
communication and wide-spread process
variation and patient ignorance.
-People responsible are the doctors, nurses,
pharmacists , technicians and Patient.
TYPES OF ERRORS
i. Adverse Health Care Event – event or omission arising during clinical care
and causing physical or psychological injury to a patient
ii. Error – failure to complete a planned action as intended, or the use of an
incorrect plan of action to achieve a given plan
iii. Health Care Near Miss – situation in which an event or omission (or
sequence) arising during clinical care fails to develop further, whether or not
as the result of compensating action, thus preventing injury.
iv. Adverse Drug Reaction – any response to a drug which is noxious,
unintended and occurs at doses used for prophylaxis, diagnosis or therapy1
      Predictable
      Unpredictable
v. Medication Error – any preventable event that may cause or lead to
inappropriate medication use or patient harm while the medication is in the
control of health professional, patient or consumer
      vi. Sentinel error-
           Surgery on the w r o n g b o d y p a r t
      Surgery on the w r o n g p a t i e n t
      Patients receiving the w r o n g m e d i c a t i o n
FOCUS ON NEAR MISSES



•   No patient harm, therefore no blame
•   No guilt
•   No fear of litigation
•   Focus on future prevention
HUMANE ERROR

   “ To Err Is HUMANE”
   “Human beings make mistakes because the systems, tasks and
   processes they work in are poorly designed.”
   (Professor Lucian Leape, testifying to the US President’s Commission on Consumer
   Protection and Quality in Health)

  Every Error has a root cause and every cause has
  a solution.
 One Un willful Error is a miss
 Repeated Error is a Crime.
    Errors can be prevented with Every one’s
    Initiative in the system.

“HERE COMES THE ROLE OF PATIENT SAFETY”
“WHA” INITIATIVE
• Jan 2002 – Executive Board discuss patient
  safety
• May 2002 – resolution adopted by 55th World
  Health Assembly
• May 2004 – WHA support establishing World
  Alliance for Patient Safety
• October 2004 – launch of the World Alliance
  and Forward Programme by DG of WHO
• December 2005 – first progress report of the
  Alliance
WHO/WORLD ALLIANCE FOR PATIENT
           SAFETY
  Co-ordinate,  spread and accelerate improvements in patient
  safety worldwide
  WHO Patient Safety was created to facilitate the development of
  patient safety policy and practice across all WHO Member States
  and to act as a major force for patient safety improvement across
  the world.
  Our mission
  The mission of WHO Patient Safety is to coordinate,
  facilitate and accelerate patient safety improvements around
  the world by:
  •being a leader and advocating for change;
  •generating and sharing knowledge and expertise;
  •supporting Member States in their implementation of patient
  safety actions.
  Our vision
  •Every patient receives safe health care, every time, everywhere.
WORLD ALLIANCE FOR PATIENT
       SAFETY: TEN ACTION AREAS
Global Patient Safety Challenges :                       Solutions to improve
1. Clean Care is Safer Care                              patient safety
2. Safe Surgery Saves Lives
                                                                   High 5s WHO Project

  Patients for
  Patient Safety


                                     Catalyse                        Technology for
                                                                     Patient Safety
     Research for
     Patient Safety                  countries’ action
                                     to achieve                      Knowledge Management


     International                   safety of care                 Special projects:
     Classification for                                             - Education
     Patient Safety (ICPS)                                          - Radiotherapy
                                                                    - Rewarding excellence
                                                                    - When things go wrong
               Reporting &                                          - Vincristine sulphate
               Learning
HIGH 5s WHO PROJECT
A High 5s Steering Group was established in 2006 to determine the overall
architecture of the initiative. The project is being implemented in three phases.
The first phase (2006-2008), initiated in late 2006, has involved the
identification of five evidence-based solutions for patient safety and the
development of a Standard Operating Protocol (SOP) for each solution.
The solutions are:
Managing Concentrated Injectable Medicines;
Assuring Medication Accuracy at Transitions in Care;
Communication During Patient Care Handovers;
Improved Hand Hygiene to Prevent Health Care-Associated Infections; and
Performance of Correct Procedure at Correct Body Sites
The second phase (2008 -2010) identify a lead technical agency in each
participating country to coordinate the High 5s initiative at the country level.
Impact will be measured using the following tools:
Root cause analyses of indicator events and other adverse events
Patient safety indicators
Cultural assessments
Economic impact indices.
The third phase (2010-2011) Over time, the project will encourage participating
countries to use their established relationships with other countries
PATIENT SAFETY INITITIVE
•Patients know that their ailments may not always be cured, but they
don’t expect to be inadvertently harmed during their medical care.
• The “blame and train” approach to medical errors and close calls
doesn’t work well.
• human factors engineering techniques tease out root causes of
medical errors and close calls.
• Playing the Blame Game: An Ineffective strategy for improving
patient safety
• Preventing inadvertent harm to patients requires use of human
factors engineering principles.
• In other high hazard jobs such as airplane flying and running nuclear
reactors, systems have been developed to minimize risks based on the
science of human factors engineering.
         There fore concept of Patient safety has been derived from
         Aviation industry.
Summary

   SHARED SAFETY BEHAVIORS
      AVIATION & MEDICINE
• Broaden dimensions
     •   human factors engineering
     •   fatigue & stress management
     •   effective communication
     •   shared awareness
     •   teamwork
• Countermeasures
     •   briefings, debriefings
     •   workload distribution
     •   cross-monitoring
     •   graded assertiveness
     •   checklists
LESSONS FOR HEALTH FROM THE AIRLINE INDUSTRY

    • Statutory reporting of procedures
    • A voluntary (without jeopardy) reporting
      culture
    • Recurring statutory examinations
    • Systems development
    • Safety analysis of data
    • Acceptance that staff make mistakes
    • Role of teamwork
PATIENT SAFETY GOAL
Improve the accuracy of patient identification.
Improve the effectiveness of communication among
caregivers.
Improve the safety of using medications.
Reduce the risk of healthcare associated infections.
Accurately and completely reconcile medications across
the continuum of care.
Reduce the risk of patient harm resulting from falls.
Special emphasis on ,Dangerous abbreviations, infection
control, “Look alike and sound-alike” medications, time outs.
PRINCIPLE OF PATIENT SAFETY




  PROPER IDENTIFICATION OF PATIENT
AND MATCHING TO THEIR CARE ELEMENTS
          PREVENTION OFPATIENT HAND OVER
         ERROR AND SAFETY DURING TRANITION
            ASSESING MEDICAL ACCURACY WHILE
                GIVING CARE TO A PATIENT
               PERFORMANCE OF CORRECT PROCEDURE
                      AT CORRECT BODYSITE
                      TAKE APPROPRIATE PRECAITIONARY
                        MEASURES TO AVOID INFECTION
PRINCIPLE OF PATIENT SAFETY
TYPES OF SAFETY
 ENVIRONMENTAL            MEDICAL               SURGICAL
     SAFETY               SAFETY                 SAFETY




     EQUIPMENT           PATIENT SAFETY    ELECTRICAL SAFETY
INSTALLATION SAFETY




                           SANITATION
   BLOOD SAFETY        INFECTION CONTROL   LABORATORY SAFETY
                          BMW DISPOSAL
WORK ENVIRONMENT SAFETY
 There is a direct link between work environment and
  patient safety
 Therefore, if not addressing work environment, we are
  not addressing patient safety
 Healthy work environments do not just happen
 Therefore, if we do not have a formal program in place
  addressing work environment issues, little will change
 Creating healthy work environments requires changing
  long-standing cultures, traditions and hierarchies
 Therefore, though everyone must be involved in the
  creation of healthy work environments, the onus is on
  organizational, departmental and unit leaders to
  ensure that it happens
ENVIRONMENTAL SAFETY
•   Adequate light
•   Adequate ventilation, exhaust fan
•   Stairs with hand rails
•   Window-door-closer
•   Slip preventing floors
•   Fire extinguishers and fire alarms
•   Prevent noise pollution
•   Heavy and fixed beds
•   Safe wheel chairs and trolleys
•   No water logging in bathrooms
•   Call bell system for patients
•   Adequate no. of bed screens to maintain privacy of the patient.
MEDICAL SAFETY
1.   Illegible Writing prescription by doctors.
2.   Wrong medicines or wrong does or wrong patient.
3.   Wrong injection, wrong does or wrong patient, wrong route
     of administration.
4.   Drip sets, air bubbles, over hydration, drip speed.
5.   Oxygen flow check empty gas cylinders.
6.   Clear, written medication guidelines.
7.   Identification of each patient with Similar patient names
8.   Proper handing taking over during change of shift.
9.   Look alike and Sound Alike “LASA”
A- Medication orders should be written legibly in ink and should include:
• Patient’s name and location (ward, room No, and bed No) .
• Medication Generic Name.
• Dosage, frequency and route of administration.
• Signature of the physician.
• Date and hour the order was written.
B- Any abbreviations used in medication orders should be agreed to and
jointly adopted by the medical, nursing, pharmacy, and medical records staff
of the institution. Lately, in the interest of patient safety, “Do Not Abbreviate”
is the new practice nowadays.
C- Before dispensing the drug The pharmacist must receive the physician’s
original order or a direct copy of the order (except in emergency situations).
This permits the pharmacist to:
•Resolve questions or problems with drug orders before the drug is dispensed
and administered.
• Eliminate errors which may arise when drug orders are transcribed into
another form for use by the pharmacy.
D- to check at least two patient identifiers before providing care, treatments
or services.
• Patient name and medical record number
E- Discourage Telephonic orders , Do not accept verbal order
F- Examine safety Code
Methods of sending the Physician’s orders to the pharmacy are:
1. Self-copying order forms: This method provides the pharmacist
with a duplicate copy of the order and does not require special
equipment. There are two basic formats:
a. Orders for medications included among treatment orders.
b. Medication orders separated from other treatment orders on the
order form.
`
2. Electromechanical: Copying machines or similar devices may be
used to produce an exact copy of the physician’s order. Provision
should be made to transmit physicians’ orders to the pharmacy in the
event of mechanical failure.

3. Computerized: Computer systems, in which the physician enters
orders into a computer which then stores and prints out the orders in
the pharmacy or elsewhere.
SURGICAL SAFETY
1.      Consent of the patient/ relative in writing
2.      Proper identification of patient, name wrist band
3.      Proper identification mark of parts to be operated
4.      Pre- anesthetic check-up
5.      Anesthetic Safety
6.      Ensure no foreign body left inside
7.      Safety measures from ward to OT & coming back (Safety check
        list)
8.      Prevention of surgical wound infections
9.      Use of Surgical safety proforma in all operations
10.     Check Safety code if available

       DNR                            Purple
       Falls Risk                     Yellow
       Allergies                      Red
      (Red for Allergy Alert, yellow for Fall Risk, and Purple for Do Not Resuscitate).
Summary

WHO SURGICAL SAFETY CHECKLIST

 • The primary benefit of the checklist may
   be to engage the medical team.
 • By using the checklist, we may be
   gaining the ability to open
   communication by the medical team, to
   encourage teamwork behaviors, & to
   develop discipline in the team.
 • Reducing sentinel error




                                              35
INSTALLATION HAZZARDS

1.  Regular checking of equipments
2.  Proper earthling to avoid shock
3.  Regular maintenance & repair
4.  Training of nurses & technical staff
5. How do you control hazards?
•     Preventing inadvertent harm to patients requires
       use of human factors engineering principles.
6. The “hierarchy of hazard control:”
•   Eliminate hazard
•   Guard against hazard
•   Train to avoid hazards
•   Warn against hazards
Patient safety
NEW DEVICES

• Acceptance, safety inspection,
  compatibility, education, procedures, and
  appropriate purchasing documents
  (including loan agreements).
• When in doubt, have CE (Certified
  Equipment)check, supply chain
  management .(SCM),
WHY REPORTING MEDICAL DEVICE
           PROBLEMS
• Prevent future problems and protect patients, staff,
  families, and visitors
• Achieve performance improvement goals
• Assist Risk Management with claims or litigation
• Provide information to manufacturers and/or Food and
  Drug Administration
• Publicize report for the general good of patients and
  health care providers
• Effect changes in policies and procedures of procurement
WHEN TO REPORT

• When you think a device has or may
  have caused or contributed to any of
  the following outcomes (for a patient,
  staff member or visitor):
  – Death
  – Serious injury
  – Minor injury
  – Close calls or other potential for harm
INDIVIDUAL’s ROLE

• Identify actual and potential problems,
  adverse events, close calls with
  medical devices
• Report the problem or adverse event to
  your supervisor, according to policy
  and procedure
• Make sure your report includes details
• Remove the device, keep all affected
  items, save the packaging
ELECTRICAL SAFETY


1.   Safety fuses with each equipment
2.   No loose wires or connection
3.   Properly plugged and fixed
4.   If short circuit call electrician
5.   Electricity back up battery/ generator
6.   Use of CVT/UPS
FIRE SAFETY


Use Fire proof material for construction.
Have Fire Exit in all Buildings.
Smoke detectors and water sprinklers
on the roof of all Floors.
 Fire Extinguishers in all areas.
 Fire Hydrants in all buildings.
Training in Fire management
BLOOD SAFETY

1. Proper grouping & cross matching
2. Tests of HIV, Inf. hepatitis & VDRL
3. Proper leveling of group, name of the patient
4. Control of mismatch reaction
5. Standard operating procedure
6. Screening against HIV, Hepatitis. VD,
   Malaria.
7. Inform adverse reaction to BB
SANITATION- INFECTION CONTROL-
            BMW DISPOSAL

                         Sanitation
                                      BMW
                  HAI                 Disposal


•   Proper segregation & transportation of biomedical wastes
•   Sanitation & hygiene of different parts of hospital to avoid
    infection
•   Use of sterile procedures
•   Safety in use of incinerator, autoclave, shredder, needle
    destroyers and proper disposal of biomedical waste.
•   Formation of hospital infection control committee
•   Investigation of all hospital infections
•   Use of proper antibiotics in right doses in right time
•   Reorientation of Resident doctors & Nursing staff
LABORATORY SAFETY

•Avoid needle prick & spilling of blood
• Safety measures in Radiology & Radiotherapy
departments
• Safety norm guide lines for different areas of
hospitals.
• Regular pest control measures
• Care in handling acids, reagents, inflammable
substances.
• BMW segregation and disposal
WHO IS RESPONSIBLE
          NURSE




 DOCTOR           PATIENT
          NURSE




                    PATIENT
DOCTOR
PATIENT INVOLVEMENT

• Individual Advocacy – In doctor & hospital visits
   – Share information
      • Create lists of health problems, previous
        operations, etc.
      • List or bring all medications, supplements, and
        vitamins
   – Get information
      • Ask questions about treatments, medications, etc.
      • Research illnesses and treatments
   – Bring an Advocate
   – Know what to do before leaving
      • Ask about medications and future appointments
PREVENT MEDICAL ERRORS BY
         PATIENT
A. MEDICINES
1. Make sure that all of your doctors know about
every medicine you are taking. This includes
prescription and over-the-counter medicines and
dietary supplements, such as vitamins and herbs.
2. Bring all of your medicines and supplements to
your doctor visits. Your medicines can help you and
your doctor talk about them and find out if there are
any problems.
3. Make sure your doctor knows about any
allergies and adverse reactions you have had to
medicines.
ERRORS BY PATIENT
4. When your doctor writes a prescription for you,
make sure you can read it.
5. Ask for information about your medicines in
terms you can understand—both when your
medicines are prescribed and when you get them:
•What is the medicine for?
•How am I supposed to take it and for how long?
•What side effects are likely? What do I do if they
occur?
•Is this medicine safe to take with other medicines or
dietary supplements I am taking?
•What food, drink, or activities should I avoid while
taking this medicine?
6. When you pick up your medicine from the
pharmacy, ask: Is this the medicine that my doctor
prescribed?
7. If you have any questions about the directions on
your medicine labels, ask if "four times daily" means
taking a dose every 6 hours around the clock or just
during regular waking hours.
8. Ask your pharmacist for the best device to
measure your liquid medicine. Special devices, like
marked syringes, help people measure the right dose.
9. Ask for written information about the side effects
your medicine could cause. If you know what might
happen, you will be better prepared if it does or if
something unexpected happens.
B. HOSPITAL STAYS
10. If you are in a hospital, consider asking all health
care workers who will touch you whether they have
washed their hands. Hand washing can prevent the
spread of infections in hospitals.
11. When you are being discharged from the hospital,
ask your doctor to explain the treatment plan you will
follow at home.
•About your new medicines,
•When you can get back to your regular activities.
•Continuing old medicines before your hospital stay.
•When to come back to the hospital for check up
C. SURGERY
12. If you are having surgery, make sure that you,
your doctor, and your surgeon all agree on
exactly what will be done.
Surgeons are expected to sign their initials directly
on the site to be operated on before the surgery.
13. If you have a choice, choose a hospital where
many patients have had the procedure or surgery
you need. Research shows that patients tend to
have better results when they are treated in hospitals
that have a great deal of experience with their
condition.
D. OTHER STEPS
14. Speak up if you have questions or
concerns.
15. Make sure that someone, such as your
primary care doctor, coordinates your
care.
16. Make sure that all your doctors have
your important health information.
20. Learn about your condition and
treatments by asking your doctor and nurse
and by using other reliable sources.
PATIENT INVOLVEMENT


• Patient Representative – In health care
  organizations
  – Work to improve safety at the organization
    and individual unit level
  – Serve on committees and boards
  – Assist on rounds and here patient
    greivences
  – Support staff and families
PATIENT INVOLVEMENT

• Patient Participant/Activist
  – Participate on state and regional coalitions
    and organizations and/or
  – Serve nationally
  – Advocate for public reporting and
    accountability of hospital and health system
    performance
  – Volunteer, make donations, work with fund-
    raising
  – Be aware of state and national legislation,
    contact legislators
PATIENT INVOLVEMENT


• Patient Advocate – For friends and family
  – Willingness to go with the patient to
    appointments, be with them in the hospital
    and clinics
  – Listening and taking notes
  – Speak up when necessary to clarify an
    issue and to ask a question
  – Question when something does not seem
    right in the hospital, nursing homes, clinics,
    etc.
PREVENT MEDICAL ERRORS BY
           MEDICAL STAFF
Communication & coordination deficits drive
errors
Application of Aviation Safety concepts & skills are
being introduced in healthcare
Strong Correlation between Teamwork results in:
   •Improved Patient Outcomes
   •Patient Satisfaction
   •Staff Satisfaction
     •Reduced Errors
     •Reduce malpractice
     claims
     •Reduce ‘Blame culture’
TWO-CHALLENGE RULE :
It is your responsibility to assertively voice your
concern at least two times to ensure that it has
been heard
The member being challenged must
acknowledge
Provide supporting information with second
challenge
If the outcome is still not acceptable use ‘CUS’
Concern, Un comfortable , Stop
     Take a stronger course of action “Empower
     any member of the team to “stop the line” if he
     or she senses or discovers an essential safety
     breach.”
EFFECTIVE COMMUNICATION
Communication Breakdowns Contributing Factor in
43% of adverse surgical events
Pivotal Factor in 65% of Sentinel Events (3,000
events 1995-2005)
    (Joint Commission on Accreditation of Healthcare
    Organizations. (2006)
Primary contributing factor in adverse events 70-80%
of root cause analysis
    (National Center for Patient Safety(2006). Root
    Cause Analysis Database)
 Common in:
   •Medical errors
   •Medical malpractice cases
   •Adverse surgical events
   •Adverse medical events
   •Sentinel events
ADVERSE INCIDENT REPORTING
• Complete and submit
• Notify Risk Management
• Drug controller notification if Medical
  Device or Medication
• Begin Root Cause/Intensive analysis to
  examine process changes that may
  prevent future events
• Take preventing measures for future
  near miss.
PEER REVIEW
Monitor and improve physician care of
patients
Accomplish by:
   •Open, non-punitive discussion
   •Review and discuss alternatives
   •Disseminate to ALL physicians
   •Monthly review schedule
Move towards: review previous 48 hour record (Code Blue)
   •Could this event have been prevented?
   •Were signs of deterioration missed?
       Elevated BP, dropping BP
       Elevated HR, dropping HR
       Elevated RR
HEALTH EXECUTIVE’S ROLE

   Set Culture
  Accountability
  Measures
  High Reliability/Redesign
  Communication and Teamwork
  Professional Development

   Reliability principles:
         simplification
         standardization
         relation of humans to the work
         environment
BARRIERS TO IMPLEMENTATION




                    SOURCE: INTERNATE
PRATICE OF PATIENT SAFETY
              ( WHO )
1.  Be aware of Look-Alike, Sound-Alike Medication
    Names.
2. Proper Patient Identification.
3. Explain in Detail During Patient Hand/Take- Overs.
4. Performance of Correct Procedure at Correct Body
    Site.
5. Careful About Electrolyte Imbalance.
6. Assuring Proper Treatment During Shifting.
7. Avoid Catheter and Tubing, Wrong Connections .
8. Single Use of Injection Syringes.
9. Improved Hand Hygiene to Prevent Health Care-
    Associated Infections .
10. Proper Disposal of BMW and Good House Keeping.
11 Practice Surgical Safety Guide Lines.
TIPS FOR IMPROVING PATIENT SAFETY

1. Constitution of Patient Safety Committee.
2. Develop clear policies and protocols for patient safety.
3. Discuss regularly patient safety initiative within hospital
   staff.
4. Orientation, Re-orientation hospital staff on patient safety
5. Encourage transparency in the regular death review.
6. Non- punitive incident reporting by staff.
7. Each department to devise their own patient safety
   protocols.
8. Investigate each accident/ incident reported and take
   remedial measures.
9. Review, monitor & evaluate. safety procedures regularly.
hospiad
          Hospital Administration Made Easy




      http//hospiad.blogspot.com
    An effort solely to help students and aspirants
    in their attempt to become a successful
    Hospital Administrator.


                                            DR. N. C. DAS

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Patient safety

  • 1. PATIENT SAFETY DR. N. C. DAS
  • 2. WHAT IS SAFETY S – Sense the error A – Act to prevent it F – Follow Safety Guidelines E – Enquire into accidents/Deaths T – Take appropriate remedial measure Y – Your responsibility
  • 3. WHY SAFETY IN THE HOSPITAL • Hospital is a people intensive place • Provide services to sick people round the clock 24 hours daily 365 days a year. • People have a free access to enter any part of the hospital any time for advice and treatment • The hospital atmosphere is filled with emotions, excitement, life & happiness, death & sorrow • Since hospital operates under continuous strain, it gives rise to irritation, confrontation, conflicts & aggression, threatening the life of hospital staff & hospital properties
  • 8. PATIENT SAFETY Patient safety is the absence of preventable harm to a patient during the process of health care. The discipline of patient safety is the coordinated efforts to prevent harm to patients, caused by the process of health care itself.  It is generally agreed upon that the meaning of patient safety is…“Please do no harm”
  • 9. ORIGIN OF PATIENT SAFETY CONCEPT  HIPPOCRATIC OATH I will prescribe regimens for the good of my patients according to my ability and my judgment and ”never do harm” to anyone.  Improving Patient Safety means reducing patient harm.  Hospitals were founded to give care to those who need it and to keep patients safe is their moral duty
  • 10. CURRENT ENVIRONMENT • Errors and system failures repeated • Action on known risks is very slow • Detection systems in their infancy • Many events not reported • Understanding of causes limited • Few examples of successful scale up • Limited measurement of impact • Blame culture 'alive and well' • Defensiveness and secrecy
  • 11. M E D IC A L E R R O R S •1 in 10 patients admitted to hospital suffers an adverse event •The Institute of Medicine in their study found out that in USA. •Medical Error injures 1 in 25 hospital patients. •Kills about 44000 to 98,000 patients every year. •Medical errors cost the United States billions of dollars each year.
  • 12. HOW DANGEROUS IS HEALTH CARE • Less than one death per 100 000 encounters – Nuclear power – European railroads – Scheduled airlines • One death in less than 100 000 but more than 1000 encounters – Driving – Chemical manufacturing • More than one death per 1000 encounters – Bungee jumping ( Tying rope on leg) – Mountain climbing – Health care SOURCE: Internate
  • 13. WHO’S ERROR B A 16% 66% C D 14% 4% 66% - Accidents caused entirely by patient. 16% - Accidents due to error by hospital staff. 14% - Accidents staff and patient both equally responsible. 4% - Accidents due to physical, mechanical or electrical errors. SOURCE: Internate
  • 14. WHY ERROR -In most cases fault is not willful negligence, but systemic flaws, inadequate communication and wide-spread process variation and patient ignorance. -People responsible are the doctors, nurses, pharmacists , technicians and Patient.
  • 15. TYPES OF ERRORS i. Adverse Health Care Event – event or omission arising during clinical care and causing physical or psychological injury to a patient ii. Error – failure to complete a planned action as intended, or the use of an incorrect plan of action to achieve a given plan iii. Health Care Near Miss – situation in which an event or omission (or sequence) arising during clinical care fails to develop further, whether or not as the result of compensating action, thus preventing injury. iv. Adverse Drug Reaction – any response to a drug which is noxious, unintended and occurs at doses used for prophylaxis, diagnosis or therapy1 Predictable Unpredictable v. Medication Error – any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of health professional, patient or consumer vi. Sentinel error- Surgery on the w r o n g b o d y p a r t Surgery on the w r o n g p a t i e n t Patients receiving the w r o n g m e d i c a t i o n
  • 16. FOCUS ON NEAR MISSES • No patient harm, therefore no blame • No guilt • No fear of litigation • Focus on future prevention
  • 17. HUMANE ERROR “ To Err Is HUMANE” “Human beings make mistakes because the systems, tasks and processes they work in are poorly designed.” (Professor Lucian Leape, testifying to the US President’s Commission on Consumer Protection and Quality in Health) Every Error has a root cause and every cause has a solution. One Un willful Error is a miss Repeated Error is a Crime. Errors can be prevented with Every one’s Initiative in the system. “HERE COMES THE ROLE OF PATIENT SAFETY”
  • 18. “WHA” INITIATIVE • Jan 2002 – Executive Board discuss patient safety • May 2002 – resolution adopted by 55th World Health Assembly • May 2004 – WHA support establishing World Alliance for Patient Safety • October 2004 – launch of the World Alliance and Forward Programme by DG of WHO • December 2005 – first progress report of the Alliance
  • 19. WHO/WORLD ALLIANCE FOR PATIENT SAFETY Co-ordinate, spread and accelerate improvements in patient safety worldwide WHO Patient Safety was created to facilitate the development of patient safety policy and practice across all WHO Member States and to act as a major force for patient safety improvement across the world. Our mission The mission of WHO Patient Safety is to coordinate, facilitate and accelerate patient safety improvements around the world by: •being a leader and advocating for change; •generating and sharing knowledge and expertise; •supporting Member States in their implementation of patient safety actions. Our vision •Every patient receives safe health care, every time, everywhere.
  • 20. WORLD ALLIANCE FOR PATIENT SAFETY: TEN ACTION AREAS Global Patient Safety Challenges : Solutions to improve 1. Clean Care is Safer Care patient safety 2. Safe Surgery Saves Lives High 5s WHO Project Patients for Patient Safety Catalyse Technology for Patient Safety Research for Patient Safety countries’ action to achieve Knowledge Management International safety of care Special projects: Classification for - Education Patient Safety (ICPS) - Radiotherapy - Rewarding excellence - When things go wrong Reporting & - Vincristine sulphate Learning
  • 21. HIGH 5s WHO PROJECT A High 5s Steering Group was established in 2006 to determine the overall architecture of the initiative. The project is being implemented in three phases. The first phase (2006-2008), initiated in late 2006, has involved the identification of five evidence-based solutions for patient safety and the development of a Standard Operating Protocol (SOP) for each solution. The solutions are: Managing Concentrated Injectable Medicines; Assuring Medication Accuracy at Transitions in Care; Communication During Patient Care Handovers; Improved Hand Hygiene to Prevent Health Care-Associated Infections; and Performance of Correct Procedure at Correct Body Sites The second phase (2008 -2010) identify a lead technical agency in each participating country to coordinate the High 5s initiative at the country level. Impact will be measured using the following tools: Root cause analyses of indicator events and other adverse events Patient safety indicators Cultural assessments Economic impact indices. The third phase (2010-2011) Over time, the project will encourage participating countries to use their established relationships with other countries
  • 22. PATIENT SAFETY INITITIVE •Patients know that their ailments may not always be cured, but they don’t expect to be inadvertently harmed during their medical care. • The “blame and train” approach to medical errors and close calls doesn’t work well. • human factors engineering techniques tease out root causes of medical errors and close calls. • Playing the Blame Game: An Ineffective strategy for improving patient safety • Preventing inadvertent harm to patients requires use of human factors engineering principles. • In other high hazard jobs such as airplane flying and running nuclear reactors, systems have been developed to minimize risks based on the science of human factors engineering. There fore concept of Patient safety has been derived from Aviation industry.
  • 23. Summary SHARED SAFETY BEHAVIORS AVIATION & MEDICINE • Broaden dimensions • human factors engineering • fatigue & stress management • effective communication • shared awareness • teamwork • Countermeasures • briefings, debriefings • workload distribution • cross-monitoring • graded assertiveness • checklists
  • 24. LESSONS FOR HEALTH FROM THE AIRLINE INDUSTRY • Statutory reporting of procedures • A voluntary (without jeopardy) reporting culture • Recurring statutory examinations • Systems development • Safety analysis of data • Acceptance that staff make mistakes • Role of teamwork
  • 25. PATIENT SAFETY GOAL Improve the accuracy of patient identification. Improve the effectiveness of communication among caregivers. Improve the safety of using medications. Reduce the risk of healthcare associated infections. Accurately and completely reconcile medications across the continuum of care. Reduce the risk of patient harm resulting from falls. Special emphasis on ,Dangerous abbreviations, infection control, “Look alike and sound-alike” medications, time outs.
  • 26. PRINCIPLE OF PATIENT SAFETY PROPER IDENTIFICATION OF PATIENT AND MATCHING TO THEIR CARE ELEMENTS PREVENTION OFPATIENT HAND OVER ERROR AND SAFETY DURING TRANITION ASSESING MEDICAL ACCURACY WHILE GIVING CARE TO A PATIENT PERFORMANCE OF CORRECT PROCEDURE AT CORRECT BODYSITE TAKE APPROPRIATE PRECAITIONARY MEASURES TO AVOID INFECTION
  • 28. TYPES OF SAFETY ENVIRONMENTAL MEDICAL SURGICAL SAFETY SAFETY SAFETY EQUIPMENT PATIENT SAFETY ELECTRICAL SAFETY INSTALLATION SAFETY SANITATION BLOOD SAFETY INFECTION CONTROL LABORATORY SAFETY BMW DISPOSAL
  • 29. WORK ENVIRONMENT SAFETY  There is a direct link between work environment and patient safety  Therefore, if not addressing work environment, we are not addressing patient safety  Healthy work environments do not just happen  Therefore, if we do not have a formal program in place addressing work environment issues, little will change  Creating healthy work environments requires changing long-standing cultures, traditions and hierarchies  Therefore, though everyone must be involved in the creation of healthy work environments, the onus is on organizational, departmental and unit leaders to ensure that it happens
  • 30. ENVIRONMENTAL SAFETY • Adequate light • Adequate ventilation, exhaust fan • Stairs with hand rails • Window-door-closer • Slip preventing floors • Fire extinguishers and fire alarms • Prevent noise pollution • Heavy and fixed beds • Safe wheel chairs and trolleys • No water logging in bathrooms • Call bell system for patients • Adequate no. of bed screens to maintain privacy of the patient.
  • 31. MEDICAL SAFETY 1. Illegible Writing prescription by doctors. 2. Wrong medicines or wrong does or wrong patient. 3. Wrong injection, wrong does or wrong patient, wrong route of administration. 4. Drip sets, air bubbles, over hydration, drip speed. 5. Oxygen flow check empty gas cylinders. 6. Clear, written medication guidelines. 7. Identification of each patient with Similar patient names 8. Proper handing taking over during change of shift. 9. Look alike and Sound Alike “LASA”
  • 32. A- Medication orders should be written legibly in ink and should include: • Patient’s name and location (ward, room No, and bed No) . • Medication Generic Name. • Dosage, frequency and route of administration. • Signature of the physician. • Date and hour the order was written. B- Any abbreviations used in medication orders should be agreed to and jointly adopted by the medical, nursing, pharmacy, and medical records staff of the institution. Lately, in the interest of patient safety, “Do Not Abbreviate” is the new practice nowadays. C- Before dispensing the drug The pharmacist must receive the physician’s original order or a direct copy of the order (except in emergency situations). This permits the pharmacist to: •Resolve questions or problems with drug orders before the drug is dispensed and administered. • Eliminate errors which may arise when drug orders are transcribed into another form for use by the pharmacy. D- to check at least two patient identifiers before providing care, treatments or services. • Patient name and medical record number E- Discourage Telephonic orders , Do not accept verbal order F- Examine safety Code
  • 33. Methods of sending the Physician’s orders to the pharmacy are: 1. Self-copying order forms: This method provides the pharmacist with a duplicate copy of the order and does not require special equipment. There are two basic formats: a. Orders for medications included among treatment orders. b. Medication orders separated from other treatment orders on the order form. ` 2. Electromechanical: Copying machines or similar devices may be used to produce an exact copy of the physician’s order. Provision should be made to transmit physicians’ orders to the pharmacy in the event of mechanical failure. 3. Computerized: Computer systems, in which the physician enters orders into a computer which then stores and prints out the orders in the pharmacy or elsewhere.
  • 34. SURGICAL SAFETY 1. Consent of the patient/ relative in writing 2. Proper identification of patient, name wrist band 3. Proper identification mark of parts to be operated 4. Pre- anesthetic check-up 5. Anesthetic Safety 6. Ensure no foreign body left inside 7. Safety measures from ward to OT & coming back (Safety check list) 8. Prevention of surgical wound infections 9. Use of Surgical safety proforma in all operations 10. Check Safety code if available DNR Purple Falls Risk Yellow Allergies Red (Red for Allergy Alert, yellow for Fall Risk, and Purple for Do Not Resuscitate).
  • 35. Summary WHO SURGICAL SAFETY CHECKLIST • The primary benefit of the checklist may be to engage the medical team. • By using the checklist, we may be gaining the ability to open communication by the medical team, to encourage teamwork behaviors, & to develop discipline in the team. • Reducing sentinel error 35
  • 36. INSTALLATION HAZZARDS 1. Regular checking of equipments 2. Proper earthling to avoid shock 3. Regular maintenance & repair 4. Training of nurses & technical staff 5. How do you control hazards? • Preventing inadvertent harm to patients requires use of human factors engineering principles. 6. The “hierarchy of hazard control:” • Eliminate hazard • Guard against hazard • Train to avoid hazards • Warn against hazards
  • 38. NEW DEVICES • Acceptance, safety inspection, compatibility, education, procedures, and appropriate purchasing documents (including loan agreements). • When in doubt, have CE (Certified Equipment)check, supply chain management .(SCM),
  • 39. WHY REPORTING MEDICAL DEVICE PROBLEMS • Prevent future problems and protect patients, staff, families, and visitors • Achieve performance improvement goals • Assist Risk Management with claims or litigation • Provide information to manufacturers and/or Food and Drug Administration • Publicize report for the general good of patients and health care providers • Effect changes in policies and procedures of procurement
  • 40. WHEN TO REPORT • When you think a device has or may have caused or contributed to any of the following outcomes (for a patient, staff member or visitor): – Death – Serious injury – Minor injury – Close calls or other potential for harm
  • 41. INDIVIDUAL’s ROLE • Identify actual and potential problems, adverse events, close calls with medical devices • Report the problem or adverse event to your supervisor, according to policy and procedure • Make sure your report includes details • Remove the device, keep all affected items, save the packaging
  • 42. ELECTRICAL SAFETY 1. Safety fuses with each equipment 2. No loose wires or connection 3. Properly plugged and fixed 4. If short circuit call electrician 5. Electricity back up battery/ generator 6. Use of CVT/UPS
  • 43. FIRE SAFETY Use Fire proof material for construction. Have Fire Exit in all Buildings. Smoke detectors and water sprinklers on the roof of all Floors.  Fire Extinguishers in all areas.  Fire Hydrants in all buildings. Training in Fire management
  • 44. BLOOD SAFETY 1. Proper grouping & cross matching 2. Tests of HIV, Inf. hepatitis & VDRL 3. Proper leveling of group, name of the patient 4. Control of mismatch reaction 5. Standard operating procedure 6. Screening against HIV, Hepatitis. VD, Malaria. 7. Inform adverse reaction to BB
  • 45. SANITATION- INFECTION CONTROL- BMW DISPOSAL Sanitation BMW HAI Disposal • Proper segregation & transportation of biomedical wastes • Sanitation & hygiene of different parts of hospital to avoid infection • Use of sterile procedures • Safety in use of incinerator, autoclave, shredder, needle destroyers and proper disposal of biomedical waste. • Formation of hospital infection control committee • Investigation of all hospital infections • Use of proper antibiotics in right doses in right time • Reorientation of Resident doctors & Nursing staff
  • 46. LABORATORY SAFETY •Avoid needle prick & spilling of blood • Safety measures in Radiology & Radiotherapy departments • Safety norm guide lines for different areas of hospitals. • Regular pest control measures • Care in handling acids, reagents, inflammable substances. • BMW segregation and disposal
  • 47. WHO IS RESPONSIBLE NURSE DOCTOR PATIENT NURSE PATIENT DOCTOR
  • 48. PATIENT INVOLVEMENT • Individual Advocacy – In doctor & hospital visits – Share information • Create lists of health problems, previous operations, etc. • List or bring all medications, supplements, and vitamins – Get information • Ask questions about treatments, medications, etc. • Research illnesses and treatments – Bring an Advocate – Know what to do before leaving • Ask about medications and future appointments
  • 49. PREVENT MEDICAL ERRORS BY PATIENT A. MEDICINES 1. Make sure that all of your doctors know about every medicine you are taking. This includes prescription and over-the-counter medicines and dietary supplements, such as vitamins and herbs. 2. Bring all of your medicines and supplements to your doctor visits. Your medicines can help you and your doctor talk about them and find out if there are any problems. 3. Make sure your doctor knows about any allergies and adverse reactions you have had to medicines.
  • 50. ERRORS BY PATIENT 4. When your doctor writes a prescription for you, make sure you can read it. 5. Ask for information about your medicines in terms you can understand—both when your medicines are prescribed and when you get them: •What is the medicine for? •How am I supposed to take it and for how long? •What side effects are likely? What do I do if they occur? •Is this medicine safe to take with other medicines or dietary supplements I am taking? •What food, drink, or activities should I avoid while taking this medicine?
  • 51. 6. When you pick up your medicine from the pharmacy, ask: Is this the medicine that my doctor prescribed? 7. If you have any questions about the directions on your medicine labels, ask if "four times daily" means taking a dose every 6 hours around the clock or just during regular waking hours. 8. Ask your pharmacist for the best device to measure your liquid medicine. Special devices, like marked syringes, help people measure the right dose. 9. Ask for written information about the side effects your medicine could cause. If you know what might happen, you will be better prepared if it does or if something unexpected happens.
  • 52. B. HOSPITAL STAYS 10. If you are in a hospital, consider asking all health care workers who will touch you whether they have washed their hands. Hand washing can prevent the spread of infections in hospitals. 11. When you are being discharged from the hospital, ask your doctor to explain the treatment plan you will follow at home. •About your new medicines, •When you can get back to your regular activities. •Continuing old medicines before your hospital stay. •When to come back to the hospital for check up
  • 53. C. SURGERY 12. If you are having surgery, make sure that you, your doctor, and your surgeon all agree on exactly what will be done. Surgeons are expected to sign their initials directly on the site to be operated on before the surgery. 13. If you have a choice, choose a hospital where many patients have had the procedure or surgery you need. Research shows that patients tend to have better results when they are treated in hospitals that have a great deal of experience with their condition.
  • 54. D. OTHER STEPS 14. Speak up if you have questions or concerns. 15. Make sure that someone, such as your primary care doctor, coordinates your care. 16. Make sure that all your doctors have your important health information. 20. Learn about your condition and treatments by asking your doctor and nurse and by using other reliable sources.
  • 55. PATIENT INVOLVEMENT • Patient Representative – In health care organizations – Work to improve safety at the organization and individual unit level – Serve on committees and boards – Assist on rounds and here patient greivences – Support staff and families
  • 56. PATIENT INVOLVEMENT • Patient Participant/Activist – Participate on state and regional coalitions and organizations and/or – Serve nationally – Advocate for public reporting and accountability of hospital and health system performance – Volunteer, make donations, work with fund- raising – Be aware of state and national legislation, contact legislators
  • 57. PATIENT INVOLVEMENT • Patient Advocate – For friends and family – Willingness to go with the patient to appointments, be with them in the hospital and clinics – Listening and taking notes – Speak up when necessary to clarify an issue and to ask a question – Question when something does not seem right in the hospital, nursing homes, clinics, etc.
  • 58. PREVENT MEDICAL ERRORS BY MEDICAL STAFF Communication & coordination deficits drive errors Application of Aviation Safety concepts & skills are being introduced in healthcare Strong Correlation between Teamwork results in: •Improved Patient Outcomes •Patient Satisfaction •Staff Satisfaction •Reduced Errors •Reduce malpractice claims •Reduce ‘Blame culture’
  • 59. TWO-CHALLENGE RULE : It is your responsibility to assertively voice your concern at least two times to ensure that it has been heard The member being challenged must acknowledge Provide supporting information with second challenge If the outcome is still not acceptable use ‘CUS’ Concern, Un comfortable , Stop Take a stronger course of action “Empower any member of the team to “stop the line” if he or she senses or discovers an essential safety breach.”
  • 60. EFFECTIVE COMMUNICATION Communication Breakdowns Contributing Factor in 43% of adverse surgical events Pivotal Factor in 65% of Sentinel Events (3,000 events 1995-2005) (Joint Commission on Accreditation of Healthcare Organizations. (2006) Primary contributing factor in adverse events 70-80% of root cause analysis (National Center for Patient Safety(2006). Root Cause Analysis Database)  Common in: •Medical errors •Medical malpractice cases •Adverse surgical events •Adverse medical events •Sentinel events
  • 61. ADVERSE INCIDENT REPORTING • Complete and submit • Notify Risk Management • Drug controller notification if Medical Device or Medication • Begin Root Cause/Intensive analysis to examine process changes that may prevent future events • Take preventing measures for future near miss.
  • 62. PEER REVIEW Monitor and improve physician care of patients Accomplish by: •Open, non-punitive discussion •Review and discuss alternatives •Disseminate to ALL physicians •Monthly review schedule Move towards: review previous 48 hour record (Code Blue) •Could this event have been prevented? •Were signs of deterioration missed? Elevated BP, dropping BP Elevated HR, dropping HR Elevated RR
  • 63. HEALTH EXECUTIVE’S ROLE  Set Culture Accountability Measures High Reliability/Redesign Communication and Teamwork Professional Development  Reliability principles:  simplification  standardization  relation of humans to the work  environment
  • 64. BARRIERS TO IMPLEMENTATION SOURCE: INTERNATE
  • 65. PRATICE OF PATIENT SAFETY ( WHO ) 1. Be aware of Look-Alike, Sound-Alike Medication Names. 2. Proper Patient Identification. 3. Explain in Detail During Patient Hand/Take- Overs. 4. Performance of Correct Procedure at Correct Body Site. 5. Careful About Electrolyte Imbalance. 6. Assuring Proper Treatment During Shifting. 7. Avoid Catheter and Tubing, Wrong Connections . 8. Single Use of Injection Syringes. 9. Improved Hand Hygiene to Prevent Health Care- Associated Infections . 10. Proper Disposal of BMW and Good House Keeping. 11 Practice Surgical Safety Guide Lines.
  • 66. TIPS FOR IMPROVING PATIENT SAFETY 1. Constitution of Patient Safety Committee. 2. Develop clear policies and protocols for patient safety. 3. Discuss regularly patient safety initiative within hospital staff. 4. Orientation, Re-orientation hospital staff on patient safety 5. Encourage transparency in the regular death review. 6. Non- punitive incident reporting by staff. 7. Each department to devise their own patient safety protocols. 8. Investigate each accident/ incident reported and take remedial measures. 9. Review, monitor & evaluate. safety procedures regularly.
  • 67. hospiad Hospital Administration Made Easy http//hospiad.blogspot.com An effort solely to help students and aspirants in their attempt to become a successful Hospital Administrator. DR. N. C. DAS

Editor's Notes

  1. At present – no one player or country has the expertise – let alone funding and research capabilities to tackle the full range of patient safety issues. The Alliance aims to bring together the knowledge and resources that have been developed from patient safety work form around the world in the last decade. Alliance – big ideas, committed collaborative network of learners – expanding and progressing each year. Highlight main components of the Alliance. When it started just 3 yrs ago – there were six main planks – now 10. Solutions High 5s Technology Knowledge Management Special projects Reporting and Learning ICPS Research Patients for Patient Safety Global Patient Safety challenges
  2. 03/15/12 NNLM Individual {Gibson}
  3. 03/15/12 NNLM Representative {Frankel} - More and more hospitals are including patient representatives on committees, boards and even rounds.
  4. 03/15/12 NNLM National {Gibson} – Being aware of legislation, being on listservs, participating in groups such as Consumers Advancing Patient Safety - www.patientsafety.org Josie King Foundation - josieking.org Medically Induced Trauma Support Services - mitss.org Pulse America - pulseamerica.org
  5. 03/15/12 NNLM Advocate {NPSF} – going with patient to doctor/ hospital, being willing to speak up.