Safety Event Management in Healthcare
110 Questions
0 Views

Safety Event Management in Healthcare

Created by
@ValiantElm

Podcast

Play an AI-generated podcast conversation about this lesson

Questions and Answers

What must a healthcare worker (HCW) do immediately after identifying a safety event?

  • Develop a clinical care plan
  • Notify their line manager (correct)
  • Document the event in the patient file
  • Notify the patient and their family

    • A safety event report can include the names of the patient and the staff involved.

    False

    What is required before engaging with the patient or their family after a safety event?

    Legal advice

    The HCW must complete the event report on the Safety Event Management System before the end of the __________.

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

    Match the following steps in the management of a safety event:

    <p>Notify line manager = Step 1 Complete event report = Step 2 Notify treating doctor = Step 1 Obtain legal advice = Step 1</p> Signup and view all the answers

    Which type of information is NOT required on the Safety Event Report?

    <p>Who is responsible for the event</p> Signup and view all the answers

    The patient's treating doctor does not need to be notified if no harm occurred from the safety event.

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

    Name one role of the PxM in the management of a safety event.

    <p>Provide feedback to the patient or their family</p> Signup and view all the answers

    What must happen within 5 working days of an event being reported?

    <p>A review of the event classification must occur.</p> Signup and view all the answers

    The ISBAR layout is used for reporting all safety events without exception.

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

    What should be done if agency staff members are involved in a safety event?

    <p>They must complete the electronic Safety Event Report.</p> Signup and view all the answers

    The level of __________ as selected by the reporter must be reviewed and changed to the most appropriate harm level.

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

    Match the following terms with their definitions:

    <p>ISBAR = Information, Situation, Background, Assessment, Recommendation PSM = Patient Safety Manager Safety Event Report = Document to report safety incidents Multi-Events = More than one individual impacted by harm</p> Signup and view all the answers

    Which of the following is a requirement if the event results in serious harm or death?

    <p>An initial ISBAR report must be completed by the PSM.</p> Signup and view all the answers

    Classification of multiple events requires identifying common causal factors.

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

    What is the purpose of reviewing the Type of Event selected by the reporter?

    <p>To determine the correct classification of the event.</p> Signup and view all the answers

    What must all reports include, even if submitted anonymously?

    <p>Patient’s information</p> Signup and view all the answers

    The After Action Review focuses on discussing the future actions to prevent harm.

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

    What are the two types of events that must document all questions in the After Action Review?

    <p>Serious harm or death events</p> Signup and view all the answers

    The Unit/Line Manager must conduct an Initial Review to ensure _____ and correctness.

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

    Match the step with its description:

    <p>Initial Review = Ensures completeness and correctness of the event report After Action Review = Reviews actions taken and identifies gaps and lessons learnt First Team Review = Determines the level of review and recommends improvements Legal Support = Provides guidance following incidents that cause harm</p> Signup and view all the answers

    What should the Unit/Line Manager do after reporting an event verbally?

    <p>Seek immediate legal support if there was harm</p> Signup and view all the answers

    The First Team Review can occur after the After Action Review.

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

    Which framework is used to identify contributing factors during investigations?

    <p>Yorkshire Contributing Factors Framework</p> Signup and view all the answers

    During the First Team Review, the Unit/Line Manager ensures that _____ principles are adhered to.

    <p>Just Culture</p> Signup and view all the answers

    What must be documented in the Safety Event Management System for a low harm event?

    <p>Questions ‘iv’ and ‘v’ need to be completed</p> Signup and view all the answers

    Investigations are required only for serious harm or death events.

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

    What is the primary purpose of conducting an After Action Review?

    <p>To identify gaps and lessons learnt</p> Signup and view all the answers

    An event that poses a risk of patient harm must be discussed with the _____ Department.

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

    Match the following actions with their corresponding terms:

    <p>Verbal report to Review Team = First Team Review Documentation in Safety Event System = After Action Review Seeking Legal advice = Legal Support Initial assessment for correctness = Initial Review</p> Signup and view all the answers

    What is primarily expected from the outcomes of analysis following a safety event?

    <p>Development of Continuous Improvement activities to enhance patient safety</p> Signup and view all the answers

    Which of the following best describes an 'almost harmed' situation in patient safety management?

    <p>A potential hazard is identified but no patient harm occurs</p> Signup and view all the answers

    What role does the Legal Department play in the management of safety events?

    <p>They advise on further management of incidents involving harm or potential harm</p> Signup and view all the answers

    Which of the following actions is required following safety events that result in serious harm or death?

    <p>Consultation with the Legal Department for management guidance</p> Signup and view all the answers

    What should be documented in the Safety Event Management System for low harm events?

    <p>Basic event reports without detailed analysis</p> Signup and view all the answers

    What best describes a Never Event?

    <p>An event that is largely preventable and can cause serious harm.</p> Signup and view all the answers

    Which of the following is NOT a part of the DMAIC process?

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

    What is the role of the Serious Event Management Team (SEMT)?

    <p>To manage safety events and assess their impact.</p> Signup and view all the answers

    In which scenario is an Adverse Event defined as having occurred?

    <p>An event that leads to unintended harm due to an act of commission or omission.</p> Signup and view all the answers

    Which best describes the concept of Psychological Safety in a team?

    <p>The ability to give and receive feedback without fear of negative consequences.</p> Signup and view all the answers

    What is the correct order of steps in the management of safety events?

    <p>Event identification, categorization, initial review, improvement actions</p> Signup and view all the answers

    Which category of safety event includes those that must be reported to a regulatory authority?

    <p>Serious Reportable Events (SRE)</p> Signup and view all the answers

    What characterizes a Near Miss event?

    <p>An event that did not reach the patient</p> Signup and view all the answers

    Which level of harm indicates that a patient can expect full recovery within a short duration?

    <p>Low Harm</p> Signup and view all the answers

    What is the primary focus during an After Action Review (AAR)?

    <p>Discussing corrective actions for future prevention</p> Signup and view all the answers

    What is the minimum requirement for reporting a safety event anonymously?

    <p>A description of the event and unit information</p> Signup and view all the answers

    Which question is NOT typically included in the After Action Review (AAR)?

    <p>What was the immediate response to the event?</p> Signup and view all the answers

    During the First Team Review, what must be evaluated for appropriateness?

    <p>Actions taken to prevent future harm</p> Signup and view all the answers

    What must happen if an event resulted in severe harm or death?

    <p>A Serious Event Management Team must be established</p> Signup and view all the answers

    Which aspect should be documented for No, Low, and Moderate harm events in the Safety Event Management System?

    <p>Contributing factors and actions to prevent future harm for serious events</p> Signup and view all the answers

    What must the PSM do within 5 working days after an event is reported?

    <p>Review and possibly adjust the classification of the event.</p> Signup and view all the answers

    Which of the following is NOT a responsibility of the Serious Event Management Team (SEMT)?

    <p>Conducting the initial reporting of events.</p> Signup and view all the answers

    What is the purpose of conducting a preliminary investigation by the PSM?

    <p>To gather facts and data about the incident.</p> Signup and view all the answers

    How should the event be classified if it is serious harm or results in death?

    <p>An ISBAR layout report must be completed before further investigation.</p> Signup and view all the answers

    What should the Unit Manager ensure regarding the actions determined from the event analysis?

    <p>That they are suitable and implemented by unit staff.</p> Signup and view all the answers

    What must occur following the completion of an event investigation in relation to the Final Review?

    <p>The Risk Assessment Scale must be completed and documented.</p> Signup and view all the answers

    Which report is considered the preferred format for documenting serious harm events?

    <p>Root Cause report.</p> Signup and view all the answers

    What is the responsibility of the Unit Manager concerning actions planned in response to a safety event?

    <p>To oversee that actions are completed by the unit's staff or relevant individuals.</p> Signup and view all the answers

    When should all safety events be loaded and managed to ensure reflection in Clinical Indicator Reports?

    <p>By the 7th of the following month.</p> Signup and view all the answers

    What action should be taken if the event involves agency staff members?

    <p>The agency's management should be notified.</p> Signup and view all the answers

    What key factor must be included in reports for serious events requiring system analysis?

    <p>Contributing factors outlined in the London Protocol.</p> Signup and view all the answers

    Who is responsible for ensuring that the alert distribution email groups are maintained?

    <p>An allocated individual, typically the PSM or HCM/NM.</p> Signup and view all the answers

    What is the timeline for reporting contributing factors after a safety event is reported?

    <p>5 working days from the event reported.</p> Signup and view all the answers

    What is the primary purpose of utilizing the SMART principles in addressing Safety Events?

    <p>To establish specific, measurable, achievable, realistic, and time-based actions.</p> Signup and view all the answers

    Which role is primarily responsible for driving improvement initiatives in a unit?

    <p>Unit Manager</p> Signup and view all the answers

    What is the correct sequence in the DMAIC continuous improvement methodology?

    <p>Define, Measure, Analyze, Improve, Control</p> Signup and view all the answers

    After a Never Event is reported, within how many hours must the event report be emailed to the Regional Clinical Manager?

    <p>48 hours</p> Signup and view all the answers

    Which maternal death category refers to deaths caused directly by a pregnancy complication?

    <p>Direct maternal death</p> Signup and view all the answers

    What type of neonatal event does NOT require reporting due to known complications?

    <p>A baby with a severe congenital anomaly</p> Signup and view all the answers

    Who is responsible for managing healthcare-associated infections within a unit?

    <p>Infection Prevent Control Manager</p> Signup and view all the answers

    What is the primary impact of immigration on a country's population?

    <p>It increases the population size.</p> Signup and view all the answers

    What historical period is associated with the beginning of significant population growth due to advancements in agriculture?

    <p>The Neolithic Revolution</p> Signup and view all the answers

    Which factor is considered in calculating the birth rate of a country?

    <p>Number of babies born per year per 1,000 people</p> Signup and view all the answers

    Which country has a noteworthy high birth and death rate mentioned?

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

    What could potentially lead to a high death rate in a population?

    <p>High number of elderly people</p> Signup and view all the answers

    What is a consequence of rapid population growth mentioned in the content?

    <p>Decrease in food security</p> Signup and view all the answers

    Which of the following best describes emigration?

    <p>Leaving a country to live elsewhere</p> Signup and view all the answers

    Which of the following statements is accurate regarding death rates globally?

    <p>The world average death rate is about 8.6 per 1000 people.</p> Signup and view all the answers

    What primarily influences rapid population growth in a country?

    <p>A high birth rate and low death rate</p> Signup and view all the answers

    How is the population growth rate calculated?

    <p>(Birth rate + Immigration rate) - (Death rate + Emigration rate)</p> Signup and view all the answers

    What does a high infant mortality rate indicate about a country's health system?

    <p>Ineffective healthcare for mothers and infants</p> Signup and view all the answers

    Which factor is likely to lead to lower population growth rates in a country?

    <p>Increased access to education for women</p> Signup and view all the answers

    What was the global average life expectancy according to WHO in 2022?

    <p>73 years</p> Signup and view all the answers

    Which factor tends to decrease mortality and fertility rates in a country?

    <p>Improved standard of living</p> Signup and view all the answers

    Which region had the highest recorded life expectancy as per the provided data?

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

    What would typically cause a region's population to grow?

    <p>An influx of immigrants</p> Signup and view all the answers

    In what way can age distribution affect population dynamics?

    <p>Younger populations often lead to higher birth rates.</p> Signup and view all the answers

    What effect does economic development usually have on population growth rates?

    <p>It tends to lower population growth rates.</p> Signup and view all the answers

    What is the primary focus of environmental conservation?

    <p>Preservation and protection of the natural environment</p> Signup and view all the answers

    Which of the following represents an ecological reason for conservation?

    <p>Maintaining oxygen levels via photosynthesis</p> Signup and view all the answers

    What term is used for areas set aside to protect natural ecosystems and wildlife?

    <p>Conservation areas</p> Signup and view all the answers

    Which economic reason is crucial for conservation efforts?

    <p>Reliance on natural resources for various industries</p> Signup and view all the answers

    What ethical belief underlies the importance of nature conservation?

    <p>All living things deserve the right to exist</p> Signup and view all the answers

    What is a significant threat to conservation efforts in South Africa?

    <p>Poaching of endangered species</p> Signup and view all the answers

    Which option best describes an aesthetic reason for conservation?

    <p>Nature should be preserved for beauty and enjoyment</p> Signup and view all the answers

    Which of the following definitions aligns with conservation areas in oceans?

    <p>Marine protected areas (MPAs)</p> Signup and view all the answers

    What is a primary threat to the habitats of animals within urban areas?

    <p>Habitat loss due to urbanization</p> Signup and view all the answers

    Which of the following represents a benefit of wetlands?

    <p>They provide habitat for many species.</p> Signup and view all the answers

    What type of area is specifically designated for scientific research and observation of ecological changes?

    <p>Scientific reserves</p> Signup and view all the answers

    What is an important purpose of Transfrontier Conservation Areas (TFCAs) in South Africa?

    <p>To promote regional cooperation and development</p> Signup and view all the answers

    Which of the following is NOT a type of conservation area recognized in South Africa?

    <p>Urban reserves</p> Signup and view all the answers

    How can individuals contribute to conservation efforts in South Africa?

    <p>By participating in local clean-up events</p> Signup and view all the answers

    What is a significant consequence of climate change on ecosystems?

    <p>Acceleration of biodiversity loss</p> Signup and view all the answers

    Which of the following describes a characteristic feature of grasslands?

    <p>They prevent soil erosion and store carbon.</p> Signup and view all the answers

    What unique aspect do biosphere reserves encompass?

    <p>Partnerships with local landowners</p> Signup and view all the answers

    Which of the following contributes to pollution as a threat to wildlife?

    <p>Litter, especially plastic</p> Signup and view all the answers

    Which is a primary role of the South African National Parks (SANParks)?

    <p>Manage conservation areas representing biodiversity</p> Signup and view all the answers

    What is the significance of marine protected areas (MPAs) in South Africa?

    <p>They help protect underwater ecosystems.</p> Signup and view all the answers

    What percentage of South Africa is covered by forests?

    <p>Only 1%</p> Signup and view all the answers

    Which type of conservation area involves significant restrictions on access and development?

    <p>Wilderness areas</p> Signup and view all the answers

    Study Notes

    Initial Management and Reporting of Safety Events

    • Healthcare Worker (HCW) who identifies a safety event must notify their line manager immediately.

    • A clinical care plan is developed to monitor the patient's response to interventions.

    • Patient's treating doctor must be notified.

    • Patient and/or family must be notified if an event caused harm.

    • Patient Experience Manager (PxM) provides feedback to the patient/visitor and/or family.

    • Legal advice is obtained prior to engaging with the patient/visitor and/or family.

    Reporting of Safety Events

    • HCW or immediate Supervisor documents the event in the patient file.

    • Reporter completes a Safety Event Report on the Safety Event Management System (short and simple with minimal information).

    • Confidentiality must be maintained, no patient, staff, or doctor names are included.

    • Reporter classifies the event based on their opinion, using Annexure C for event types.

    • Reporters can receive feedback on the event by including their email address.

    • Events can be reported anonymously, but must include patient information, hospital/business unit, and location.

    Initial Review by Unit/Line Manager and After Action Review (AAR)

    • Unit/Line Manager conducts an Initial Review to ensure completeness and correctness of the report.

    • A feedback or debriefing session is arranged with staff involved in the event, as well as the rest of the shift, to conduct an After Action Review (AAR).

    • AAR identifies gaps and lessons learned, reinforces risk mitigation and prevention measures.

    • AAR questions:

      • What was supposed to happen? (plan)
      • What happened? (Action)
      • What was the difference between the plan and the action? (review)
      • What can we learn from this? (Personal and collective change)
      • What will you do in the future?

    • Unit/Line Manager documents the following on the Safety Event Management System:

      • AAR information, especially for Serious harm or death events.
      • Contributing factors, as per the Yorkshire Contributing Factors Framework.

    First Team Review (All Events)

    • Unit/Line Manager reports the event to the Review Team verbally (either immediately or at handover meetings).

    • Just Culture principles are adhered to, level of review is determined, and action loop is closed.

    • Review Team evaluates if:

      • Response and recovery efforts are appropriate.
      • Actions to prevent future harm to others are appropriate.
      • HCWs involved have received psychological support.
      • All contributing factors are identified (as per the Yorkshire Contributing Factors Framework).

    • Advice from the Legal Department is required when there is harm or potential harm to a patient.

    • Legal advice is obtained telephonically, ensuring immediate assistance.

    • An email is sent to the Legal Department with the event reference number.

    Decision for Further Investigation

    • Serious harm or death events require a Serious Event Management Team (SEMT) to be established.

    • Low harm but repeating events may require an investigation to establish common factors.

    • Near misses with significant learning opportunities should also be investigated.

    Categorisation of Events

    • PSM reviews the safety event report and the Type of Event selected by the reporter.

    • PSM determines the correct classification of the event using Annexure D.

    • Level of harm is reviewed and changed to the most appropriate level using Table 1.

    • This may require engagement with the Unit Manager or HCWs.

    • Categorization occurs within 5 working days of the event being reported.

    • An initial report using the ISBAR format is completed by the PSM for Serious harm or death events.

    • Agency staff must complete the electronic Safety Event Report.

    • If no further investigation is required, the event can be "closed" and feedback provided to the reporter if they provided their email.

    • Principles for the classification of multiple events:

      • Multi-Events occur when more than one individual or a group are impacted by harm.
      • Events with the same cause should be investigated individually.
      • Common causal factors or associations are identified for improvement.

    Patient Safety Event Management Policy

    • The policy aims to standardize patient safety definitions and processes for identifying, reporting, investigating, escalating, and improving safety events.
    • The policy incorporates definitions of events, an algorithm for classifying event types and harm levels, and a detailed outline of roles and responsibilities.
    • The policy establishes protocols for reporting procedures, investigation processes, and notification/escalation pathways for various safety events.
    • Specific timeframes are set for completing safety event reports and investigations.
    • The policy highlights the importance of continuous improvement activities designed to enhance patient safety and minimize harm.
    • A dedicated 'alert' email group and escalation flows for serious events are established.
    • The Legal Department is involved to provide advice and guidance on managing matters related to patient harm or potential harm.

    Acronyms

    • DMAIC: Define, Measure, Analyze, Improve, Control.
    • DRM: Doctor Relationship Manager.
    • HCW: Healthcare Worker.
    • IPC: Infection Prevention and Control.
    • HAI: Healthcare-associated infections.
    • ISBAR: Identity, Situation, Background, Assessment, Recommendation.
    • IPCM: Infection Prevention Control Manager.
    • MCSA: Mediclinic Southern Africa.
    • NM: Nursing Manager.
    • DNM: Deputy Nursing Manager.
    • OHSC: Office of Health Standards Compliance.
    • PSM: Patient Safety Manager.
    • PxM: Patient Experience Manager.
    • RCA: Root Cause Analysis.
    • RCM: Regional Clinical Manager.
    • SAHPRA: South Africa Health Products Regulatory Authority.
    • SEMT: Serious Event Management Team.
    • SRE: Serious Reportable Event.
    • TPSC: The Patient Safety Company (safety event reporting system).
    • UM: Unit Manager.

    Definitions

    • Adverse Event: An unintended harm to the patient caused by an act of commission or omission, not by the patient's underlying condition.
    • Clinical Risks: The likelihood of an Adverse Incident causing injury or harm to the patient.
    • Continuous Improvement: An ongoing process for improving products, services, or processes through incremental and breakthrough advancements, aiming for quality care and better patient outcomes.
    • Harm: Any physical or psychological injury or damage to a person's health, including temporary or permanent injury.
    • Hazard: A source of potential damage, harm, or adverse health effects on patients or healthcare personnel, posing a threat to safety.
    • Invasive Procedure: Interventions that alter a patient's anatomy permanently, including surgical procedures, biopsies, interventional radiology procedures, and line insertions.
    • Invasive Procedure Start Time: When the first incision is made or an instrument is inserted into tissues, cavities, or organs, beginning the permanent alteration of the patient's anatomy.
    • Near Miss: An event that did not reach the patient due to chance or early detection.
    • Never Events: Preventable patient safety incidents that are largely preventable through known and available guidelines or safety recommendations. Never Events have the potential to cause serious patient harm or death.
    • Non Safety Events: Events that occur without a direct impact on a patient, often related to occupational risks or hazards.
    • Patient Safety: The prevention and mitigation of harm caused by errors in healthcare, involving the establishment of systems and processes to minimize errors and maximize their interception.
    • Patient Safety Culture: A collaborative environment where clinicians respect each other, leaders promote teamwork and psychological safety, teams learn from errors and near misses, caregivers are aware of human performance limitations, and continuous improvement through debriefings is prioritized.
    • Psychological Safety: Shared team belief that the environment is safe for taking interpersonal risks, allowing for open communication, admitting mistakes, seeking help, and learning from each other.
    • Safety Event: An unexpected, undesirable, or potentially dangerous occurrence in a healthcare organization.
    • Safety Event Management System: 'The Patient Safety Company' (TPSC) - software that captures near misses and safety events for review, risk rating, and continuous improvement monitoring.
    • Serious Reportable Events (SREs): Events with serious harm or death consequences for patients, families, or staff, requiring a comprehensive response and additional resources. SREs encompass 'Never Events' and additional internationally accepted reportable events.
    • Systems Analysis: A comprehensive analysis of factors that contributed to a Patient Safety Event, focusing on identifying system design flaws and promoting proactive safety measures.

    Classification of Safety Events

    • Near Miss: An event that did not reach the patient, either through luck or early detection.
    • Adverse Event: An event that resulted in unintended harm to the patient.
    • Serious Reportable Event (SRE): A patient safety incident with serious harm or death consequences. SREs include events that were previously categorized as Never Events, plus other internationally accepted reportable events.
    • Non Safety Events: Events that occur without a direct impact on a patient's safety, often related to occupational risks or hazards.

    Levels of Harm

    • No Harm: The event reached the patient, but no detectable harm occurred.
    • Low Harm: Minor and transient harm with full recovery expected.
    • Moderate Harm: Short-term harm with full recovery expected, potentially requiring medical or surgical intervention.
    • Severe Harm: Significant harm resulting in long-term incapacity or chronic pain, potentially shortening life expectancy.
    • Death: Patient death that was not expected as an outcome of healthcare by treating clinicians.

    Management of Safety Events

    • Step 1: Event Identification & Immediate Action: The HCW identifies the safety event and takes immediate action to mitigate further harm.
    • Step 2: Report Event: The HCW reports the event on the TPSC system.
    • Step 3: Initial Review & After-Action Review (AAR): The Unit Manager conducts an Initial Review and facilitates an AAR with all personnel involved in the event.
    • Step 4: Categorization & Provisional Reporting: The event is classified and provisional reporting is undertaken.
    • Step 5: First Review - Investigation Level Determination: The event is reviewed by the "Review Team," including nursing management, PSM, IPCM, Night Manager, and Hospital Clinical Manager, to determine the level of investigation needed.
    • Step 6: System Analysis Investigation: A thorough investigation is undertaken, with appropriate individuals participating to understand the systems and events leading to the safety event.
    • Step 7: Final Team Review and Report: The Review Team provides a final report to governance teams after reviewing the investigation findings.
    • Step 8: Improvement Actions & Learning: Based on the findings, improvement actions are determined and implemented to prevent similar events in the future.

    Management and Reporting of Safety Events

    • Initial Management and Verbal Reporting: The HCW who identifies the safety event informs the Line Manager immediately, establishes a clinical care plan to prevent further harm, and informs the patient's treating doctor.
    • Reporting: The HCW involved in the safety event, or their immediate supervisor, documents the event in the patient file and completes a Safety Event Report on the TPSC system.
    • Initial Review by Line Manager and AAR: The Line Manager conducts an Initial Review of the event and facilitates an AAR to identify gaps, lessons learned, and mitigation measures.
    • First Team Review: The Line Manager reports the event to the Review Team, ensuring just culture principles are adhered to and identifying associated contributing factors. This step involves evaluating the response taken and determining the need for further investigation.
    • Legal Support: In all cases where harm or potential harm exists, the Legal Department is consulted to obtain advice and guidance. This ensures legal, financial, and reputational risks are protected.

    Key Takeaways

    • The policy establishes a comprehensive framework for managing patient safety events in MCSA, emphasizing a culture of continuous improvement.
    • Timely reporting, investigation, and mitigation strategies play a vital role in patient safety.
    • Specific timeframes for completing reports and investigations ensure a prompt response to events.
    • The integration of legal guidance and just culture principles is essential in balancing patient safety and accountability.

    Safety Event Management System

    • For all safety events, the Safety Event Management System (SEMS) is used to record and manage events.
    • All events are classified and categorized.
    • The process includes reporting, investigation, review, and action planning to prevent future occurrences.

    Reporting Safety Events

    • All staff must report safety events before or by the end of their shift.
    • Reporters provide initial facts about the event.
    • The PSM (Patient Safety Manager) will review the report and categorize the event.

    Categorization & Classification

    • The PSM categorizes events based on their type and harm level.
    • Events are assigned to the most detailed classification level possible.
    • The level of harm selected by the reporter may be adjusted.
    • This process is completed within 5 working days of the event being reported.

    Investigation

    • Serious harm or death events undergo thorough investigation using a Systems Analysis Approach.
    • The goal of investigation is to determine what happened, why it happened, and what lessons can be learned.
    • Investigation steps include:
      • Gathering facts and data from HCWs, unit managers, and patient files.
      • Conducting site visits to recreate the event.
      • Reviewing relevant policies, procedures, and literature.
      • Consulting with colleagues or experts.
      • Meeting with HCWs involved to gather their perspectives.
      • Analyzing data and establishing the chronology of events.

    Review & Root Cause Analysis

    • The Serious Event Management Team (SEMT) reviews investigations of serious harm or death events.
    • The SEMT identifies contributing factors, establishes root causes, and develops action plans to prevent recurrence.
    • The SEMT includes representatives from various departments, including medical practitioners, therapeutic support providers, pharmacists, and technical teams.
    • The SEMT follows a structured process to determine whether to close the event or conduct further investigation.

    Action Plans and Continuous Improvement

    • Action plans are developed to address contributing factors and mitigate the risk of recurrence.
    • Actions are documented within the SEMS, with assigned responsibilities and deadlines.
    • Actions are designed to be specific, measurable, achievable, realistic, and time-based (SMART).
    • The Unit Manager is responsible for ensuring that actions are implemented by staff or supported by relevant individuals within the hospital.

    Communication & Feedback

    • Feedback on the investigation’s outcome is provided to patients, staff, and the reporter.
    • The hospital, Regional, and Corporate Office Clinical Governance teams receive final reports for all closed events.
    • Reports on the SEMS include:
      • After Action Review (AAR) Reports for all events.
      • Provisional Reports for SREs, serious harm, or death.
      • Final Reports for SREs and severe harm events.
      • Root Cause Reports for serious harm and death events.

    Monitoring and Continuous Improvement

    • The status of action plans is tracked monthly by Unit Managers and reported to the quality, patient safety, and clinical risk review forum.
    • The DMAIC methodology (Define, Measure, Analyze, Improve, Control) is used for implementing continuous improvement initiatives.

    Never Events

    • Never events are serious, preventable, and unambiguous events that require a specific, comprehensive response.
    • Never events trigger a more involved notification process and involve communication with corporate office.
    • A final report is completed on the SEMS, and corporate office may document actions prior to event closure.

    Maternal and Neonatal Events

    • Maternal and neonatal deaths undergo a rigorous investigation process.
    • All maternal deaths are reported on the SEMS and to the Department of Health.
    • Specific categories of neonatal mortalities and severe harm must be investigated and reported using the SEMS.
    • The Mother and Baby Collaborative Meeting discusses all maternal deaths and relevant neonatal events.

    Healthcare-Associated Infections (HAIs)

    • HAIs are managed by the Infection Prevention Control Manager (IPCM).
    • Suspected or confirmed HAIs are reported to the IPCM.
    • Investigations into HAIs involve the IPCM, Unit Manager, and IPC Link Nurse.
    • Findings are documented in the IPC surveillance system (ICNet).
    • The PSM and IPCM may collaborate with the Unit Manager on continuous improvement initiatives related to HAIs.

    Patient Safety Event Management Policy

    • This document provides a framework for managing events related to patient safety within the healthcare setting.

    Incident Categories

    • Violence: Incidents involving violence towards staff, patients, or visitors.
    • Sexual Assaults: Includes rape, indecent exposure, or any other form of sexual misconduct.
    • Missing Patient: Includes patient abduction and missing minors (newborn to 13 years old).
    • Incorrect Patient: Incidents where care is provided to the wrong patient, including patient restraint processes.
    • Unauthorized Acts: Care provided by individuals without proper qualifications or credentials.
    • Self-Harming Behavior: Includes actual self-harm, attempted self-harm, suicidal behavior, and overdose.
    • Prohibited Goods: Unauthorized use or possession of weapons or stolen goods.
    • Blood/Plasma Products: Incorrect administration, monitoring issues during and after transfusion, death or disease transmission due to transfusion.
    • Discharge: Discharge of a patient who cannot make decisions to an unauthorized person.
    • Diagnostic/Therapeutic: Incorrectly performed procedures and missed laboratory investigations.
    • Resuscitation: Resuscitation performed on the wrong patient.
    • Environmental Hazards: Exposure to hazardous substances (blood, bodily fluids, sharps, splashes), unsafe environmental conditions (evacuations, explosions, fires, radiation overexposure), and falls resulting in severe injuries.
    • Medical Devices/Equipment: Implantable device events requiring removal, and incorrect patient use or utilization.
    • Medication: Incorrect administration, adverse drug reactions, and medication errors leading to severe consequences.
    • Medical Gas Events: Incorrect administration, incorrect gas mixtures, or gas contamination.
    • Nutrition (Pharmacy Products): Incorrect patient administration.
    • Unexpected Deaths/Severe Harm: These events occur outside the patient's natural illness progression.
    • Perinatal Events: Includes maternal death, maternal injury (e.g., hysterectomy, uterine rupture), perinatal death, and neonatal events (e.g., brain hemorrhage, brachial plexus injuries, hypoxic ischemic encephalopathy, exchange transfusion, wrong breast milk, separation from parents, unexpected death).
    • Perioperative Events: Incorrect patient administration, incorrect anesthetic agents or doses, failed intubation, insufficient airway management, insufficient anesthesia, failure to recognize and respond to patient deterioration, death (intraoperative or postoperative), physiological complications (e.g., air embolus, pneumothorax, paralysis,coma, major permanent loss of function), burns, and unintended lacerations or punctures.
    • Organ Transplant: Unintended transplantation of contaminated organs or tissues.
    • Personal Property/Data/Information: Confidentiality or privacy breaches, unauthorized access or disclosure.
    • Pressure Injury: Hospital-acquired pressure ulcers, or worsening of existing pressure ulcers while in hospital.

    Non-Safety Events

    • These events have no direct impact on patient safety but may be related to other concerns (e.g., medication breakage, expiration, occupational injuries).

    Management

    • Technical/Medical Equipment Events: Equipment failures detected before or during routine checks are reported through technical processes, not the Safety Event Management System.
    • Occupational Injuries: Reported by staff members involved, AARs are completed, and appropriate forms are filled for permanent and agency staff.
    • Pharmacy Events: Events involving medication breakage, product failure, or expired medications are reported. Depending on the type of medication, evidence is collected and disposed of according to protocol. AARs are completed by the Unit Manager or Pharmacy Manager.

    Never Events

    • These are preventable patient safety incidents that have the potential to cause serious harm or death.
    • They are categorized into surgical/invasive procedures, medication, mental health, and general events.

    Surgical/Invasive Procedure Never Events

    • Wrong Patient Invasive Procedure/Surgery: Surgical or invasive procedures performed on the wrong patient.
    • Wrong Site or Side Invasive Procedure/Surgery: Procedures performed on the incorrect site or side.
    • Wrong Surgery or Invasive Procedure Performed: A procedure different from the one documented in the informed consent is performed.
    • Wrong Implant or Prosthesis: An implant or prosthesis different from the intended one is placed.
    • Unintended Retained Foreign Body After Surgery: A foreign object is left behind after surgery.

    Medication Never Events

    • Mis-Selection of a Strong Potassium Solution: Administration of a strong potassium solution instead of intended medication.
    • Administration of Medication by the Wrong Route: Administration of medication through the wrong route (e.g., intravenous chemotherapy by the intrathecal route).

    Mental Health Never Events

    • Failure to Install Functional Collapsible Shower or Curtain Rails: Failure to install functional rails that prevent suicide attempts.

    General Never Events

    • Falls from Poorly Restricted Windows: Falls resulting from poorly restricted windows.

    Patient Safety Events

    • Window Falls: This refers to situations where patients fall from windows that are within reach and accessible, even if a fitted restrictor is damaged or disabled. It does not apply to cases where the patient deliberately disables the restrictor or breaks the window immediately before falling.
    • Chest or Neck Entrapment in Bed Rails: This occurs when a patient's chest or neck becomes trapped between bed rails, the bedframe, or the mattress due to non-compliant bedrail dimensions.
    • ABO-Incompatible Blood Components or Organs Transfusion/Transplantation: This includes unintentional transfusion of ABO-incompatible blood components, excluding deliberate transfusions with appropriate management. It also includes unintentional mismatched solid organ transplantation, excluding clinically appropriate ABO-incompatible organ transplants.
    • Misplaced Naso- or Oro-gastric Tubes: This event involves the placement of a naso- or oro-gastric tube into the pleura or respiratory tract instead of the intended location, and it's not detected before starting a feed, flush, or medication administration.
    • Scalding of Patients: This occurs when a patient is scalded by water used for washing or bathing, excluding scalds from water used for other purposes like kettles.
    • Unintentional Connection of Oxygen Patient to Air Flowmeter: This situation occurs when a patient requiring oxygen is mistakenly connected to an air flowmeter instead of an oxygen flowmeter.

    Reporting Requirements for Medical Safety Events to the Office of Health Standards Compliance (OHSC)

    • Behaviour: Reporting is required for any inappropriate or aggressive behaviour towards staff by patients, visitors, other healthcare workers, or patients themselves, including physical contact (actual assault), psychological abuse (bullying and harassment), sexual assault, rape, or indecent exposure.
    • Missing Patient: Events to be reported include abduction, missing minors (newborn to children up to 13 years of age), patients leaving without informing staff, AWOL/absconded (detained patients only), and escape of a transferred prisoner.
    • Self-Harming Behaviour: Reporting of suicide is required.

    Reporting Requirements to Other Organizations

    • Blood/Plasma Products: Transfusion reactions are to be reported to the South African National Blood Service (SANBS).
    • Diagnostic/Therapeutic Process (excluding medication/blood processes): Radiological service-related events are to be reported to the OHSC.
    • Infection Prevention and Control: Unavailability of water for over 24 hours needs to be reported to the OHSC.
    • Medical Device/Equipment/Supplies: Events such as equipment failure to deliver according to specifications, implantable device removal, incorrect/ambiguous instructions, incorrect labeling, malfunction/failure, and contaminated supplies require reporting to the South African Health Products Regulatory Authority (SAHPRA).
    • Medical Gases/Oxygen: Reports to SAHPRA are required for events like illegible or incorrect product labels, contaminated products, and contaminated storage.
    • Medication/Biologics/Fluids: Events such as adverse drug reactions, adverse reactions post-immunization, expired constituents, damaged/contaminated products, illegible product labels, and damaged/contaminated delivery need to be reported to SAHPRA.
    • Perinatal Events: Maternal deaths must be reported to the National Department of Health (NDOH).
    • Peri-operative Events: Events to be reported to the OHSC include deaths during or after surgery, retained foreign objects, incorrect surgical or invasive procedures (wrong patient, side, site, or procedure).

    Population Concepts

    • Population growth has accelerated significantly, particularly since the Industrial Revolution
    • The Neolithic revolution marked the start of human dominance over nature, leading to agriculture and animal husbandry
    • Medical advancements have contributed to population growth.
    • Birth rate, the number of babies born per 1000 people, in South Africa is 19, compared to the global average of 20.
    • Death rate, the number of deaths per 1000 people, in South Africa is 15, compared to the global average of 8.6.
    • Swaziland has a high death rate of 30 per 1000 people, but it also has a high birth rate of 30 per 1000 people.
    • High death rates can occur in countries with a high number of elderly people, like Japan
    • Immigration, movement into a country, increases population growth.
    • Emigration, movement out of a country, decreases population growth.

    Population Growth Rates

    • Higher birth rates and lower death rates lead to rapid population growth.
    • Population growth is influenced by birth rate, death rate, immigration, and emigration.
    • Countries with growing populations have a positive growth rate.
    • Countries with shrinking populations have a negative growth rate.

    Infant Mortality Rates

    • Infant mortality rate is the number of babies that die before reaching the age of one per 1000 births.
    • South Africa's infant mortality rate is 24 per 1000 births, higher than the global average of 27 per 1000 births.
    • Higher infant mortality rates indicate poor healthcare systems.

    Life Expectancy

    • Life expectancy is the average age a person in a population can expect to live.
    • Global average life expectancy in 2022 was 73 years.
    • Women tend to live longer than men, with average life expectancies of 73.8 years and 69.1 years respectively.
    • The Maldives has the highest life expectancy in Africa (78.5 years).
    • South Africa's life expectancy is 62.9 years, but has improved significantly due to better HIV treatment.

    Other Factors Influencing Population Growth

    • Migration: A population grows if more people enter a region than leave it.
    • Age distribution: Populations with a high proportion of young people will have a higher birth rate and lower death rate than those with a higher proportion of older individuals.
    • Economic Development: Higher economic development is associated with lower population growth rates due to:
      • Improved healthcare and education leading to lower mortality and fertility rates.
      • Increased access to jobs and education for women leading to smaller families.
      • Increased affluence leading to more investments in family planning.

    Conservation

    • Conservation is the preservation, protection, or restoration of the natural environment.
    • It can also be defined as preventing excessive or wasteful use of resources.
    • Conservation areas are set aside to protect plant and animal life.
    • Conservation areas are also known as marine protected areas (MPAs or marine reserves) in the oceans.
    • Conservation usually involves setting aside certain areas that are protected and natural resource management practices that allow species and their habitats to be conserved.
    • Conservation is necessary for ecological, economic, aesthetic, and ethical reasons.

    Ecological Reasons for Conservation

    • Plants require carbon dioxide, sunlight, and water for photosynthesis.
    • Photosynthesis is vital for all aerobic life on Earth because it maintains normal levels of oxygen in the atmosphere and provides energy for most life on Earth.

    Economic Reasons for Conservation

    • Many industries rely on natural resources that they sell directly, like fishing, forestry, and agricultural industries.
    • These industries also use natural resources to produce processed goods, like paper and wine industries.

    Aesthetic Reasons for Conservation

    • The aesthetic value of nature is subjective and can encompass various aspects such as peace, relaxation, beauty, environmental education, and enjoyment of the outdoors.

    Ethical Reasons for Conservation

    • All living things have a right to exist.
    • Nature should be preserved for future generations.

    Threats to Conservation

    • Poaching: Illegal hunting of animals, especially rhinos for their horns, is a major problem.
    • Habitat Loss: As cities grow and more land is used for farming, many animals lose their homes.
    • Climate Change: Rising temperatures and changing rainfall patterns are affecting plants and animals.
    • Invasive Species: Introduced species from other parts of the world can harm local ecosystems.
    • Pollution: Litter, particularly plastic, can harm animals and pollute water sources.

    Conservation Areas in South Africa

    • Conservation areas are protected regions where landscapes, wildlife, and plants are conserved.
    • Examples include national parks, nature reserves, and protected zones.
    • The Department of Environmental Affairs and organizations like SANParks play a significant role in environmental conservation in South Africa.
    • South Africa has diverse fauna and flora, including endemic species that require protection.

    Types of Conservation Areas in South Africa

    • Scientific Reserves: These are undisturbed areas used for research and observing changes in nature. Access is limited.
    • Wilderness Areas: These areas are extensive, uninhabited, and underdeveloped. Access is strictly controlled.
    • National Parks and Equivalent Reserves:
      • Parks: Managed by SANParks, these parks represent the country's indigenous fauna, flora, landscapes, and cultural heritage.
      • Transfrontier Conservation Areas (TFCAs): Established in cooperation with neighboring countries, TFCAs promote regional peace, cooperation, and socioeconomic development.
      • Biosphere Reserves: These include areas with outstanding natural beauty and biodiversity. They encourage sustainable development in partnership with landowners.

    Other Types of Conservation Areas in South Africa

    • Habitat and wildlife management areas
    • Sustainable use areas
    • Wetlands
    • Botanical gardens
    • Zoos

    Areas of Conservation Focus in South Africa

    • National Parks: South Africa has 19 national parks, including the famous Kruger National Park. These parks are home to diverse wildlife, including the Big Five: lions, leopards, rhinos, elephants, and buffalo.
    • Marine Protected Areas (MPAs): Situated along South Africa's coastlines in the Atlantic and Indian Oceans, MPAs protect underwater ecosystems, including coral reefs, fish, and marine mammals.
    • Wetlands: Wetlands, covering areas with waterlogged soil, provide habitats for plants and animals, help purify water, and protect against flooding.
    • Grasslands: Grasslands cover a significant portion of South Africa's land, supporting unique plant and animal life, preventing soil erosion, and storing carbon to combat climate change.
    • Forests: A small percentage of South Africa is covered in indigenous forests and plantations. Forests are essential habitats for animals, air purifiers, and sources of timber.

    How to Help with Conservation

    • Learn about South Africa's plants and animals.
    • Reduce, reuse, and recycle to minimize pollution.
    • Participate in local clean-up events.
    • Spread awareness about conservation issues.
    • Support conservation organizations through volunteering or fundraising.
    • Every action, big or small, contributes to safeguarding South Africa's natural heritage.

    Conclusion

    • Conservation is essential for the environment and future generations.
    • South Africa's commitment to protecting wildlife and ecosystems serves as an international model.
    • Community involvement is crucial to conservation success.
    • Everyone should understand and take part in protecting the natural world.

    Studying That Suits You

    Use AI to generate personalized quizzes and flashcards to suit your learning preferences.

    Quiz Team

    Description

    This quiz covers the essential procedures for the initial management and reporting of safety events in healthcare settings. It highlights the responsibilities of healthcare workers, the importance of communication with patients and families, and the steps involved in documenting and reporting events. Understanding these protocols is crucial for maintaining patient safety and confidentiality.

    More Like This

    Use Quizgecko on...
    Browser
    Open
    Browser
    Browser