Dear Colleagues,
I would like to share this Topic (RISK MANAGEMENT) with you..
I have presented in one of the Khartoum congresses few years ago.
It may be of value for some of you mainly those taking their second part exam or those providing save women health services
The document describes creating a just culture of safety in healthcare. It discusses influences on advancing safety culture including professional accountability and a just culture approach. A just culture emphasizes quality and safety over blame, promotes error reporting to uncover root causes, and uses coaching rather than punishment for unintentional errors. Examples of errors are provided to distinguish intentional reckless behavior from mistakes. The document also summarizes Massachusetts General Hospital's approach to developing a just culture including robust safety reporting, data analysis, and leadership involvement.
1) Clinical risk management (CRM) aims to improve healthcare quality and safety by identifying and preventing circumstances that put patients at risk of harm.
2) Risk management involves risk identification, analysis, treatment, and control to minimize chances of errors and learn from past issues.
3) All healthcare staff have responsibilities for risk management including reporting incidents, identifying risks, and practicing risk prevention in their daily work.
This document provides an overview of patient safety initiatives and issues in hospitals. It discusses that 10% of hospital patients suffer adverse events, with medical errors causing around 100,000 deaths per year in the US. Common types of errors include overdoses and performing procedures on the wrong patient. The document then outlines the Patient Safety Friendly Hospital Initiative, which develops standards to assess patient safety in hospitals and has piloted the approach in 7 countries. It describes the five domains used to measure hospital performance on patient safety and provides examples of critical and core standards. The document concludes by offering recommendations on how hospitals can develop their own patient safety programs.
This document summarizes an article about medical malpractice in India. It discusses 25 problems patients face in hospitals and aims to find solutions to reduce malpractice. Medical malpractice occurs when a medical professional's treatment departs from the standard of care and harms a patient. Some common types of malpractice discussed include misdiagnosis, failure to diagnose, unnecessary treatment, and prescribing unnecessary tests or drugs. The document outlines the elements required for a medical malpractice claim under Indian law, including that a duty was owed, the duty was breached, the breach caused injury, and damages resulted. It also discusses provisions in the Indian Penal Code and Consumer Protection Act relevant to medical malpractice cases.
1. The document discusses various methods that have been used to track and reduce medical errors, including chart reviews, self-reporting, and direct observation. Errors are often caused by systemic issues rather than individual mistakes.
2. A systems approach aims to identify error sources within healthcare systems and implement solutions like checklists, improved teamwork, and computerized physician order entry.
3. An individual approach provides education to improve cognitive skills and decision-making and reduce biases. Integrating systems solutions and cognitive training shows promise but requires more research.
The document discusses medical errors and their relationship to negligence and malpractice litigation. Some key points:
- Medical errors are estimated to cause between 44,000-98,000 deaths per year in the US, making it a leading cause of death. However, other studies estimate a lower number of around 5,000 deaths due to errors.
- Only a small percentage (around 1-2%) of medical errors result in negligent injuries. Of those negligent injuries, only 10-13% result in malpractice claims.
- Common reasons for malpractice litigation include needing money, believing there was a cover up, or wanting information or revenge. However, the system rarely identifies or holds providers accountable for substandard care
The document discusses several topics related to medical malpractice including:
- Medical error is estimated to occur at a rate equivalent to 3 jumbo jet crashes per day.
- Common reasons patients sue doctors include diagnostic errors, surgical errors, and improper medical treatment. The doctors most often sued are surgeons, anesthesiologists, and obstetricians.
- While a negligent doctor has a 3 in 100 chance of being sued, a non-negligent doctor has only a 13 in 10,000 chance - suggesting most malpractice claims are not frivolous.
- Medical malpractice is defined as when a doctor fails to act as a reasonable physician would under the circumstances. Proving malpractice
The document describes creating a just culture of safety in healthcare. It discusses influences on advancing safety culture including professional accountability and a just culture approach. A just culture emphasizes quality and safety over blame, promotes error reporting to uncover root causes, and uses coaching rather than punishment for unintentional errors. Examples of errors are provided to distinguish intentional reckless behavior from mistakes. The document also summarizes Massachusetts General Hospital's approach to developing a just culture including robust safety reporting, data analysis, and leadership involvement.
1) Clinical risk management (CRM) aims to improve healthcare quality and safety by identifying and preventing circumstances that put patients at risk of harm.
2) Risk management involves risk identification, analysis, treatment, and control to minimize chances of errors and learn from past issues.
3) All healthcare staff have responsibilities for risk management including reporting incidents, identifying risks, and practicing risk prevention in their daily work.
This document provides an overview of patient safety initiatives and issues in hospitals. It discusses that 10% of hospital patients suffer adverse events, with medical errors causing around 100,000 deaths per year in the US. Common types of errors include overdoses and performing procedures on the wrong patient. The document then outlines the Patient Safety Friendly Hospital Initiative, which develops standards to assess patient safety in hospitals and has piloted the approach in 7 countries. It describes the five domains used to measure hospital performance on patient safety and provides examples of critical and core standards. The document concludes by offering recommendations on how hospitals can develop their own patient safety programs.
This document summarizes an article about medical malpractice in India. It discusses 25 problems patients face in hospitals and aims to find solutions to reduce malpractice. Medical malpractice occurs when a medical professional's treatment departs from the standard of care and harms a patient. Some common types of malpractice discussed include misdiagnosis, failure to diagnose, unnecessary treatment, and prescribing unnecessary tests or drugs. The document outlines the elements required for a medical malpractice claim under Indian law, including that a duty was owed, the duty was breached, the breach caused injury, and damages resulted. It also discusses provisions in the Indian Penal Code and Consumer Protection Act relevant to medical malpractice cases.
1. The document discusses various methods that have been used to track and reduce medical errors, including chart reviews, self-reporting, and direct observation. Errors are often caused by systemic issues rather than individual mistakes.
2. A systems approach aims to identify error sources within healthcare systems and implement solutions like checklists, improved teamwork, and computerized physician order entry.
3. An individual approach provides education to improve cognitive skills and decision-making and reduce biases. Integrating systems solutions and cognitive training shows promise but requires more research.
The document discusses medical errors and their relationship to negligence and malpractice litigation. Some key points:
- Medical errors are estimated to cause between 44,000-98,000 deaths per year in the US, making it a leading cause of death. However, other studies estimate a lower number of around 5,000 deaths due to errors.
- Only a small percentage (around 1-2%) of medical errors result in negligent injuries. Of those negligent injuries, only 10-13% result in malpractice claims.
- Common reasons for malpractice litigation include needing money, believing there was a cover up, or wanting information or revenge. However, the system rarely identifies or holds providers accountable for substandard care
The document discusses several topics related to medical malpractice including:
- Medical error is estimated to occur at a rate equivalent to 3 jumbo jet crashes per day.
- Common reasons patients sue doctors include diagnostic errors, surgical errors, and improper medical treatment. The doctors most often sued are surgeons, anesthesiologists, and obstetricians.
- While a negligent doctor has a 3 in 100 chance of being sued, a non-negligent doctor has only a 13 in 10,000 chance - suggesting most malpractice claims are not frivolous.
- Medical malpractice is defined as when a doctor fails to act as a reasonable physician would under the circumstances. Proving malpractice
This document discusses the costs of medical errors and efforts to reduce preventable hospital-acquired conditions (HACs). It notes that medical errors may cause up to 98,000 deaths per year costing up to $29 billion annually. Hospitals have little incentive to improve safety due to externalizing most error costs. In response, policies began denying Medicare/Medicaid payments for treatments from certain HACs considered preventable. This policy was expanded in 2012/2015 and may reduce payments to hospitals with the highest rates of HACs. The goal is to incentivize greater patient safety.
A pivotal trademark of evolution is the ability to adapt to the environment for survival. The health care industry, as a living system, is not immune to the effects of an ever-changing environment. Present environmental concerns affecting health care organizations include government policy, advances in technology, the need for stable finances, and patient/public perceptions of health care quality. Any one or all of these conditions could thwart the continued existence of a health care facility. A primary approach to adapting to the environment for health organizations is in the adoption of electronic health records. The benefits of electronic records could also pose risk to viability, due to the potential for fraud, theft, and abuse of data by both external and internal forces. Despite these risks, the benefits of electronic health systems, if used properly, can contribute to financial stability, employee retention, quality patient care, and patient satisfaction. As the environment continues to change, so will the demands upon the health care industry, ensuring continuous change in methods, as true and total development (apotheosis) can never be achieved.
It's National Nurses week . Acute care nurses and other healthcare staff are at high risk of injuries, particularly musculoskeletal disorders, due to intense physical demands of manually lifting and moving patients. In this white paper We discuss effective patient mobilization programs and more.
The Economic Burden of Asbestos-Related Cancers in Canada Uyen Vu
What would be the saving to society if we did not have any new cases of cancer attributable to occupational asbestos exposures in a particular year? That is the key question behind an economic burden study by the Institute for Work & Health, with support of the Canadian Cancer Society.
This document discusses medical errors and increasing patient safety. It summarizes several studies that found medical errors are common, with rates of adverse events from around 3-17% of hospital admissions. Errors result in tens of thousands of unnecessary deaths annually. Most errors are due to cognitive mistakes and "system" failures rather than individual negligence. To improve safety, the document argues we must think of errors as systems failures and implement strategies like checklists, standardized procedures, training, and a culture where safety is a top priority and errors are reported to fix underlying issues rather than blame individuals.
- The document discusses a proposed research study to examine the impact of nurse staffing levels on patient safety and mortality. The hypothesis is that regulating the number of patients each nurse cares for will decrease patient mortality and errors.
- The study would take place over 3 years in 300 randomly selected hospitals, comparing patient outcomes when nurse staffing is increased vs normal staffing levels.
- It is expected that better patient outcomes will result from lighter nurse workloads, allowing them to focus more carefully on each patient's health status. Results would be published in nursing journals to contribute to the evidence around optimal nurse staffing.
This document discusses medical error and strategies to reduce it. It notes that error is common in healthcare due to complex processes and lack of standardization. Reporting and analyzing errors can help identify systemic issues, but error reporting is currently underdeveloped. Information systems could help by providing decision support and monitoring for errors, but must be carefully designed to avoid introducing new latent errors. Overall, reducing medical error requires a systematic approach across organizations to improve safety culture, implement decision aids, and continuously learn from reported errors and close calls.
The document summarizes key aspects of the physician market in the United States, including market structure, conduct, and performance. It notes that the US has a higher proportion of specialists compared to other countries, which may contribute to higher healthcare costs. Physician practices are increasingly moving to group models, which tend to be more productive and benefit from economies of scale. Managed care places pressures on physicians to control costs and modify behavior.
This document discusses issues around civil and criminal negligence in private medical practice in India. It notes that the doctor-patient relationship has changed significantly with increasing commercialization, consumer awareness, and the ability to file negligence cases more easily. Approximately 10,000-15,000 medical negligence cases are currently pending in various Indian courts. Proper documentation, communication, awareness of errors, and building strong processes can help doctors address complaints and reduce negligence.
Defensive medicine effect on costs, quality, and access to healthcareAlexander Decker
This document discusses the practice of defensive medicine and its effects. Defensive medicine occurs when doctors order unnecessary tests or procedures in an attempt to reduce malpractice liability. The document finds that defensive medicine increases healthcare costs and can lower quality by leading doctors to avoid high-risk patients or procedures. It also discusses how defensive medicine practices like unnecessary referrals and extra diagnostic tests can limit access to care. The document examines factors that contribute to defensive medicine and its negative impacts on healthcare systems.
Burnout is a serious issue that affects many in the medical field, especially nurses. It is characterized by emotional exhaustion, low energy, and frustration. It stems from heavy workloads, understaffing, financial burdens, and inconsistent changes within the profession. Burnout leads to poorer patient outcomes and satisfaction as well as increased medical errors. It also negatively impacts nurses' performance, decision-making, and relationships. If left unaddressed, burnout can result in many medical professionals leaving the field, exacerbating staffing shortages and declining care quality within healthcare systems. Strategies such as improved management, workload distribution, and support for staff well-being are needed to combat the effects of burnout.
The highest risk areas for workplace violence are the emergency department, psychiatric wards, and waiting rooms. 70% of incidents go unreported, and women are over 8 times more likely to be victims. Hospitals should implement security measures like metal detectors, restrict access, and train staff in de-escalation techniques to help prevent and manage violent situations. An ounce of prevention is worth a pound of cure.
an insight on medical negligence and certain techniques that can be adopted to ensure that such errors or mistakes can be avoided. Deliberately or not we must always ensure that proper healthcare is provided and received.
Medical errors are common, resulting in thousands of unnecessary deaths each year in the US and other countries. Errors often stem from systemic issues rather than individual failings, such as complex systems, lack of training and oversight. To improve patient safety, healthcare systems must focus on system design and policies that reduce complexity, automate processes, and establish a culture of reporting and learning from errors without blame.
This document discusses ethical and policy factors related to care coordination. It addresses how government policies like the Affordable Care Act and HIPAA affect care coordination and can create ethical dilemmas. The American Nurses Association has developed a code of ethics to guide nursing practices related to care coordination and emphasizes patient-centered care and collaborative leadership. Social determinants of health like socioeconomic status, education, and environment influence individuals' health outcomes.
This document discusses how Johns Hopkins Home Care Group (JHHCG) has built a culture of safety over 10 years. Key aspects of their culture include transparency, trust, empowering staff to report issues without fear of punishment, collaboration, learning from mistakes, and involving patients. JHHCG uses tools like checklists, safety rounds, training, and collaborating with hospital staff to continuously improve safety. Their focus on specialization, communication, and educating providers has strengthened relationships and avoided errors.
Population health management real time state-of-health analysispscisolutions
To lower health costs, physician networks and medical homes must employ a closed loop population management program that focus on patient SOH stratification, chronic disease management, care coordination and incentive management. This approach will enable them to consistently reduce ER and inpatient admissions, which are the greatest expenditures in health care today.
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.
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.
Objectives:
1.Introduce the Measuring and Monitoring of Safety Framework to a Canadian healthcare audience
2.Describe how the framework would work in Canada
This document discusses the costs of medical errors and efforts to reduce preventable hospital-acquired conditions (HACs). It notes that medical errors may cause up to 98,000 deaths per year costing up to $29 billion annually. Hospitals have little incentive to improve safety due to externalizing most error costs. In response, policies began denying Medicare/Medicaid payments for treatments from certain HACs considered preventable. This policy was expanded in 2012/2015 and may reduce payments to hospitals with the highest rates of HACs. The goal is to incentivize greater patient safety.
A pivotal trademark of evolution is the ability to adapt to the environment for survival. The health care industry, as a living system, is not immune to the effects of an ever-changing environment. Present environmental concerns affecting health care organizations include government policy, advances in technology, the need for stable finances, and patient/public perceptions of health care quality. Any one or all of these conditions could thwart the continued existence of a health care facility. A primary approach to adapting to the environment for health organizations is in the adoption of electronic health records. The benefits of electronic records could also pose risk to viability, due to the potential for fraud, theft, and abuse of data by both external and internal forces. Despite these risks, the benefits of electronic health systems, if used properly, can contribute to financial stability, employee retention, quality patient care, and patient satisfaction. As the environment continues to change, so will the demands upon the health care industry, ensuring continuous change in methods, as true and total development (apotheosis) can never be achieved.
It's National Nurses week . Acute care nurses and other healthcare staff are at high risk of injuries, particularly musculoskeletal disorders, due to intense physical demands of manually lifting and moving patients. In this white paper We discuss effective patient mobilization programs and more.
The Economic Burden of Asbestos-Related Cancers in Canada Uyen Vu
What would be the saving to society if we did not have any new cases of cancer attributable to occupational asbestos exposures in a particular year? That is the key question behind an economic burden study by the Institute for Work & Health, with support of the Canadian Cancer Society.
This document discusses medical errors and increasing patient safety. It summarizes several studies that found medical errors are common, with rates of adverse events from around 3-17% of hospital admissions. Errors result in tens of thousands of unnecessary deaths annually. Most errors are due to cognitive mistakes and "system" failures rather than individual negligence. To improve safety, the document argues we must think of errors as systems failures and implement strategies like checklists, standardized procedures, training, and a culture where safety is a top priority and errors are reported to fix underlying issues rather than blame individuals.
- The document discusses a proposed research study to examine the impact of nurse staffing levels on patient safety and mortality. The hypothesis is that regulating the number of patients each nurse cares for will decrease patient mortality and errors.
- The study would take place over 3 years in 300 randomly selected hospitals, comparing patient outcomes when nurse staffing is increased vs normal staffing levels.
- It is expected that better patient outcomes will result from lighter nurse workloads, allowing them to focus more carefully on each patient's health status. Results would be published in nursing journals to contribute to the evidence around optimal nurse staffing.
This document discusses medical error and strategies to reduce it. It notes that error is common in healthcare due to complex processes and lack of standardization. Reporting and analyzing errors can help identify systemic issues, but error reporting is currently underdeveloped. Information systems could help by providing decision support and monitoring for errors, but must be carefully designed to avoid introducing new latent errors. Overall, reducing medical error requires a systematic approach across organizations to improve safety culture, implement decision aids, and continuously learn from reported errors and close calls.
The document summarizes key aspects of the physician market in the United States, including market structure, conduct, and performance. It notes that the US has a higher proportion of specialists compared to other countries, which may contribute to higher healthcare costs. Physician practices are increasingly moving to group models, which tend to be more productive and benefit from economies of scale. Managed care places pressures on physicians to control costs and modify behavior.
This document discusses issues around civil and criminal negligence in private medical practice in India. It notes that the doctor-patient relationship has changed significantly with increasing commercialization, consumer awareness, and the ability to file negligence cases more easily. Approximately 10,000-15,000 medical negligence cases are currently pending in various Indian courts. Proper documentation, communication, awareness of errors, and building strong processes can help doctors address complaints and reduce negligence.
Defensive medicine effect on costs, quality, and access to healthcareAlexander Decker
This document discusses the practice of defensive medicine and its effects. Defensive medicine occurs when doctors order unnecessary tests or procedures in an attempt to reduce malpractice liability. The document finds that defensive medicine increases healthcare costs and can lower quality by leading doctors to avoid high-risk patients or procedures. It also discusses how defensive medicine practices like unnecessary referrals and extra diagnostic tests can limit access to care. The document examines factors that contribute to defensive medicine and its negative impacts on healthcare systems.
Burnout is a serious issue that affects many in the medical field, especially nurses. It is characterized by emotional exhaustion, low energy, and frustration. It stems from heavy workloads, understaffing, financial burdens, and inconsistent changes within the profession. Burnout leads to poorer patient outcomes and satisfaction as well as increased medical errors. It also negatively impacts nurses' performance, decision-making, and relationships. If left unaddressed, burnout can result in many medical professionals leaving the field, exacerbating staffing shortages and declining care quality within healthcare systems. Strategies such as improved management, workload distribution, and support for staff well-being are needed to combat the effects of burnout.
The highest risk areas for workplace violence are the emergency department, psychiatric wards, and waiting rooms. 70% of incidents go unreported, and women are over 8 times more likely to be victims. Hospitals should implement security measures like metal detectors, restrict access, and train staff in de-escalation techniques to help prevent and manage violent situations. An ounce of prevention is worth a pound of cure.
an insight on medical negligence and certain techniques that can be adopted to ensure that such errors or mistakes can be avoided. Deliberately or not we must always ensure that proper healthcare is provided and received.
Medical errors are common, resulting in thousands of unnecessary deaths each year in the US and other countries. Errors often stem from systemic issues rather than individual failings, such as complex systems, lack of training and oversight. To improve patient safety, healthcare systems must focus on system design and policies that reduce complexity, automate processes, and establish a culture of reporting and learning from errors without blame.
This document discusses ethical and policy factors related to care coordination. It addresses how government policies like the Affordable Care Act and HIPAA affect care coordination and can create ethical dilemmas. The American Nurses Association has developed a code of ethics to guide nursing practices related to care coordination and emphasizes patient-centered care and collaborative leadership. Social determinants of health like socioeconomic status, education, and environment influence individuals' health outcomes.
This document discusses how Johns Hopkins Home Care Group (JHHCG) has built a culture of safety over 10 years. Key aspects of their culture include transparency, trust, empowering staff to report issues without fear of punishment, collaboration, learning from mistakes, and involving patients. JHHCG uses tools like checklists, safety rounds, training, and collaborating with hospital staff to continuously improve safety. Their focus on specialization, communication, and educating providers has strengthened relationships and avoided errors.
Population health management real time state-of-health analysispscisolutions
To lower health costs, physician networks and medical homes must employ a closed loop population management program that focus on patient SOH stratification, chronic disease management, care coordination and incentive management. This approach will enable them to consistently reduce ER and inpatient admissions, which are the greatest expenditures in health care today.
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.
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.
Objectives:
1.Introduce the Measuring and Monitoring of Safety Framework to a Canadian healthcare audience
2.Describe how the framework would work in Canada
The document discusses patient safety and adverse events in hospitals. It notes that studies show between 3-17% of hospital patients experience adverse events, with an average of 10%. Many medical errors are due to systemic problems rather than individual negligence. About half of adverse events can be prevented. Common adverse events include medication errors, wrong-site surgery, and falls. Reporting adverse events is important to learn from failures and improve the healthcare system. Factors like fatigue, understaffing, and poor systems can contribute to errors. An effective reporting system focuses on learning, has a wide scope, and recommends systems changes rather than punishing individuals.
Call for a standard framework for clinical risk management program to ensure ...Ruby Med Plus
Globally, the patient safety movement got focused in risk management by the publication of “To Err Is Human: Building a Safer Health System”, in 1999, which articulated the findings of a study of Institute of Medicine (IOM) of the devastating consequences of widespread medical error in the hospitals in USA. In addition to the unfortunate health consequences of medical error, there are direct and indirect costs borne by society as a whole. Patient Safety is the fundamental of the health care system. If care is not provided in a safe manner in a safe environment, the chances for a good outcome are lessened significantly.
As, Institute of Medicine (IOM) noted, “Patients should not be harmed by the care that is intended to help them, nor should harm come to those who work in health care.” The goal of risk management in health care must be to prevent harm from reaching patients and those involved in providing care to those patients and the place where the care is being provided . The aim of Clinical Risk Management is to improve both the safety and quality of care for patients and to reduce the costs of such risks for health care providers ” Hence, the Clinical Risk Management program needs a standard framework to fulfill this objective of Clinical Risk Management in clinical Dentistry. It gives the realization to the Dentist / Dental Team that fallibility is part of the human condition and human condition can’t be changed, but the conditions under which people work can be changed. That explains the need of Clinical Risk Management in Dentistry.
Risk Management and Patient Safety Evolution and Progress. Charles Vincent. Match Safety critical component of quality (Madrid, Ministry of Health and Consumer Affairs, 2005)
The document discusses medical errors and patient safety. It notes that medical errors result in tens of thousands of deaths each year in the US, costing billions of dollars. Underreporting of errors is a problem due to fear of punishment and a "sweep it under the rug" attitude. National organizations are working to improve safety through initiatives to reduce infections, falls, and other hospital events. Reporting of errors and "near misses" can help analyze root causes and improve systems to prevent future occurrences.
This document discusses patient safety and the role of nurses in ensuring patient safety. It makes three key points:
1) Patient safety is an essential part of nursing care according to regulatory bodies, but healthcare carries risks of adverse events due to the large number of available diagnoses, procedures, and medications. A patient has a much higher chance of experiencing a safety incident in the hospital than being killed in a plane crash.
2) Studies show that higher levels of registered nurses on staff are associated with fewer patient complications and lower mortality. Less experienced nurses and those with higher workloads also tend to make more medication errors and have more wound infections.
3) To improve safety, reports recommend increasing nurse staffing levels, making
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.
The document discusses the National Safety and Health Services Standard (NSHSS) in Australia, which aims to ensure consistent and high-quality healthcare across the country. It focuses on the Comprehensive Care Standard, particularly preventing falls and injuries from falls. This standard requires healthcare organizations to develop comprehensive care plans, deliver comprehensive care, and minimize patient harm through evidence-based policies and protocols to assess fall risk and provide safety equipment, education, and post-fall management. The case study examines applying this standard to care for an elderly patient at risk of falls and fall-related injuries.
Patient safety Incident (PSI) is an unplanned or unintended event or circumstance that could have resulted or did result in harm to a patient while in the care of a health facility. In this presentation, I explored the concepts of patient safety and patient safety incidents. I also explored the concept of Reporting systems, properly now known as reporting and learning systems - because learning is paramount in the reporting system. I focused on the minimal information model, which is more routinely used compared to the intermediate and full information models.
This document discusses effective risk management in healthcare. It defines risk and risk management, and outlines the key steps in risk management: identifying hazards, deciding who may be harmed, evaluating risks, recording findings, and reviewing assessments. Various types of risks are also categorized, including patient care risks, medical staff risks, employee risks, property risks, organizational risks, and financial risks. The document emphasizes that risk management requires an integrated, coordinated approach and accountability from leadership to encourage recognition and reduction of risks through a focus on processes and systems improvement and organizational learning.
This document discusses patient safety and clinical risk management. It defines patient safety as preventing harms, errors, and risks during healthcare provision. It also defines clinical risk management as improving quality and safety by identifying risks to patients. The document outlines principles of patient safety like proper patient identification. It also discusses common safety issues like medication errors and healthcare-associated infections. It describes technologies like barcoding and electronic health records that can enhance safety. Finally, it discusses the risk management process of identifying, assessing, and controlling risks in healthcare.
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.
The document provides facts about patient safety. Some key points:
- 20-40% of health spending is wasted due to poor quality care.
- 98,000 Americans die each year from preventable medical errors.
- Hospital errors are the 5th-8th leading cause of death in the US.
- There is a 1 in 300 chance a patient will be harmed during healthcare.
This document discusses patient safety in healthcare. It defines patient safety as aiming to prevent harm during healthcare provision. Key aspects of patient safety include accurate patient identification, effective communication among caregivers, safe medication use, clinical alarm safety, and infection prevention. National patient safety goals focus on these areas as well as fall and pressure injury prevention. Nursing plays a critical role in patient surveillance and care coordination to reduce adverse outcomes.
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.
The document discusses sharps associated infections (SAIs) among emergency department healthcare workers (EDHCWs). It finds that EDHCWs face high risk of SAIs due to the large volumes of high-risk patients and invasive procedures in the ED. Compliance with universal precautions among EDHCWs is poor. The document recommends a three-pronged approach of education, enforcement of safety policies, and engineering controls like safety devices to help prevent SAIs among EDHCWs.
Nephrology Nursing Journal September-October 2014 Vol. 41, No. 5 447
Patient Safety and Patient Safety
Culture: Foundations of Excellent
Health Care Delivery
Primum non nocere. First do no harm.
Patient safety forms the founda-tion of healthcare delivery justas biological, physiological,and safety needs form the
foundation of Maslow’s hierarchy
(Maslow, 1954). Little else can be
accomplished if the patient does not
feel safe or is, in fact, not safe. But the
healthcare system is extremely com-
plex, and ensuring patient safety
requires the ongoing, focused efforts
of every member of the healthcare
team.
Patient safety moved to the fore-
front in health care with the release in
1999 of the Institute of Medicine (IOM)
landmark report, To Err is Human:
Building a Safer Health System, which
estimated that annually in the United
States, up to one million people were
injured and 98,000 died as a result of
medical errors (IOM, 2000). The re -
port caught the attention of the media,
and there were headlines across the
nation about the safety (or lack of safe-
ty) for patients in healthcare organiza-
tions. In 2013, James updated the esti-
mate of patient harms associated with
Beth Ulrich
Tamara Kear
Continuing Nursing
Education
Beth Ulrich, EdD, RN, FACHE, FAAN, is
Editor, the Nephrology Nursing Journal, and a
Professor, the University of Texas Health Science
Center at Houston School of Nursing. She is a Past
President of ANNA and a member of ANNA’s
Sand Dollar Chapter. She may be contacted direct-
ly via email at [email protected]
Tamara Kear, PhD, RN, CNS, CNN, is an
Assistant Professor of Nursing, Villanova
University, Villanova, PA, and a Nephrology
Nurse, Liberty Dialysis. She is on the Editorial
Board for the Nephrology Nursing Journal,
serves as the ANNA Research Committee chairper-
son, and is a member of ANNA’s Keystone Chapter.
Statements of Disclosure: Please refer to page
457.
Note: Additional statements of disclosure and
instructions for CNE evaluation can be found on
page 457.
This offering for 1.4 contact hours is provided by the American Nephrology Nurses’
Association (ANNA).
American Nephrology Nurses’ Association is accredited as a provider of continuing nursing
education by the American Nurses Credentialing Center Commission on Accreditation.
ANNA is a provider approved by the California Board of Registered Nursing, provider number
CEP 00910.
This CNE article meets the Nephrology Nursing Certification Commission’s (NNCC’s) continu-
ing nursing education requirements for certification and recertification.
Copyright 2014 American Nephrology Nurses’ Association
Ulrich, B., & Kear, T. (2014). Patient safety and patient safety culture: Foundations of ex -
cellent health care delivery. Nephrology Nursing Journal, 41(5), 447-456, 505.
In 1999, patient safety moved to the forefront of health care based upon astonishing sta-
tistics and a landmark report released by the Institute of Medicine (IOM). This report,
To Err.
1. Risk Management Awareness Raising Dr.Ahmed Eltigani Elmahdi Hussain Consultant Obstetrician&Gynaecologist Cavan General Hospital, IRELAND
2.
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4. Risk Managent – Definitions …The culture, processes and structures that are directed towards the effective management of potential opportunities and adverse events Source: AS/NZS 4360 :1999 R M Standard …The process wherebye an organisation anticipates the potential for injuries or losses and acts to avoid those injuries before and/or to ameliorate them after they occur Source: R M in Health Care – Dr. G. Roberts
5. Risk Management - Process …The systemic appllication of management policies, procedures and practices to the task of establishing the context, identifying, analysing, evaluating, treating, monitoring and communicating risk Source: AS/NZS 4360 : 1999 R M tandard
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17. Clinical care The environment of care Financial resources CLINICAL GOVERNANCE ORGANISATIONAL CONTROLS FINANCIAL CONTROLS Health & Safety Human Resources Integrated Care Due Diligence Risk Strategy Quality Reviews Risk Reviews Clinical Audit Practice Developments Claims Management Education & training Performance Management Re-engineering of Systems Service Continuity Planning Healthcare Risk Management
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19. Establish Context Identify Risks Analyse Risks Treat Risks MON I TOR Evaluate Risks The Context – The Risk Management Process AS/NZS 4360:1999 Risk Management Standard COMMUNI CATE
20. Stop it Accident Incident Investigation Task Person Discipline them Past Approach: Person centred investigations Situation ??????
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22. Defence Barriers J. Reason 1994 Case Analysis Using Reason’s Statistical failures in defences Organisational Accident Causation Model
23. J. Reason 1994 Case Analysis Using Reason’s Organisational Accident Causation Model Statistical failures in defences Situation Task Errors Violations Corporate Culture Management decisions and organisational processes Local climate Error- producing conditions Violation- producing conditions Defence Barriers Latent failures in defences
24. Focus on process not individual “ People and perfect processes make a quality health service. Poor quality results from a badly designed and operated process, not from lazy or incompetent health care workers” Source: John Øvretviet, 1992 Health Service Quality
25. And Risk Management involves….. (AS/NZS 4360 and HSA “Workplace Health & Safety Management” ) IMPLEMENT MONITOR & REVIEW PLAN POLICY
31. Identifying Hazards and Risks “ Comprehensive identification using a well-structured systematic process is critical” It is important to identify both things that have happened (retrospective identification) and those that might (prospective identification)
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33. Assessing Risks “ To avoid subjective bias, the best available information sources and techniques should be used when analysing consequences and likelihood .”
36. Rating the Severity * Based on national comparisons In accordance with AS/NZS 4360:1999 Risk Management Standard Category Severity Quality & Prof. Guidelines Finance & Info . Fear, disempowerment & conflict of interest Safety (staff, patients/clients & NEHB population) Reputation/ Community Expectation (& Equity) Legal Requirements (and Equality) Low Minor non-compliance < €5K Minor loss of info. Minor cuts/ bruises Within unit Local press < 1 day coverage Minor out-of- court settlement. Minor legislative breach, no consequences Minor Single failure to meet internal standards or follow protocol € 5K - €25K Claim below excess Verbal representation from minority groups. Concerns expressed by staff in 1 area/Dept . Cuts/ bruises < 3 days absence < 3 days extended hospital stay Emotional distress Regulator concern Local press < 7 day of coverage Civil action Improvement Direction. Moderate Repeated failures to meet internal standards or follow protocols € 25K - €1M Loss of or unauthorised access to confidential information Sustained campaign by minority group(s). Consistent indication of fear/concern across 1 or more sites Single system injury e.g. fracture, > 3 days absence, 3-8 days extended hospital stay HSA reportable Semi-permanent physical/emotional trauma Regional/ National media < 3 day coverage Department notification/ executive action Class action – no defence Criminal prosecution Improvement Notice Severe Failure to meet national norms*/stds. Repeated failure to meet professional std. € 1M - €5M Loss or corruption of key clinical information Judicial review finds conflict of interest. Collapse of management relations across Hosp. Group. Increased sickness absence/resignations >9 days extended hospital stay Fatality Permanent physical/emotional disability/trauma National media > 3 day of coverage Questions in the D áil . Independent external enquiry Criminal prosecution - no defence. Executive officer fined or imprisoned. Prohibition Notice . Catastrophic Gross failure to meet professional standards > €5M Multiple Fatalities Multiple permanent physical/emotional injuries/trauma Full Public Enquiry Prohibition Notice Widespread culture of bullying.
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38. Risk Rating Matrix Catastrophic Severe Moderate Minor Low 5 4 3 2 1 Rare 10 8 6 4 2 Unlikely 15 12 9 6 3 Possible 20 16 12 8 4 Likely 25 20 15 10 5 Almost Certain Likelihood Severity
39. Recording the Outcome of the Assessment (The Risk Register) Having completed the assessment of risk, the outcome is entered onto a risk register. The risk register then becomes a summary of all known hazards/risks and is used to decide priorities for actions to control hazards/risks and to monitor the progress of those actions.
44. Making it Happen “ The responsibility, authority and the inter-relationship of personnel who perform and verify work affecting risk management shall be defined and documented”
45. A Plan not a Strategy? IMPLEMENT MONITOR PLAN POLICY Local Risk Assessments Feedback on risks Prioritise resources/responses Training Actions Responsibility Results of risk assessments Incident Reporting Claims Complaints Audits/Inspections Sickness Absence
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47. C0NCLUSION Blame culture “ We don’t make mistakes” culture “ So what” culture Silo or “tribal” culture “ not my business” culture Support don’t blame We all make mistakes Feedback & meaning Team culture It is everyone’s business
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Editor's Notes
The nuclear and aircraft industries were the first to develop formal methods for risk management in the 1950’s. Following the Flixborough disaster the chemical industry adopted these formal methods and developed further techniques (for example, HAZOP). The oil and gas industry began to take risk management seriously after Piper Alpha, and the Transport sector following the Clapham Junction crash and Kings Cross fire. The push for the Finance Sector came from Barings Bank. It is interesting to note that the Paddington crashes occurred after they had apparently put all of the necessary safety systems in place. Reviews of those crashes agree that all the right systems were in place, but that the culture in the organisations was wrong.
In 1991 a famous study was conducted in the US (known as the “Harvard Study”) where a large number of patient records, and corresponding outcomes, were reviewed retrospectively. The reviewers were asked to identify where there was clear evidence that patients had been harmed by their care while in hospital and where this had led to significant detriment to the outcome. The results were shocking, and led to further studies and then action supported directly by the then US President. These included the establishment of national systems (e.g. Sentinel Event Reporting) to reduce the levels of such occurrences. The US study was repeated in the UK and the levels of medical error were, unsurprisingly, found to be similar. A further study in Australia has found similar evidence. The Australian studies were undertaken in 1995 and 1999 and showed a much higher rate – 16.6%. The UK study was in 2000 and showed a 10.8% rate (comparable with the 4% and 16.6% and thus coming in about the middle). A 2000 study in New Zealand came out at 10.7% No such study has yet been conducted in Ireland but it would be remarkable if the levels of error here were much better then those in the U.S., Australia and the UK. What was regarded as one of the most shocking statistics in all of these studies was the number of avoidable deaths that occur. In the UK study it was estimated nationally to be 40,000 each year making it one of the most common causes of death! It should be noted that the researchers are now extremely wary of extrapolation, giving various reasons why you can’t extrapolate. Medical staff in particular may ask questions about the research and the definitions etc. However, this is irrelevant as the extrapolations are now widely reported (including in the press) and the health service has a job on its hands both internally in terms of reducing error and externally in terms of PR!!