This document outlines patient safety in healthcare facilities. It defines key terms like patient safety, psychological safety, and safety culture. It discusses the roles of the patient safety committee and the components of a patient safety plan. Specific patient safety issues in the intensive care unit are examined, like collaboration among ICU staff and common errors. International patient safety goals are provided, such as accurately identifying patients and reducing healthcare-associated infections. Root cause analysis is introduced as a way to investigate incidents and prevent future errors.
Patient safety is the absence of preventable harm to a patient during the process of health care and reduction of risk of unnecessary harm associated with health.
patient safety and staff Management system ppt.pptxanjalatchi
Patient Safety is a health care discipline that emerged with the evolving complexity in health care systems and the resulting rise of patient harm in health care facilities. It aims to prevent and reduce risks, errors and harm that occur to patients during provision of health care.
In the presentation, a summary of initiatives to be taken by hospitals in different areas for patient safety have been described for the knowledge, practices and implementation of patient safety initiative by hospital managers/Administrators.
Patient safety is the absence of preventable harm to a patient during the process of health care and reduction of risk of unnecessary harm associated with health.
patient safety and staff Management system ppt.pptxanjalatchi
Patient Safety is a health care discipline that emerged with the evolving complexity in health care systems and the resulting rise of patient harm in health care facilities. It aims to prevent and reduce risks, errors and harm that occur to patients during provision of health care.
In the presentation, a summary of initiatives to be taken by hospitals in different areas for patient safety have been described for the knowledge, practices and implementation of patient safety initiative by hospital managers/Administrators.
patient safety and staff Management system ppt.pptxanjalatchi
What is Patient Safety? Patient Safety is a health care discipline that emerged with the evolving complexity in health care systems and the resulting rise of patient harm in health care facilities. It aims to prevent and reduce risks, errors and harm that occur to patients during provision of health care.
International Patient Safety Goals (IPSG) help accredited organizations address specific areas of concern in some of the most problematic areas of patient safety.
International-Patient-Safety-GoalsGoal 1: Identify patients correctly
Goal 2: Improve effective communication
Goal 3: Improve the safety of high-alert medications
Goal 4: Ensure safe surgery
Goal 5: Reduce the risk of health care-associated infections
Goal 6: Reduce the risk of patient harm resulting from falls
This presentation has the measures to be taken for the safety of patients. It covers the 6 goals
Goal 1: Identify patients correctly
Goal 2: Improve effective communication
Goal 3: Improve the safety of high-alert medications
Goal 4: Ensure safe surgery
Goal 5: Reduce the risk of health care-associated infections
Goal 6: Reduce the risk of patient harm resulting from falls
Medical errors are ubiquitous and the costs (human and financial) are substantial. The top priority must be to redesign systems geared to prevent, detect and minimise effects of undesirable combinations of design, performance, and circumstance.
Current Situation of Medical ErrorsPrepared byAsOllieShoresna
Current Situation of Medical Errors
Prepared by Asma Alshammari Alhanoof Alaniz Teflah Ali Mai Alrweeli Munyfaa Aldhafeeri Norah Almoteri
Introduction
Health care processes are increasingly being implicated in causing harm to patients. Medical errors and adverse events are primarily responsible for this harm. These errors, which may occur at every level of the custom are both common and diverse in nature.
Medical errors can occur anywhere in the health care system in hospitals, clinics, surgery centers, doctors' offices, nursing homes, pharmacies, and patients' homes and can have serious consequences. Errors can involve medicines, surgery, diagnosis, equipment, or lab reports.
Medical errors represent a serious public health problem and pose a threat to patient safety. As health care institutions establish “error” as a clinical and research priority, the answer to perhaps the most fundamental question remains elusive: What is a medical error? To reduce medical error, accurate measurements of its incidence, based on clear and consistent definitions, are essential prerequisites for effective action.
Despite a growing body of literature and research on error in medicine, few studies have defined or measured “medical error” directly. Instead, researchers have adopted surrogate measures of error that largely depend on adverse patient outcomes or injury (i.e., are outcome-dependent).
A lack of standardized nomenclature and the use of multiple and overlapping definitions of medical error have hindered data synthesis, analysis, collaborative work and evaluation of the impact of changes in health care delivery.
Medical error is defined as “failure of a planned action to be completed as intended or use of a wrong plan to achieve an aim”. A medical error is a threat to patient safety and has a negative effect on health as well.
Definition of Medical Error
Medical error the term “error” has been variously defined. The Oxford Dictionary of Current English (1998) defines it as “mistake” or the condition of being morally “wrong”. Error has also been defined in a wider context as the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim (Reason, 1990). Although the definition of “error” has its origins in behavioral psychology, the term is appropriate for medical usage. Using Reason's definition, IOM has tried to separate medical error into two parts (Kohn et al., 2000): the first half of the definition constitutes “error of execution” and the latter half, “error of planning.” In this context, two other related terms, “adverse event” and “patient safety.” Bates et al. (1997) defined adverse events as injuries that result from medical management, rather than from the underlying disease. Patient safety, as defined by IOM, is freedom from accidental injury (Kohn et al., 2000). All three terms, “medical error,” “adverse event,” and “patient safety” complement one another.
Type ...
Delirium Care Pathway MoDelirium Care Pathway Model Design: STOP DELIRIUMdel ...komalicarol
We present a delirium care pathway model that we have dubbed
STOP DELIRIUM. Due to delirium's magnitude and effect in elderly hospitalized patients, we recommend hospitals must have
a delirium care pathway for early identification, prevention, and
delirium management. The protocol STOP DELIRIUM is driven
from evidence-based guidelines to help establish the aim "STOP"
for Spot, Think, Optimize and Prevent delirium. The clinical
pathway model needs to incorporate a clinical information management system and educational materials to increase delirium
awareness. The implementation should be scalable and adaptable
to incorporate other departments.
2. Outlines
1-Objective. ž
2-Introduction. ž
ž 3-Definition of patient safety. ž
ž 4-Psychological safety. ž
ž 5-Safety culture. ž
ž 6-Patient safety committee. ž
ž 7-Patient safety plan. ž
ž 8-Leadership related standards on patient safety. ž
ž 9-Patient safety in Intensive Care Unit ž
-ICU Team Collaboration ž
- Barriers to Team Collaboration ž
ž -Causes of un safe ICU ž
ž -Error in ICU ž
ž 10-Patient safety goals ž
11-Root cause analysis ž
ž 12-Reference ž
3. Objectives
ž
ž
Define patient safety.
Understand Psychological safety.
Define culture of safety.
Identify patient safety committee
Explain patient safety plan
Understand leadership related standards on
patient safety
Discuss patient safety in ICU.
List international patient safety goals.
Identify Root Cause Analysis.
4. Introduction
Medical errors have become a leading causes of death, killing more people
each year than AIDS or Airplane crashes.
These medical errors can be classified into five categories:
1- Poor communication.
2- Poor decision making.
3- Poor patient monitoring.
4- Poor patient identification.
5- Poor patient tracking.
Definition of patient Safety
Freedom from accidental injury, ensuring the establishment of operational
systems and processes that minimize the likelihood of errors so they won’t
occur.
ž
Psychological safety :
Psychological safety is a belief that one will not be punished or humiliated
for speaking up with ideas, questions, concerns, or mistakes.
A shared sense of psychological safety is a critical input to an effective
learning system.
5. Safety culture:
An atmosphere of mutual trust in which all staff Members can talk freely
about safety problems and how to solve it ---without fear of blame or
punishment.
Creating a safety culture :
1- Support teamwork and respect others.
2- Educate staff.
3- Engage physicians.
4-Share lessons learned.
5- Encourage use of communicating.
6- Assign 1 (one) or 2 (two) clinical staff members.
7-Take a proactive approach to error.
8-Study and learn from near misses.
9- Search for information about how to do things safely.
10-Provide team training to a culture of safety.
11- Encourage patient and family involvement in the care process.
12- Share information about safety with others.
What Gets in the Way of Optimal Care ?
1- Not knowing the plan.
2- Communication issues.
3- Surprises.
4- Missing information.
5- Lack of resources.
6- Failure to plan, recognize and rescue others.
ž Patient safety committee
ž
A patient safety committee is a multidisciplinary team that takes a proactive
approach to patient safety; It provides coordination and oversight to
advance an organizations safety program and implement safety-related
policies and procedures.
6. What is a patient safety committee do?
ž
The patient safety committee coordinates the following:
1- Risk management.
2- Environmental safety.
3- Infection control.
4- Quality improvement.
Patient safety plan:
1- Should standardize the definitions and categorize medical errors.
2- Establish or enhance an error, near miss reporting mechanism.
3-Identify data collection plan, reporting structure, as well as performing
scheduling.
Leadership related standards on patient safety :
The leadership is to build an environment that recognizes the importance of
safety.
Leadership focus :
1- Create & maintain a culture of safety.
2- Encourage decision making.
3- Implement patient safety program throughout the organization.
4- Ensure that the processes are designed well, using available information
from internal or external sources about potential risks to patient and successful
practices.
Patient safety in Intensive Care Unit:
Patient safety in the ICU and collaboration among ICU care
providers are interconnected.
Poor collaboration leads to increased errors and increased risk of bad
outcomes for ICU patients.
7. ICU team
Doctors
Nurses
Respiratory
therapists
Barriers to Team Collaboration
Clinical
pharmac
y
Poor communication
Poor decision making.
Shared knowledge and skills of care providers influence the care given,
decision making, problem solving, conflict management, and
coordination.
causes of an unsafe ICU:
Problems with the organization and structure of the unit .
Problems with the process of care used.
Poor communication between physician and nurse.
Error in intensive care:
Medication errors.
Inappropriate disconnection of lines, catheters and drains.
Equipment failure.
Loss, obstruction or leakage of artificial airway.
Inappropriate turning-off of alarms.
The presence of organ failure.
Higher intensity in level of care and time of exposure all related.
Other
Social worker
Dietitians
8. Take Action to Reduce Risk :
Reactive:
Investigate significant patient incidents (sentinel events).
Proactive:
Monitor patient safety and redesign high-risk processes to prevent a
sentinel event from occurring.
Example of sentinel event:
An inpatient received 2 (two) unit of the incorrect type of blood at the time.
The patient’s blood was drawn for a type/cross match; the sample was
mislabeled with another patient's name. The transfusion was given to the
patient whose name appeared on the type/cross match lab report, not the
patient whose blood was in the lab specimen vial.
International Patient Safety Goals
Goal (1) identify patients correctly.
Goal (2) improve effective Communication.
Goal (3) improve the safety of high-alert medications.
Goal (4) ensure correct-site, correct-procedure, correct-patient
surgery.
Goal (5) reduce the risk of health care–associated infections.
Goal (6) reduce the risk of patient harm resulting from falls.
9. ž
Goal 1
Identify patients correctly
Use at least two patient identifiers when
providing Care, treatment, and services.
when administering medications, blood, or blood
components;
when collecting blood samples and other specimens for
clinical testing;
When providing treatments or procedures. The patient's room number or
physical location is not used as an identifier.
Label containers used for blood and other specimens in the presence of the
patient.
Eliminate transfusion errors related to patient misidentification.
Before initiating a blood or blood component transfusion:
- Match the blood or blood component to the order.
- Match the patient to the blood or blood component.
- Use a two-person verification process or a one-person verification process
accompanied by automated identification technology, such
As bar coding.
Misidentification lead to:
Wrong medication.
Wrong procedure.
Wrong operation.
Late giving medication.
Cancelled operation
10. Report critical results of tests and diagnostic procedures on a timely
basis.
Verbal order should be in emergency situation only and should be
written as soon as possible.
Before a procedure, label medicines that are not labeled. For
example, medicines in syringes, cups and basins. Do this in the area
where medicines and supplies are set up.
Reduce the patient harm associated with the use of anticoagulant
therapy.
Maintain and communicate accurate patient medication information.
High alert medication
Insulin.
Narcotic drugs.
Coagulant drugs.
Potassium chloride.
Sodium chloride >0.9%
Remove concentrated electrolytes(including, but not limited to,
potassium chloride, potassium phosphate, Nacl >0.9%) from
patient care units
Standardize and limit the number of drug concentrations available
in the organization
Goal 2
Improve the effectiveness of communication
among caregivers.
Goal 3
Improve the safety of using medications.
11. Official “Do Not Use” List
Do Not Use Potential Problem Use Instead
Write "unit"
“0” (zero), the number “4”
(four) or “cc”
U, u (unit)
Write
"International Unit"
IV (intravenous) or the
number 10 (ten)
IU (International
Unit)
Write "daily"
ž
Write "every
other day"
Mistaken for each other
Period after the Q mistaken
for "I" and the "O"
mistaken for "I
Q.D., QD, qd
(daily)
Q.O.D.,QOD,q.o.d,
qod (every other
day)
Write
"morphine
sulfate" Write
"magnesium
sulfate"
Can mean morphine
sulfate or magnesium
sulfate Confused for one
another
MS
MSO4 and
MgSO4
Goal 4
eliminate wrong-site, wrong-patient and
wrong-procedure surgery.
Wrong-site, wrong-procedure surgery can be prevented if appropriate
processes are in place:
-Effective communication.
- Mark the procedure site by physician.
-Preoperative checklist.
-Documentation.
- Time-out is performed before the procedure.
12. Goal 5
Reduce the risk of health care-associated
infections
Hand hygiene.
Prevent health care–associated infections due to multidrug-resistant
organisms in critical access hospitals.
This requirement applies to, but is not limited to,
epidemiologically important organisms such as methicillin
resistant staphylococcus aureus (MRSA), clostridium difficile
(CDI), vancomycin-resistant enterococci (VRE), and
multidrug-resistant gram-negative bacteria.
Prevent central line–associated bloodstream infections.
Central venous catheters and peripherally inserted central
catheter (PICC) lines.
13. Preventing surgical site
infections.
Prevent indwelling catheter-associated urinary tract infections
(CAUTI).
Goal 6
Reduce the risk of patient harm resulting from
falls.
Risk assessment
Periodic reassessment of individual patients
Assessment of environment of care.
Assessment Yes No Comments
Assess for injury including range of movement, pain,
bruises, lacerations, etc.
Assess vital signs and mental /neurological status
Assess degree of injury: SCORE LOCATION
0 = none
1 = minor injury ( bruises, abrasions, minor)
( Laceration which require no suturing )
2 = major injury ( fractures, head trauma,
( laceration requiring sutures
3 = death: a sentinel event which
Requires immediate review and reporting
14. Goal 7
Prevent health care-associated pressure ulcers
ž
(decubitus ulcers).
ž
ž
ž
ž
ž Assess and periodically reassess each resident’s risk for developing a
pressure ulcer and take action to address any identified risks.
ž
Goal 8
The organization identifies safety risks inherent
in its patient population.
Identify patients at risk for suicide.
Identify risks associated with home oxygen therapy, such as
home fires.
Root Cause Analysis :
Reviewing the process:
What happen?
How did it happen?
Why did it happen?
What can we do differently?
15. References
-Rothschild JM, Landrigan CP, Cronin JW, et al. The Critical Care Safety
Study: the incidence and nature of adverse events and serious medical
errors in intensive care.
Critical Care Med. 2005;33(8):1694-1700.
-Alberts WM. The importance of health-care teams [president’s report].
2006;1:11.
-The Joint Commission. Accreditation Program: Hospital—National
Patient Safety
Goals. http://www.jointcommission.org.
-Thomas EJ, Sexton JB, Helmreich RL. Discrepant attitudes about
teamwork among critical care nurses and physicians. Crit Care Med.
2003;31(3):956-959.
-American Association of Critical-Care Nurses. AACN standards for
establishing and sustaining health work environments: a journey
to excellence. Aliso Viejo, CA: AACN; 2005.
http://www.aacn.org/aacn/pubpolcy.nsf
/Files/HWEStandards/$file/HWEStandards .pdf. Accessed January 30,
2009.
