Patient safety in Healthcare; Developing Patient Safety Culture by reporting ...VENODEN DHARMARAJAN
A guide and stimulant for the Medical Professionals on Patient Safety.
Patient safety is defined as the prevention and reduction of adverse outcomes (Alahmadi,2009). Learning from the mistake is the key to improve patient safety.
12.9% of admissions to public hospital in New Zealand is associated with a hospital adverse event.
10% of such admissions in UK
7.5% of such admissions in Canada
2.5 billion of Euros are spent yearly for compensation due to mistakes in hospitals in Italy
Active failure
It is related to errors of procedures or treatment at the site of the action
Latent failure
It is related to design failure, building failure and regulatory and procedure failures.
Active errors
occur at the level of the frontline operator
their effects are felt almost immediately
Latent errors
Not under the direct control of the operator
poor design, incorrect installation, faulty maintenance, bad management decisions, and poorly structured organizations
The safety culture of an organisation is the product of individual and group values, attitudes, perceptions, competencies and patterns of behaviour that determine the commitment to, and the style and proficiency of, an organisation’s health and safety management.”
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.
Simple and Safe Approaches Towards Patient SafetyEhi Iden
A conference presentation on simple approaches and steps in achieving and managing patient safety in health. It talks about team approach, mutual support, just system, leadership commitment, complications of blame game and case study of the popular Kimberly Hiatt story.
Patient safety in Healthcare; Developing Patient Safety Culture by reporting ...VENODEN DHARMARAJAN
A guide and stimulant for the Medical Professionals on Patient Safety.
Patient safety is defined as the prevention and reduction of adverse outcomes (Alahmadi,2009). Learning from the mistake is the key to improve patient safety.
12.9% of admissions to public hospital in New Zealand is associated with a hospital adverse event.
10% of such admissions in UK
7.5% of such admissions in Canada
2.5 billion of Euros are spent yearly for compensation due to mistakes in hospitals in Italy
Active failure
It is related to errors of procedures or treatment at the site of the action
Latent failure
It is related to design failure, building failure and regulatory and procedure failures.
Active errors
occur at the level of the frontline operator
their effects are felt almost immediately
Latent errors
Not under the direct control of the operator
poor design, incorrect installation, faulty maintenance, bad management decisions, and poorly structured organizations
The safety culture of an organisation is the product of individual and group values, attitudes, perceptions, competencies and patterns of behaviour that determine the commitment to, and the style and proficiency of, an organisation’s health and safety management.”
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.
Simple and Safe Approaches Towards Patient SafetyEhi Iden
A conference presentation on simple approaches and steps in achieving and managing patient safety in health. It talks about team approach, mutual support, just system, leadership commitment, complications of blame game and case study of the popular Kimberly Hiatt story.
An Orientation to quality and patient safety for new hire in health care faci...kiran
An introduction to quality and patient safety for new employees in health care with basic concepts on quality and patient safety that every new hire must know.
Risk Management Training Slides.
Slides prepared based on "The Healthcare Quality Handbook" by Janet A Brown. Very useful health care quality reference for CPHQ exam preparation. For more slides, contact ckmujeeb@hotmail.com
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.
Risk Management has been a valuable and essential subject in projects and financial businesses but it is new to health care management. This presentation will help you understanding basics of Risk Managment.
An Orientation to quality and patient safety for new hire in health care faci...kiran
An introduction to quality and patient safety for new employees in health care with basic concepts on quality and patient safety that every new hire must know.
Risk Management Training Slides.
Slides prepared based on "The Healthcare Quality Handbook" by Janet A Brown. Very useful health care quality reference for CPHQ exam preparation. For more slides, contact ckmujeeb@hotmail.com
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.
Risk Management has been a valuable and essential subject in projects and financial businesses but it is new to health care management. This presentation will help you understanding basics of Risk Managment.
Patient Safety and Professional Nursing Practice C.docxkarlhennesey
Patient Safety and
Professional
Nursing Practice
Chapter 8
Patient Safety
• Ensures that nursing practice is safe, effective,
efficient, equitable, timely, and patient-centered
(ANA)
• Minimization of risk of harm to patients and
providers through both system effectiveness and
individual performance (QSEN & NOF)
To Err is Human: Building a Safer
Health System (IOM, 2000)
• At least 44,000 and possibly up to 98,000
people die each year as the result of
preventable harm
• Cause of the errors is defective system
processes that either lead people to make
mistakes or fail to stop them from making a
mistake, not the recklessness of individual
providers
Error
• Error is the failure of a planned action to be
completed as intended, or the use of a wrong
plan to achieve an aim with the goal of
preventing, recognizing, and mitigating harm
• Common errors include drug events and
improper transfusions, surgical injuries and
wrong-site surgeries, suicides, restraint-related
injuries or death, falls, burns, pressure ulcers,
and mistaken patient identities (IOM, 2000)
Event Analysis
• Individual approach or system approach
– Culture of blame
– Culture of safety
– Just culture
• Root-cause analysis
• TERCAP
• Reason’s Adverse Event Trajectory
Classification of Error
• Type of error
– Communication
– Patient management
– Clinical performance
• Where the error occurs
– Latent failure and active failure
– Organizational system failures and system process
or technical failure
Human Factor Errors
• Skill-based
– Deviation in the pattern of a routine activity such
as an interruption
• Knowledge-based
• Rule-based
– Conscious decision by the nurse to “workaround”
or take a shortcut, so the system defense
mechanisms are bypassed, thereby increasing risk
of harm to patient
To Err is Human: Building A Safer
Health System (IOM, 2000) (1 of 2)
• User-centered designs with functions that make
it hard or impossible to do the wrong thing
• Avoidance of reliance on memory by
standardizing and simplifying procedures
• Attending to work safety by addressing work
hours, workloads, and staffing ratios
• Avoidance of reliance on vigilance by using
alarms and checklists
To Err is Human: Building A Safer
Health System (IOM, 2000) (2 of 2)
• Training programs for interprofessional teams
• Involving patients in their care; anticipation of
the unexpected during organizational changes
• Design for recovery from errors
• Improvement of access to accurate, timely
information such as the use of decision-making
tools at the point of care
Crossing the Quality Chasm: A New
Health System for the 21st Century
(IOM, 2000)
• STEEEP
– Safe
– Timely
– Effective
– Efficient
– Equitable
– Patient-centered
• 10 rules for redesign
– Rule #6: Safety is a
system property
Keeping Patients Safe: Transforming the
Work Environment of Nurses
(IOM, 2004) ...
Patient Safety and Professional Nursing Practice C.docxssuser562afc1
Patient Safety and
Professional
Nursing Practice
Chapter 8
Patient Safety
• Ensures that nursing practice is safe, effective,
efficient, equitable, timely, and patient-centered
(ANA)
• Minimization of risk of harm to patients and
providers through both system effectiveness and
individual performance (QSEN & NOF)
To Err is Human: Building a Safer
Health System (IOM, 2000)
• At least 44,000 and possibly up to 98,000
people die each year as the result of
preventable harm
• Cause of the errors is defective system
processes that either lead people to make
mistakes or fail to stop them from making a
mistake, not the recklessness of individual
providers
Error
• Error is the failure of a planned action to be
completed as intended, or the use of a wrong
plan to achieve an aim with the goal of
preventing, recognizing, and mitigating harm
• Common errors include drug events and
improper transfusions, surgical injuries and
wrong-site surgeries, suicides, restraint-related
injuries or death, falls, burns, pressure ulcers,
and mistaken patient identities (IOM, 2000)
Event Analysis
• Individual approach or system approach
– Culture of blame
– Culture of safety
– Just culture
• Root-cause analysis
• TERCAP
• Reason’s Adverse Event Trajectory
Classification of Error
• Type of error
– Communication
– Patient management
– Clinical performance
• Where the error occurs
– Latent failure and active failure
– Organizational system failures and system process
or technical failure
Human Factor Errors
• Skill-based
– Deviation in the pattern of a routine activity such
as an interruption
• Knowledge-based
• Rule-based
– Conscious decision by the nurse to “workaround”
or take a shortcut, so the system defense
mechanisms are bypassed, thereby increasing risk
of harm to patient
To Err is Human: Building A Safer
Health System (IOM, 2000) (1 of 2)
• User-centered designs with functions that make
it hard or impossible to do the wrong thing
• Avoidance of reliance on memory by
standardizing and simplifying procedures
• Attending to work safety by addressing work
hours, workloads, and staffing ratios
• Avoidance of reliance on vigilance by using
alarms and checklists
To Err is Human: Building A Safer
Health System (IOM, 2000) (2 of 2)
• Training programs for interprofessional teams
• Involving patients in their care; anticipation of
the unexpected during organizational changes
• Design for recovery from errors
• Improvement of access to accurate, timely
information such as the use of decision-making
tools at the point of care
Crossing the Quality Chasm: A New
Health System for the 21st Century
(IOM, 2000)
• STEEEP
– Safe
– Timely
– Effective
– Efficient
– Equitable
– Patient-centered
• 10 rules for redesign
– Rule #6: Safety is a
system property
Keeping Patients Safe: Transforming the
Work Environment of Nurses
(IOM, 2004).
Jeanette Ives Erickson: Influencing professional nursing practiceThe King's Fund
Jeanette Ives Erickson, Senior Vice President for Patient Care and Chief Nurse, Massachusetts General Hospital and Instructor, Harvard Medical School articulates the importance of a structure for clearly understanding fundamental standards that is accepted and embraced by both the public and health care professionals.
Chapter 7 Assuring Safety and Security in Healthcare Insti.docxmccormicknadine86
Chapter 7: Assuring Safety and
Security in Healthcare Institutions
Safety and Security – Risk?
• Health facilities that experience adverse
events due to safety or security issues can
incur penalties ranging from large fines to loss
of accreditation.
• An aggressive and well-organized safety and
security management program can help
minimize risk of and adverse event.
Regulation and Accreditation
• Medicare and Medicaid require a participating
healthcare organization to satisfy the
Conditions of Participation (CoP) relevant to
the management of safety and security.
– Accreditation by the Joint Commission, DNV
Healthcare Inc. or HFAP ensures that the facility
meets the CoP requirements
• State Departments of Health also regulate
safety and security in healthcare organizations
Safety vs. Security
• Safety can be a broad category with standard
policies and procedures throughout a facility or
system.
– Hand-washing policy
– Use of Personal protective gear
– Hazardous waste disposal
• Security must be more site specific.
• Safety and security policies sometimes conflict.
High Risk Events
• A facility may incur major penalties if a
“never” adverse event occurs (an event that
should not occur if appropriate safety/security
measures were in place)
• CMS may not reimburse costs of a never event
and many third party payers have a non-
reimbursement program as well.
Techniques for Managing
Safety and Security
• Risk Assessment Estimate
• Failure Modes and Effects Analysis (FMEA)
• Root-cause Analysis (RCA)
• Technological Redundancy
• Crew Resource Management
• Red Rules
Potential Environmental Hazards
• OSHA has a list of the types of hospital-wide
hazards and provides information on how to
prevent and respond to them
• Three categories of hazardous materials
– Biological
– Chemical
– Radioactive
Security: Unwanted Intruders
• Use of high-tech solutions to manage visitor
and employee access
– Automated turnstiles with card swipe readers for
employee entrances
– Visitor areas/desk where all visitors enter and
sign-in.
– Employee ID badges
– Secured areas
Potential Security Hazards
• Theft of Patient Valuables/Employee theft
• Infant abduction
• Workplace Violence
• Gangs
Patient Valuables
• Provide a safe in the building to house
valuables
• Provide receipts for any valuable stored by
facility
• Encourage patients to leave valuables at
home or give to family to take home
Violence in the Workplace
• Patients have a right to treatment but staff
have a legal right to a safe workplace
• Watch for signs that may lead to violence
(in patients, visitors and staff)
– Anger
– Stress
– Under the influence of drugs/alcohol
Gangs
• Many health facilities treat victims of gang
violence and occasionally the dispute
continues upon arrival at the facility.
• Use of metal detectors is increasing to prevent
entrance of weapons into the health facility
Information ...
Patient Safety
Presenter : Dr. Dipendra Bhusal
Moderator: Dr. Sunil Jwarchan
Department of General Surgery
Pokhara Academy of Health Sciences
Introduction
• Increased life expectancy >25years in
over last semicentennial.
The Nature Journal
Law of supply and demand applied to health
services.
• 2 big challenges in proving
safe and effective service,
• greater demand and larger options ,
• increasing complexity in healthcare
• "First, do no harm" is a fundamental healthcare principle prioritizing
patient safety.
• Global evidence indicates a significant burden of avoidable patient
harm across healthcare systems.
• Avoidable patient harm has major implications, including human,
moral, and ethical consequences.
• The prevalence of harm challenges established healthcare principles
and ethics.
• Financial implications accompany the human toll, affecting healthcare
systems globally.
• Defined as “the absence of preventable harm to a patient and
reduction of risk of unnecessary harm associated with health care to
an acceptable minimum”
• to prevent harm to patients,
caused by the process of
health care itself.
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
CURRENT ENVIRONMENT
• Errors and system failures repeated
• Action on known risk is very slow
• Detection systems in their infancy
• Many events not reported
• Understanding of causes limited
• Blame culture alive and well
• Defensiveness and secrecy
Prevalence of adverse health care event
• WHO estimates that, even in advanced hospital settings, one in ten
patients receiving healthcare will suffer preventable harm
• The report “To Err is Human: building a safer health system” by IOM
of the national academy of health system drew widespread attention
to the alarming statistics that there were between 44000 and 98000
preventable deaths , 7000 related to medication error only.
• If medical error was a disease then it would be 3rd leading cause of
death in USA after heart issues and cancer
Why ERROR?
• Usually not willful negligence, but systemic flaws,
-inadequate communication and wide spread process variation and
patient ignorance.
Patient safety incidents
• An Adverse event: An incident which results in harm to the patient.
• A near miss: An incident that could have resulted in unwanted
consequences but did not either by chance or through a timely
intervention preventing the event from reaching the patient.
• A no harm event: An incident that occurs and reaches the patient but
results in no injury to the patient. Harm is avoided by chance or due
to mitigating circumstances
Common causes of adverse health events
• Preventable Events
• Of these, inadequate communication ranks highest in frequency
Hey Sugar: An Ecstacy Appeal with Monster impactNilly Shams
Anecstacy Appeal of Sugar
The sweet danger of sugar
Attention deficit hyperactivity disorder
in children & adolescents
Cognitive Dysfunction
Obesity
Immunity
Asthma
Recommendations
Phosphorus and Hemodialysis: a Predator that can be Tamed.Nilly Shams
How to defeat hyperphosphatemia for hemodialysis patients without the risk of protein energy malnutrition: quality matters.
by dr Nilly Shams
Clinical Nutrition and Public Health Consultant
The Well Being of Breast Cancer Patient Can Nutrition Help? by Nilly ShamsNilly Shams
Good nutrition is important for cancer patients.
Understanding Malnutrition and Cancer, why should we care?
Anorexia and cachexia.
Nutrition and breast cancer management.
Diet and Lifestyle in Women with Breast Cancer: is their a link?
Breast cancer and diet/physical activity.
Dietary intake and breast cancer chemoprevention.
Special Diets for Breast Cancer, do they wok?
Support with nutrition for women receiving chemotherapy for breast cancer.
Can Nutrition Lower the Risk of Recurrence in Breast Cancer?
Nutrition Goals of prevention and treating cancer.
Side Effects of Cancer and Cancer Treatment, How to Deal with?
If it is that simple so why it does not work??
Take Home Messages.
Antibiotic Stewardship by Anushri Srivastava.pptxAnushriSrivastav
Stewardship is the act of taking good care of something.
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
WHO launched the Global Antimicrobial Resistance and Use Surveillance System (GLASS) in 2015 to fill knowledge gaps and inform strategies at all levels.
ACCORDING TO apic.org,
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
ACCORDING TO pewtrusts.org,
Antibiotic stewardship refers to efforts in doctors’ offices, hospitals, long term care facilities, and other health care settings to ensure that antibiotics are used only when necessary and appropriate
According to WHO,
Antimicrobial stewardship is a systematic approach to educate and support health care professionals to follow evidence-based guidelines for prescribing and administering antimicrobials
In 1996, John McGowan and Dale Gerding first applied the term antimicrobial stewardship, where they suggested a causal association between antimicrobial agent use and resistance. They also focused on the urgency of large-scale controlled trials of antimicrobial-use regulation employing sophisticated epidemiologic methods, molecular typing, and precise resistance mechanism analysis.
Antimicrobial Stewardship(AMS) refers to the optimal selection, dosing, and duration of antimicrobial treatment resulting in the best clinical outcome with minimal side effects to the patients and minimal impact on subsequent resistance.
According to the 2019 report, in the US, more than 2.8 million antibiotic-resistant infections occur each year, and more than 35000 people die. In addition to this, it also mentioned that 223,900 cases of Clostridoides difficile occurred in 2017, of which 12800 people died. The report did not include viruses or parasites
VISION
Being proactive
Supporting optimal animal and human health
Exploring ways to reduce overall use of antimicrobials
Using the drugs that prevent and treat disease by killing microscopic organisms in a responsible way
GOAL
to prevent the generation and spread of antimicrobial resistance (AMR). Doing so will preserve the effectiveness of these drugs in animals and humans for years to come.
being to preserve human and animal health and the effectiveness of antimicrobial medications.
to implement a multidisciplinary approach in assembling a stewardship team to include an infectious disease physician, a clinical pharmacist with infectious diseases training, infection preventionist, and a close collaboration with the staff in the clinical microbiology laboratory
to prevent antimicrobial overuse, misuse and abuse.
to minimize the developme
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Telehealth Psychology Building Trust with Clients.pptxThe Harvest Clinic
Telehealth psychology is a digital approach that offers psychological services and mental health care to clients remotely, using technologies like video conferencing, phone calls, text messaging, and mobile apps for communication.
India Clinical Trials Market: Industry Size and Growth Trends [2030] Analyzed...Kumar Satyam
According to TechSci Research report, "India Clinical Trials Market- By Region, Competition, Forecast & Opportunities, 2030F," the India Clinical Trials Market was valued at USD 2.05 billion in 2024 and is projected to grow at a compound annual growth rate (CAGR) of 8.64% through 2030. The market is driven by a variety of factors, making India an attractive destination for pharmaceutical companies and researchers. India's vast and diverse patient population, cost-effective operational environment, and a large pool of skilled medical professionals contribute significantly to the market's growth. Additionally, increasing government support in streamlining regulations and the growing prevalence of lifestyle diseases further propel the clinical trials market.
Growing Prevalence of Lifestyle Diseases
The rising incidence of lifestyle diseases such as diabetes, cardiovascular diseases, and cancer is a major trend driving the clinical trials market in India. These conditions necessitate the development and testing of new treatment methods, creating a robust demand for clinical trials. The increasing burden of these diseases highlights the need for innovative therapies and underscores the importance of India as a key player in global clinical research.
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1. Patient Safety
Dr. Nilly Shams
CPHQ, TQM, Public Health Specialist
President of the Egyptian Nutrition and Health Coaching
Association
Certified Health Coach, IIN. USA
2. MAP
• Patient safety guidelines.
• Some definitions related to patient safety.
• How to create the culture of patient safety?
• What are the national patient safety goals?
• Comprehensive patient safety program.
3. Patient safety guidelines
• AHRAQ : Agency for Healthcare
Research and Quality
• NQF: National Forum for Quality
Measurement and Reporting
• NHS: National health and Safety
• NPSA: National Patient Safety Agency
• WHO: World Health Organization
4. Did you hear about this study?
• The Institute of Medicine (IOM)
study “To Err is Human; Building a
Safer Healthcare System”
• Adverse events occur in 2.9 to 3.7%
of all hospitalizations
5. Medical errors
• At least 44,000 people, and perhaps as many as
98,000 people, die in hospitals each year as a
result of medical errors that
could have been prevented.
• Medical errors:
the failure of a planned action to be completed
as intended or the use of a wrong plan to
achieve an aim.
8. Why do we care?
• Errors…are costly in terms of loss
of trust in the health care system
by patients and diminished
satisfaction by both patients and
health professionals.
10. What is Patient Safety ?
• Freedom from injury or illness resulting from
the processes of care
National Forum for Quality Measurement and Reporting
• Safety is the avoidance and prevention of
patient injuries or adverse events resulting
from the processes of healthcare delivery
Agency for Healthcare Research and Quality
11. HOW of CARE
• Human beings make mistakes because the
systems, tasks and processes they work in are
poorly designed.”
Dr Lucian Leape, testifying to the US President’s Commission on
Consumer Protection and Quality in Health
12. Patient safety???
• First, do no harm – Safety is the most
basic dimension of performance necessary for
the improvement of healthcare quality.
13. Organizational culture
(how work gets done)
• It’s the habitual/behavior that
characterize the organization, reflects
the beliefs, attitudes and priorities of
its members, and influences the
effectiveness of performance.
• Culture of safety and quality exists when
ALL who work in the organization are
focused on excellent performance
(personal responsibility).
15. Just culture
• one that support the discussion of errors so
that lessons can be learned from them
• one in which frontline staff feel comfortable in
disclosing errors including their own while
maintaining professional accountability
AHRQ
20. The organization adopting safety culture
• Committed to ongoing learning & flexible to
accommodate changes
• Encourage team work
• Encourage & reward reporting
• Focus on system & process rather than individual
• Respect people working in the organization
regardless of their position.
• No blame culture
• Proactive
22. A scenario………….:
• Person low in hierarchy (unit coordinator)
• Something seems not quite right in preparation for a patient’s
procedure and the patient is first on a full schedule. Clarifying
requires calling the head nursing who was not available in the
theater . The coordinator stopped the process and said
“I need clarity”
• The case is delayed 45 minutes and it turns out that there is
no problem at all regarding the safety of the patient
What happens to her?
23. Safety cultured organizations ….
• She gets thanked by the physician.
• The manager thanks her and makes
sure the CEO, CNO, or CMO come by
later in the day to congratulate her.
• Her action becomes a story told in
the organization.
24. Not a Safety Culture organizations……..
• People whisper about her.
• She gets grief from the charge nurse in the
procedure area for messing up the entire
schedule.
• The physician demands that a unit
secretary cannot delay a case again.
• She says to colleagues: “Never doing that
again.”
26. International Patient Safety
Goals (IPSG)
• promote specific improvements in patient
safety
• Highlight problematic areas in healthcare
• Describe evidence- and expert-based
consensus solutions to these problems
29. National patient safety goals
• Identify patients
correctly
• Improve staff
communication
• Use medication safely
• Prevent infection
• Check patient
medicines
• Prevent patient from
falling
• Help patients to be
involved in their care
• Identify patient safety
risks
• Watch patient closely
• Prevent errors in
surgery
33. Comprehensive patient safety program
• Infrastructure
• Policies & procedure
• Education
• Occurrence/event reporting system
• Proactive activities
• Process for immediate response
34. Mention the steps that you will do to create
the safety culture in your organization ?
• Leadership commitments
• Communication among care givers
• Environment of Care ( safe design)
• Simple and standardized system
• Assigned roles and responsibilities
• Incident Reporting system
• Team work
35. Role of leaders in creating culture
• Commitment
• Taking actions by creating
structures, processes, and
programs that allow a culture
of safety and quality to
flourish
• Focus plan on improving
patient safety
• Provide accurate and usable
information related to safety
• Use data
• Education that focuses on
safety
• Team approach
• Openly discuss issues of
safety and quality.
• Include patients
• Creating and implementing
a process for managing
disruptive and
inappropriate behaviors.
A Safety Culture is one in which the senior leaders hear
bad news
38. Teach back/ Ask me 3:
• Self care on return
home
• How/who to contact
for help
• Medication uses and
doses
• What is my main
problem? (Diagnosis)
• What do I need to
do? (Treatment)
• Why is it important
for me to do this?
(Context)
41. Structure
Assigned roles and responsibilities
• Patient safety officers
• Patient safety committee
• Safety action teams
42. Role of a PSO
• Import new ideas and best practices and
oversees their local application.
• Teach, mentor, and reinforce good practices
within the organization.
• Considers and recommends organizational
policies to advance patient safety.
• Report to the CEO, COO, Chief Medical Officer
43.
44. Patient Safety Committee
• Is a comprehensive leadership-level action
committee that reviews all safety issues
across the organization through regular
meetings.
45. Safety Action Teams:
• These are small cross-functional groups of people
within units who meet periodically (perhaps
monthly) to discuss safety issues.
Role of safety Action Teams:
• Discuss information from the safety reporting system
• Identify solutions and corrective action planning .
• Provide direct feedback to senior leader about the
impact of their changes
46. Incident report review
Occurrence/event incident
reporting system
• One documentation
mechanism
• Early warning system
Circumstances examples:
• Death
• Medical incident requiring
emergency/intervention
• Unplanned admission
• Attempted suicide
• Injury requiring medical
treatment
• Medication error
47. Sentinel event review
• Event: occurrence that is either deemed to be or
result in a significant adverse event or sentinel event.
• Adverse event: unintended injury to a patient
resulting from a medical intervention.
• Near miss: any process variation that didn’t affect an
outcome but a recurrence carries a significant chance
of a serious adverse outcome.
• Sentinel event: unexpected occurrence involving
death or serious physical or psychological injury.
48. Sentinel event
100% analysis
0% acceptance
• Suicide within 72 hours of discharge
• Unanticipated death of full term
infant
• Abduction
• Discharge if an infant to wrong
family
• Rape
• Hemolytic transfusion
49. What should you do?
• Identify & respond
• RCA, action plan, improvement
50. RCA
• A systematic process to identify the most basic
or casual factors that underlies variation in the
process. An intensive, in depth analysis of a
problem event. Focus on system & process.
