Patient Safety Incidents Guidelines 2021 Revision
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Questions and Answers

Which of the following indicators is NOT part of the Severity Assessment Code (SAC)?

  • PSI closure rate
  • SAC 1 reported within 24-hour rate
  • PSI closure rate within 60 working days
  • PSI impact score (correct)

    • What step in the management of PSIs involves taking immediate measures after identifying an incident?

  • Immediate action taken (correct)
  • Prioritisations
  • Notification
  • Investigation

    • How is progress with the implementation of the National PSI guideline measured?

  • Using direct patient feedback
  • By analyzing compliance reports generated from the web-based information system (correct)
  • Based on external inspections
  • Through patient safety audits

    • What does a high level of reporting of PSIs indicate regarding patient safety culture?

    <p>It indicates a good reporting culture.</p> Signup and view all the answers

    Which of the following is NOT a step in the management of PSIs?

    <p>Training</p> Signup and view all the answers

    What does PSI stand for in the context of patient safety reporting?

    <p>Patient Safety Incidents</p> Signup and view all the answers

    Which of the following is NOT a component of the Minimum Information Model (MIM) for PSI reporting?

    <p>Patient demographics</p> Signup and view all the answers

    In reporting PSIs, what type of incidents are included?

    <p>Harmful incidents, near misses, and no harm incidents</p> Signup and view all the answers

    What aspect of incidents is addressed in the 'resulting actions' of PSI reporting?

    <p>Immediate or indirect actions to improve situations</p> Signup and view all the answers

    Which organization provided technical assistance for the development of guidelines related to patient safety?

    <p>WHO (World Health Organization)</p> Signup and view all the answers

    What is the primary objective of the guideline regarding Patient Safety Incidents (PSIs)?

    <p>To create a framework for managing PSIs</p> Signup and view all the answers

    Which of the following is NOT part of the legal and policy framework mentioned?

    <p>Health Insurance Reform Act</p> Signup and view all the answers

    Which of the following statements correctly represents the definition of a PSI?

    <p>An unplanned or unintended event that could harm patients</p> Signup and view all the answers

    What is a key element that all health facilities must adopt according to the Regulations?

    <p>Openness about failures</p> Signup and view all the answers

    The guideline suggests that statistical data on PSIs should be used for what purpose?

    <p>Planning and decision making</p> Signup and view all the answers

    Which category of personnel is NOT explicitly included in the scope of the guideline?

    <p>Private healthcare practitioners</p> Signup and view all the answers

    What should be the approach towards failures according to the mandatory requirements?

    <p>Emphasis on learning</p> Signup and view all the answers

    What is the aim of ensuring appropriate communication with patients?

    <p>To enhance the quality of care</p> Signup and view all the answers

    What prompted the revision of the guidelines in 2021?

    <p>Inadequate classification analysis and WHO's action plan</p> Signup and view all the answers

    What was identified as a primary issue in the management of PSIs?

    <p>High percentage of incidents classified as 'Other'</p> Signup and view all the answers

    Which aspect of the PSI guidelines was updated in Version 2?

    <p>The definition of a Patient Safety Incident</p> Signup and view all the answers

    What additional tool was introduced in Version 2 to assist staff?

    <p>A decision tree for identifying PSIs</p> Signup and view all the answers

    What does the purpose of the guideline include?

    <p>Directing public health sector management of PSIs</p> Signup and view all the answers

    What was one of the revisions made to improve reporting forms?

    <p>Rearranged for a logical flow</p> Signup and view all the answers

    Which of the following is NOT a contributing factor addressed in the revision?

    <p>Staff training programs</p> Signup and view all the answers

    Which action is part of the purpose of the guideline related to patient feedback?

    <p>To provide guidance on appropriate feedback</p> Signup and view all the answers

    What defines a patient safety incident (PSI)?

    <p>An event that occurs during the delivery of care.</p> Signup and view all the answers

    When should an event not be reported as a PSI?

    <p>When the event does not reach the patient.</p> Signup and view all the answers

    If an event occurs while the patient is in the care of health facilities, what is the first question to consider?

    <p>Is the event due to the natural progression of the disease?</p> Signup and view all the answers

    What is the implication if an event occurs while the patient was receiving care and they are harmed?

    <p>It should be reported as a patient safety incident.</p> Signup and view all the answers

    What is the result of an event that is deemed a near miss?

    <p>It should not be reported unless harm occurs.</p> Signup and view all the answers

    Which of the following situations would automatically be reported as a PSI?

    <p>An adverse event while in care.</p> Signup and view all the answers

    What should be the course of action if an event occurs and the patient is unharmed?

    <p>Assess the situation before reporting.</p> Signup and view all the answers

    Which of the following would NOT classify as a PSI when evaluating the event outcome?

    <p>Event caused by the condition's natural progression.</p> Signup and view all the answers

    Study Notes

    PSI Guideline Revision

    • The Office of Health Standards Compliance (OHSC) revised their guideline on patient safety incidents (PSIs) in 2021.
    • The revision was prompted by the 2020/21 National Annual PSI report, which included an analysis of two years of data on the National PSI Reporting and Learning System (RLS).
    • The report highlighted a need for additional classification for the reported incidents, as well as the lack of proper incident classification by staff. The 'Other' category for the type of PSI represented 25% of the incident reports.
    • The revision was also motivated by WHO's Global Patient Safety Action Plan 2021-2030, which introduced advanced indicators for patient safety that countries must report.

    Changes in Version 2

    • The revision included updates to various classifications in the PSI reporting system, such as the type of PSI, contributing factors, outcome, and Severity Assessment Code (SAC).
    • Version 2 included a revised definition of a PSI, a decision tree to guide staff in identifying PSIs, and a redesigned reporting form including updated classifications and prompts to guide staff.
    • The guideline also implemented an algorithm based on "Just Culture" principles to guide staff in assessing individual acts of staff.

    Guideline's Purpose and Objectives

    • The guideline provides direction to South Africa's public health sector on managing PSI reporting.
    • It guides the provision of feedback to patients, families, and clinicians.
    • Aims to share learned lessons to prevent reoccurrence of patient harm.
    • Provides a framework for implementing a PSI RLS.
    • Assists facilities in complying with norms and standards regulations applicable to health establishments.
    • Aims to prevent and reduce patient harm during medical care.
    • Standardizes definitions, classifications, methodologies for reporting, investigating, and responding to PSIs.
    • Ensures access to statistical data on PSIs for planning and decision-making.
    • Uses reported PSI data for preventing reoccurrence and implementing preventative measures.
    • Continuously improves the quality of care.
    • Ensures appropriate communication with patients.
    • The guideline is aligned with several legal and policy documents, including:
      • National Health Act no 61 of 2003
      • National Health Amendment Act 12 of 2013
      • Ethical rules for health practitioners
      • National Patients’ Rights Charter
      • Health Professions Amendment Act 29 of 2007
      • Births and Deaths Registration Act 51 of 1992
      • Inquest Act (as amended)
      • Mental Health Care Act 17 of 2002
      • Medicines and Related Substances Act, 1965 (Act 101 of 1965) as amended
      • Regulations relating to blood and blood products (no.179)

    Scope of the Guideline

    • Applicable to all public health establishments in South Africa, covering both clinical and non-clinical staff.
    • Defines roles and responsibilities, mandated reporting requirements, timeframes, and processes for aggregating, analyzing, learning, and taking action on reported incidents at the facility, district, provincial, and national levels.

    Mandatory Requirements

    • All health facilities are mandated to have a system in place for managing PSIs based on the following principles:
      • Confidentiality
      • Timeliness
      • Just culture
      • Openness about failures
      • Responsiveness
      • Emphasis on learning

    PSI Definition

    • A PSI is any unplanned or unintended event that could have resulted in harm to a patient while in the care of a health facility, but that was not caused by the patient's underlying health condition or natural progression of disease.
    • A decision tree is included in the guideline to guide staff in identifying a PSI.

    Reporting a PSI

    • The WHO Minimum Information Model (MIM) is used for PSI reporting.
    • Classifications for reported PSI information include:
      • Incident identification (patient details, time, location)
      • Contributing factors
      • Incident type
      • Incident outcomes (patient & organization)
      • Resulting actions
      • Reporter
      • Free text summary of the PSI and findings or recommendations

    Severity Assessment Code (SAC)

    • The SAC is a crucial aspect of the PSI reporting system.
    • Three key indicators based on SAC:
      • PSI closure rate
      • SAC 1 reported within 24-hour rate
      • PSI closure rate within 60 working days

    Managing PSIs

    • Nine steps are outlined for managing PSIs:
      • Identifying PSIs
      • Taking immediate action
      • Prioritizing PSIs
      • Notifying relevant stakeholders
      • Investigating PSIs
      • Classifying PSIs
      • Analyzing data on PSIs
      • Implementing recommendations based on analysis
      • Learning from the process

    Progress Made Since Implementation in 2018

    • A compliance report is generated from the web-based information system.
    • The compliance report is used as a proxy measure for progress made with implementing the national PSI guideline.

    Key Considerations

    • The guideline emphasizes the importance of a good reporting culture even if it leads to high levels of reported PSIs.
    • The guideline is available online at www.idealhealthfacility.co.za and https://www.knowledgehub.org.za.
    • The OHSC has a key role in supporting the implementation of the national PSI and its impact on improving patient safety in South Africa.

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    Related Documents

    National Guideline for Patient Safety Incident Reporting and Learning PDF

    Description

    This quiz examines the revisions made to the patient safety incidents (PSIs) guidelines by the Office of Health Standards Compliance in 2021. It covers the motivations behind the changes, analysis from the National Annual PSI report, and updates to classifications within the PSI reporting system. Test your knowledge of these crucial updates in patient safety management.

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