Patient Safety Awareness Course for Junior Healthcare Professionals 2024 PDF

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1 "'""""IAITllll;;::;,.,: MINISTRY OF HEALTH MALAYSIA AWARENESS COURSE FOR JUNIOR HEALTHCARE PROFESSIONAL · 2024., I.. PATIENT SAFETY UNIT MEDICAL CARE QUALITY SECTION MEDICAL DEVELOPMENT DIVISION MINISTRY OF HEALTH MALAYSIA Copyright © Patient Safety Unit, Ministry of Health Malaysia All rights reserved. This book may not be reproduced, in whole or in part, in any form or means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system now known or here after invented, without written permission from the producer. PATIENT SAFETY AWARENESS COURSE FOR JUNIOR HEALTHCARE PROFESSIONAL 2024 e ISBN: 978-967-26250-2-5 Mei 2024 Produced and distributed by: Patient Safety Unit, Medical Care Quality Section, Medical Development Division, Ministry of Health Malaysia, Level 4, Blok E1, Complex E, Federal Government Administrative Centre, 62590 W.P. Putrajaya Foreword by Datuk Dr. Muhammad Radzi Abu Hassan Director-General of Health Malaysia As you embark on your journeys in healthcare, prioritizing patient safety becomes the cornerstone of everything you do. This course equips you with the foundational knowledge and practices to ensure the well-being of those entrusted to your care. Ensuring patient safety is a commendable endeavour. By understanding core principles like effective communication, safe surgery, infection control, and medication safety, you actively contribute to a culture of excellence within healthcare settings. Patient safety is an This module specifically addresses the needs of junior healthcare professionals, as ongoing journey, it provides you with the tools to navigate one that requires potential hazards and cultivate a proactive approach to patient care. You'll learn how continuous learning to identify and prevent them, fostering a safer environment for everyone. and collaboration. Patient safety is an ongoing journey, one that requires continuous learning and collaboration. Therefore, this course is your first step. Embrace the knowledge you gain, ask questions, and actively participate. By prioritizing patient safety, you not only protect those you serve, but also contribute to a stronger, more trustworthy healthcare system. I'm confident that by completing this course, you'll be better prepared to make a positive impact on patient safety from the very beginning of your career. Finally, I would like to acknowledge the commendable efforts of the Patient Safety Unit within the Medical Care Quality Section of the Medical Development Division, as well as all the Technical Coordinators and the Technical Committee, in developing this training module. CONTENTS THE BASIC SAFE CONCEPT SURGERY PAGE 7 PAGE 27 EFFECTIVE INFECTION COMMUNI- PREVENTION CATION & CONTROL PAGE 49 PAGE 65 ANTI- MICROBIAL MEDICATION RESISTANCE SAFETY PAGE 97 PAGE 113 INCIDENT REPORTING & LEARNING SYSTEM PAGE 139 7 8 9 10 11 12 13 14 15 16 17 18 19 20  KEY POINTS FOR PRESENTATION SLIDE 1: The Basic Concept of Patient Safety SLIDE 2: In this module, you will learn about the burden of patient safety incidents, the basic concept of patient safety which includes common definitions and factors contributing to the incidents, prevention of patient safety incidents and Ministry of Health Malaysia patient safety strategies. SLIDE 3: Now let us look at an example of actual patient safety incident that occur in the hospital: Our patient here is a 66 years old gentleman with underlying DM on OHA. He came to the hospital accompanied by his son for community acquired pneumonia. He was stranded in the Emergency Dept. for more than 10 hours before he was admitted to the ward. His son went back home to pick up his essentials for the admission. At 11pm, an attending doctor in the ward forgot to pull up the railing and lower the bed for this patient after a blood taking procedure as he was rushing to attend another patient in a different ward. Being tired from a long day, the patient fell asleep. At 12am, the patient rolled off the bed and hit his head on the floor. He suffered a massive ICB and passed away. This incident is preventable and should not occur during patient care. SLIDE 4: The World Health Organisation had estimated that 4 in 10 patients in primary and outpatient health care suffer from patient safety incidents and 80% of these incidents are preventable. SLIDE 5: In the hospital setting, it is estimated that 1 in 10 patients is harmed while receiving hospital care and up to 50% of these incidents are preventable. SLIDE 6: In Malaysia, patient safety performance is monitored using the Malaysia Patient Safety Goals 2.0. From MPSG 2.0 2022 data, it is reported that we have 8 cases of wrong surgery, 60 cases of unintended retained surgical items, 50 cases of actual blood transfusion error, 3010 cases of actual medication error and 4461 cases of patient falls. It is a global public health crisis and requires collective efforts to strengthen the safety of our health system. 21 KEY POINTS FOR PRESENTATION SLIDE 7: Patient safety incidents are costly. Globally, the cost associated with medication errors alone has been estimated at RM 126 BILLION annually. In MoH Malaysia we spend about RM30 million in 2023 for compensation and ex- gratia and the amount is increasing in trend. SLIDE 8: Some of these incidents led to litigation and were published in the newspaper. Here are some examples of newspaper articles on patient safety incidents. SLIDE 9: As mentioned previously, medico legal litigation cases has been showing an increasing trend, SLIDE 10: And in 2021 alone the total no. of cases are 72 cases which involve a payout of RM30 million. SLIDE 11: To put this in perspective, RM 30 million is equal to the purchase of 75 ambulances and 200 ventilator units! SLIDE 12: Prevention of patient safety incidents lead to significant financial savings and better patient outcomes. SLIDE 13: Patient safety investment is “value for money” and it is estimated that 1 USD investment in patient safety can save about 9 to 20 USD in cost due to patient safety incidents. Reference Data : OECD 2017 in Bonn, Germany SLIDE 14: In 2021, the World Health Organisation had come up with a Global Action Plan for Patient Safety which outlines salient areas that need collective actions globally to improve patient safety. In the document, patient safety is defined as : “A framework of organised activities that creates cultures, processes, procedures, behaviours, technologies and environments in health care that consistently and sustainably lower risks, reduce the occurrence of avoidable harm, make errors less likely and reduce the impact of harm when it does occur.” 22  KEY POINTS FOR PRESENTATION SLIDE 15: Why do patient safety incidents occur? SLIDE 16: In 1990, James Reasons introduced the “Swiss Cheese Model” to explain how patient safety incidents occur in health care. The model is widely used globally in reference to patient safety and it explained that every health care system is built with multiple levels of barriers to prevent patient safety incidents. However, due to the complex nature of the health care system which involves various services and human intervention, these barriers usually have gaps in it which if every gap in the barrier aligns, patient safety incidents can occur. SLIDE 17: Tip of the iceberg What we see is the tip of the iceberg. Patient safety incidents are usually a symptom of a failed system rather than the fault of an individual. Usually when an incident occurs, it is easier to look at the direct cause and blame someone for the incident. However, this will not fix the problem. We need to examine the incident deeper and find the weakness in the system to prevent future incidents. SLIDE 18: When an incident occur, the superficial issues would be the unsafe acts and conditions Investigations are required to find the deeper problem or root cause (system factors) which answer why the unsafe acts or conditions occur. SLIDE 19: Unsafe acts = “Not following accepted good and safe practices” Examples of unsafe acts : not wearing gloves, not practising proper hand hygiene SLIDE 20: Additional examples of unsafe acts : poor documentation, copy and pasting notes, using illegible handwriting and “chartology” Chartology describes a practice where charts or checklists are filled in without even checking the patient or process SLIDE 21: Another example of unsafe acts is not practising proper patient identification Correct patient identification requires two acceptable patient identifiers, such as: patient’s full name, IC no./ Passport no., MRN no./ unique registration no.,birth date and address. Proper patient identification is required in multiple points of care, especially the one that is prone for errors. 23 KEY POINTS FOR PRESENTATION SLIDE 22: Other example of unsafe acts are : Using shortcut in work process and skipping safety steps Assuming without clarification Rushing to complete a task Inappropriate team work or “gotong-royong haram”. For example taking blood for GSH and GXM but with different people doing the blood taking and labelling process. The labelling is done at the nursing counter without checking the patient's identification to save time. This could lead to wrong labelling of specimens Learning wrong and unsafe teaching from seniors which are practised in the facilities. SLIDE 23: Unsafe conditions : Hazardous physical conditions or circumstances Examples of unsafe conditions are broken flooring, medications that are look alike, broken equipment and old wiring with frequent short circuit SLIDE 24: How to prevent patient safety incidents? SLIDE 25: Patient safety culture need to be nurtured and institutionalised The steps of patient safety are safety thinking (where you should think about safety at all time), safe practice (by implementing good practices and following safety steps in the SOP), safe condition or environment (ensure the facility is safe for patient and health care provider) and finally system improvement. It involves individual action to the collective action of everyone in the organisation In the next few slide, we will delve into the explanation of each components SLIDE 26: Safety thinking To practise safely, you should think about safety at all time This involves everyone in the system Before conducting any procedure or practising, one must always think about whether it is safe, “do I need help?”, “do I have the skills?”, “how can I make it safer?” and so on. The mental check is important to ensure patient safety SLIDE 27: Safe practice Always improve in terms of knowledge, competency and skills. (e.g. training) Make sure follow the policy, guidelines and SOPs Practise effective communication and good team work and don’t be scared to ask for help 24  KEY POINTS FOR PRESENTATION SLIDE 28: Safe condition/ environment Everyone has a role in making sure the working condition and environment is safe for all (patient and staff) Don’t assume that others will inherently be aware of the environmental hazards. It is a teamwork to notify and take action to fix it SLIDE 29: System improvement To improve patient safety, the safety gaps in the system need to be identified and corrected System improvement in healthcare refers to factors such as individual/staff factors, patient factors, work/care environment factors, team factors, task/technology factors and management & organisational factors SLIDE 30: Patient Safety is all about T.E.A.M.S T.E.A.M.S. is an acronym for patient safety, summarising key areas for improvement. The ultimate aim of patient safety is to cultivate a culture within the organisation where all components actively strive towards improving and consistently practising safety measures. SLIDE 31: Moving towards patient safety culture Cultivating patient safety is a process and it will start at the lowest where pathological culture exists and improves to patient safety culture. Pathological - very low level of awareness towards importance of incident report and learning system. Systems mostly viewed as punishment for individuals and cases are "swept under the carpet" to save face or in fear of being reprimanded. Reactive - awareness of importance of Incident Report and Learning System has been promoted through the facility however reporting is solely done if an listed incident occurs. Less blaming culture and more towards improving system Proactive - Importance of the system is flourishing and more cases of near misses and hazard being reported and prevented before it happened. Predictive - some patterns of patient safety incidents have been identified and preventive measure are taken to strengthen the system Patient Safety Culture - the institution has already made patient safety a culture and it is present in every level of healthcare SLIDE 32: Malaysian Patient Safety Goals In an effort to improve patient safety in Malaysia, the Ministry of Health Malaysia established its own patient safety targets and indicators in 2013, as outlined in the Malaysian Patient Safety Goals (MPSG). The latest version, MPSG 2.0 (2022), outlines 7 goals and 9 key performance indicators (KPIs) for hospitals and 4 goals and 4 KPIs for clinics. SLIDE 33: Goals in Malaysian Patient Safety Goals 2.0 25 KEY POINTS FOR PRESENTATION SLIDE 34: World Patient Safety Day Malaysia, a member of the World Health Assembly, supported Resolution WHA 72.6 in May 2019 and recognises September 17th as World Patient Safety Day each year. World Patient Safety Day aims to elevate global awareness regarding patient safety and foster solidarity and unified action among all countries and international partners in reducing patient harm. SLIDE 35: World Patient Safety Day Each year, iconic monument in Malaysia will be lighted up in orange and it is celebrated with the theme selected by WHO SLIDE 36: Take home message Remember!. While acknowledging that mistakes are inevitable ("to err is human"), actively concealing them is unforgivable and neglecting to learn from these errors is inexcusable. SLIDE 37: Official Patient Safety Council of Malaysia Portal To learn more about patient safety programs in Malaysia, visit the official portal of the Patient Safety Council of Malaysia: https://patientsafety.moh.gov.my/v2/. SLIDE 38: Thank you SLIDE 39: Acknowledgement 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42  KEY POINTS FOR PRESENTATION SLIDE 1: Safe Surgery Training Module SLIDE 2: Learning Objectives Objectives; at the end of this lectures, junior healthcare professionals should be able to understand: Importance of practising safe surgery How wrong surgery can occur Safe Surgery Checklist SLIDE 3: What is surgery? Surgery is defined as all operations done under general/ regional anaesthesia or local anaesthesia. Usually performed in the operation theatre by a team of doctors and nurses. SLIDE 4: Definition of safe surgery Safe Surgery is A Collaborative Journey Collective Effort: Safe surgery prioritises patient safety throughout the entire journey, encompassing admission, the procedure itself, discharge, and follow-ups. Communication is Key: The program's theme, "Safer Surgery Through Better Communication", highlights the critical role of clear and effective communication in achieving optimal patient outcomes SLIDE 5: Why is it important? Across the globe, an estimated 310 million major surgical procedures are conducted annually. While these interventions aim to improve health and well- being, inadequate safety measures can have severe consequences. Nearly half of all adverse events experienced by hospitalised patients are directly linked to surgical care. Furthermore, the reported mortality rate following major surgery ranges from 0.5% to 5%, and complications can affect up to 25% of inpatients undergoing surgery. 50% of these incidents are preventable by use of CHECKLIST SLIDE 6: Surgical errors Video reveals the devastating consequences of wrong surgery. SLIDE 7: Malaysia’s statistics for wrong surgery Malaysian Patient Safety Goals (MPSG) statistics from 2019 to 2022 showed that wrong surgery still happened, although the target is zero. (Patient Safety Unit, MOH 2023) SLIDE 8: Rate of wrong surgery Incident rate of wrong surgery in Malaysia for 2021: 2 per 1 million surgeries. 43 KEY POINTS FOR PRESENTATION SLIDE 9: Malaysia’s statistics for URSI Malaysian Patient Safety Goals (MPSG) statistics from 2019 to 2022 showed that incidents of unintended retained surgical items still occur, although the target is zero. (Patient Safety Unit, MOH 2023) SLIDE 10: Types of surgical errors SLIDE 11: What can go wrong in a patient’s surgical journey? Despite aiming to improve health, surgery carries inherent risks. Errors like misidentification, incorrect procedures, operating on the wrong body part, or procedures done without consent can occur during a patient’s surgical journey. Infections and documentation errors are further concerns. Prioritising patient safety throughout the process is crucial to minimise these risks. Make sure to follow all standard operating procedures (SOPs) and use two identifiers to avoid wrong surgery. SLIDE 12: Common type of wrong surgery Wrong side contributes the most of wrong surgery incidents (MPSG data 2013-2022) SLIDE 13: Factors for surgical error There are many factors that can contribute to errors. One of the most common factors is communication error. SLIDE 14: Safe surgery checklist and preoperative visits SLIDE 15: Safe surgery checklist Operation theatre is a very complex environment because it involves many operating rooms, multiple levels of staff and multiple disciplines. Furthermore the patients may look similar when they are wearing surgical attire and unconscious. Hence, a systematic and comprehensive “checking system” is essential to ensure adequate preparation of the surgery, correct and safe surgery is being conducted to the right patient. This is why, “Safe Surgery Checklist” was developed by WHO. The Ministry of Health (MOH) Malaysia has adopted this checklist and incorporated other related documents to produce a 4-pages Safe Surgery Checklist in 2009. There are 4 components of MOH Malaysia Safe Surgery Saves Lives (SSSL) Checklist The second page of the checklist comprises the operating team checklist, outlining crucial checks undertaken to prevent surgical errors prior to surgery. SLIDE 16: Pre-Operative Checklist Page 1 of the checklist: Pre-Operative Checklist. Checking is done by the staff nurse 1) in the ward and 2) during patient reception in the operation theatre (OT) 44  KEY POINTS FOR PRESENTATION SLIDE 17: Pre-Operative Checklist Prior to surgery, the nurse will perform the following crucial checks: Patient verification: Confirming the patient's identity to ensure it matches the intended surgical recipient. Surgical site confirmation: Ensuring the correct body part or area is marked for the procedure. Operative consent verification: Checking that the patient has signed the informed consent form and that all necessary information is complete. SLIDE 18: Pre-Operative Checklist Video demonstrating the usage of surgical checklist in airlock SLIDE 19: Swab Count Form Page 3: Swab Count Form, is filled up by the scrub nurse and circulating nurse throughout the procedure / surgery. This form is important in ensuring the swabs and instruments used are not left behind within the cavity of patient (eg. preventing unintended retained foreign body) SLIDE 20: Pre-Discharge Checklist Page 4: Pre-Discharge Checklist, is filled up by the recovery nurse and ward nurse. This checklist ensures that the patient is stable enough to be transferred to ward following the surgery. SLIDE 21: Pre-Discharge Checklist Pre-Discharge Checklist will also ensure that the operated specimen is handled correctly (i.e correct labelling etc) SLIDE 22: Operating Team Checklist Page 2 of the checklist: this is where house officers (HOs) should be involved. The HOs needs to: Help in the process of identifying the patient correctly in the operation theatre Write on the ‘white board’ - patient’s name, diagnosis, proposed operation, site of operation, name of team members, special instruction etc. Involved in the ‘time out’ together with the operating surgeon and other team members. SLIDE 23: Operating Team Checklist The activities involved during ‘sign in’, normally conducted by anaesthetist together with the paramedics. SLIDE 24: The White Board The content of the white board that should be written. 45 KEY POINTS FOR PRESENTATION SLIDE 25: The White Board Example of information written on the white board. SLIDE 26: Operating Team Checklist (Video) Video demonstrating sign in and time out SLIDE 27: Intra-operative communication The MOH SSSL program has incorporated intraoperative communication as one of the main components in the checklist. It emphasises the importance of communication between the team members during operation. It ensures that each of the team members knows what is going on and updates the operation. The surgeon should inform the anaesthetist about the progress of the surgery. Similarly, the anaesthetist should update the surgeon about the patient's vital signs and condition while the surgery is being conducted. Main components of intra-operative communication includes: Check in Periodic updates Shout it out Pre-closure disclosure SLIDE 28: Intra-operative communication Examples of “shout out” and “pre-closure disclosure” communication. SLIDE 29: Sign out Sign out is also called debriefing. The surgeon summarises the operative findings and procedure. He will verify what specimen will be sent and how it should be labelled. The anaesthetist will discuss any special post-operative instructions with the team. The scrub nurse will inform the team about the swab count. Proper swab count is very important to prevent incidents of unintended retention of foreign bodies. Any problem needs to be reported to the surgeon immediately and openly. SLIDE 30: Informing Relatives Informing the relatives about the progress of surgery is very important especially when the surgery needs to be prolonged and also after the surgery is completed. Some may show the specimen of anatomical structure or related picture to the relatives. This usually enhances communication between relatives and the healthcare staff. 46  KEY POINTS FOR PRESENTATION SLIDE 31: Preoperative Visit It is best for the surgeon to review the patient (and explain to patient/ relatives) about the surgery and answer any questions before the operation is conducted. The surgeon also needs to make sure that everything is ready and the patient’s condition is optimum to go through surgery. It is good for HO to follow the operating surgeon and learn about the process as well as assisting the surgeon when necessary. SLIDE 32: Postoperative Visit Post-operative visit is done after the operation. The surgeon should make a post op visit to review the patient’s condition after the surgery and answer any queries that the patient might have. SLIDE 33: The Role Of Junior Health Care Professional In Ensuring Safe Surgery SLIDE 34: Do Preoperative Visits Junior healthcare professionals should assist with pre operative visit under supervision During the visit, it is required to ensure proper patient identification, check if all the investigation is ok, address any questions the patient has concerning the surgery and check the consent. SLIDE 35: Mark site of surgery Video for marking surgical site When marking surgical sites, use permanent markers (black or dark blue) and confirm with the patient regarding the site prior to marking. SLIDE 36: Fill-Up WHITE BOARD Before Surgery Prior to surgery, the whiteboard must be filled in, ensuring the accuracy of the patient's name, procedure, and staff involved. Cross-check these details with the patient's notes and documents. SLIDE 37: Antibiotics & X-Rays Additionally, junior healthcare professionals should assist in preparing prophylactic antibiotics in selected cases and ensure the patient's latest radiological imaging is readily available. SLIDE 38: Conduct/ Participate in “TIME OUT” Junior healthcare professionals should assist in performing time-out Time-out is the final check prior to the start of surgery and it is a crucial safety step SLIDE 39: Fill Up Request For HPE Junior healthcare professionals should assist in filling out the HPE request form Make sure the form is filled out correctly and label the specimens correctly 47 KEY POINTS FOR PRESENTATION SLIDE 40: Carry Out Post Operative Visit Junior healthcare professionals should involve with post operative visit under supervision of the operating team During the visit, the team will review patient’s condition after the operation, meet with the patient’s relatives and answer questions relating to the surgery SLIDE 41: Good practices When doing or assisting a Surgery, junior health care professionals need to ensure the patient is identified correctly, know of the patient's history and the planned procedure, observe and understand the procedure before performing it, perform the procedure under supervision and know your limitations and get assistance if necessary. If unexpected situation occurred/ something went wrong CALL FOR HELP IMMEDIATELY And remember to inform your superior if you observe unsafe practice / unsafe situations SLIDE 42: Thank you and always be safe SLIDE 43: Acknowledgement 48 49 50 51 52 53 54 55 56 57 58 59 KEY POINTS FOR PRESENTATION Slide 1: Effective Communication (EC) To Improve Patient Safety Slide 2: Learning objectives Understand the importance of Effective Communication. Learn the basic concept of Effective Communication & its barriers. Understand how Effective Communication can improve Patient Safety. Slide 3: Why Communication in Healthcare is Important? Communication failures contribute to 27% of medicolegal complaints. Poor communication by healthcare professionals leads to 27% of medical malpractice cases. Failure to communicate safety concerns and collaborate effectively can result in incidents like medication errors and wrong surgeries. Slide 4: Level of Communication Involving Junior Health Care Professionals Junior Health Care Professionals: Must communicate effectively with various healthcare personnel in the working environment. Effective communication at all levels is crucial in healthcare to ensure: o Correct management and treatment: Clear communication minimises errors and fosters informed decision-making. o Patient safety: Timely and accurate information sharing is essential for providing safe and appropriate care. Slide 5: Communication Failure… Communication failure can occur at any point of a patient care The following are some examples of communication failure that could occur during the process of care. Slide 6: Communication failure leading to cancellation of OT This is an example of communication failures leading to incidents such as surgery cancellations. In this case, the pre-operative plan regarding fasting was not communicated properly to the patient, resulting in the baby not being fasted before the operation. Notes on patient safety issues: If a patient undergoes surgery without proper fasting, there's an increased risk of aspiration and potential complications arising from it. Slide 7: Communication Failure due to noisy environment Miscommunication can lead to serious consequences, as illustrated in this example. A medical officer's instruction for a dosage of S/C Actrapid was misheard due to a noisy environment and the junior officer's hesitation to clarify. This resulted in the patient receiving a higher dosage than intended, leading to hypoglycemia. Strategies to improve communication in this situation : o Using clear and concise language. o Repeating back instructions for confirmation. o Asking clarifying questions. 60  KEY POINTS FOR PRESENTATION Slide 8: Allergic information was not communicated Incomplete communication and its consequences: This case highlights the dangers of failing to thoroughly document and communicate crucial patient information like allergies. In the example, the junior officer forgot to document the patient’s penicillin allergy (written as "NKDA" - No Known Drug Allergies) and failed to mention it during handover. Consequently, the patient received Augmentin (a penicillin-based antibiotic) and suffered a severe allergic reaction. Slide 9: Miscommunication during patient transfers Now, let's see this example of miscommunication during patient transfers. The junior doctor mistakenly wrote "T. Amiodarone" instead of "T. Amitriptyline" in the referral letter. Fortunately, the error was caught at the receiving facility, preventing a medication error. Note: o While the error was fortunately caught, it highlights the potential consequences of communication breakdowns. o Emphasise the importance of a culture of safety where healthcare professionals are encouraged to report errors and near misses for continuous improvement. Slide 10: Basic Communication Concept - Effective Communication (EC) Loop Successful communication relies on clarity in both encoding and decoding the message. Misunderstandings can occur due to factors like unclear language, cultural differences, or lack of attention. The slide shows the basics of communication concept which includes : o Message to Send: The communication process begins with a thought, idea, or information you intend to convey. o Encode: This thought is then translated into a message using words, body language, facial expressions, or symbols. (e.g., writing a sentence, speaking verbally, using gestures) o Message Medium: The channel chosen to transmit the message is crucial. This could be verbal (spoken language), written (emails, letters), non-verbal (facial expressions, body language), or even visual (images, videos). o Decode: The receiver interprets the message based on their own understanding, experiences, and cultural background. o Message Receiver: The recipient receives and attempts to understand the decoded message. Effective communication loop involves the sender communicating a message to the receiver, who will then provide feedback to the sender to complete the loop. 61 KEY POINTS FOR PRESENTATION Slide 11: Ways of Communicating There are various and increasing communication modalities like case notes, documents, photos, body language and social media platforms. Despite having various modalities of communication, we still have problem to communicate effectively Discussion points on why the problem occur : o Misunderstandings arise due to unclear language, cultural differences, or simply being overloaded with information. o To bridge this gap, we need to be clear and concise in our messages, actively listen to understand, and choose the communication method best suited for the situation. Slide 12: Barrier to an Effective Communication This slide highlights various personal and environmental factors that can hinder clear communication. Personal factors: o Language barriers: Difficulty understanding the spoken or written language can lead to misunderstandings. o Attitudes: Preconceived notions, biases, or lack of interest can affect how a message is received. o Knowledge gaps: If the receiver lacks the necessary background knowledge to understand the information, miscommunication can occur. o Fatigue and stress: These factors can impair focus and listening ability. o Gadget distractions: Being overly focused on devices can hinder active listening and result in missed information. Environmental factors: o Noisy surroundings: Background noise can make it difficult to hear and understand the message. o Cultural differences: Varying cultural norms regarding communication styles, nonverbal cues, and etiquette can lead to misinterpretations. o Weather: Extreme weather conditions can disrupt effective communication and limit our ability to focus. o Environmental disruptions: Distractions like sudden interruptions or technical difficulties can hinder the flow of communication. Slide 13: Steps to Effective Communication in Clinical Setting The steps to communicating effectively consist of : CLARIFY the problem & gather data / facts CONCISELY describe the problem Actively LISTEN to response Assert CONCERNS if needed 62  KEY POINTS FOR PRESENTATION Slide 14: Effective Communication Effective communication is a two-way street. While clearly expressing yourself is crucial, actively listening and interpreting non-verbal cues is equally important. Verbal Communication: Our words are the foundation, ensuring they are: Clear: Easy to understand, avoiding jargon or ambiguity. Brief and Concise: Delivering the message effectively without unnecessary elaboration. Timely: Addressing information at the appropriate moment for maximum impact. Respectful: Maintaining a considerate and professional tone. Assertive: Clearly expressing your ideas and needs while acknowledging others. Non-Verbal Communication: Our body language speaks volumes: Eye Contact: Demonstrates attentiveness and engagement. Posture: Upright and open posture conveys confidence and professionalism. Dressing: Attire appropriate for the context creates a positive first impression. Facial Expressions: Reflect genuine emotions and interest in the conversation. Confident Demeanour: Projects a sense of self-assurance and credibility. In effective communication, the most important aspect is to clarify if you are unclear of the message given. Slide 15: Situations Requires Effective Communication The followings are some examples of situations requiring effective communication: Seek Consultation/ Referring case / Informing case Passing over cases Informing concerns / red flags Taking consents Breaking bad news Communicating error Slide 16: Informing Concerns / Red Flags RED FLAG is warning sign to tell you that an adverse situation may be developing When RED FLAG is detected you should say it (voice out concern) , see it and fix it (require action by senior / supervisor or team). Slide 17: Approach when communicating with a patient Effective communication is required when communicating with a patient Health care providers need to actively listen to the patient’s concerns, acknowledging their feelings with empathy. You should also maintain a respectful and professional tone throughout the communication, recognize your limitations and seek guidance from senior colleagues when necessary. When dealing with a difficult patient / relative (aggressive / abusive / harassment ) seek help from your senior / superior / ward manager and don’t handle it on your own 63 KEY POINTS FOR PRESENTATION Slide 18: Patient Safety Assertion Model The slide describes the Patient Safety Assertion Model for seeking consultation, referring cases, and informing cases One of the most frequently missed step in the model is proposing an action where the communication stops at describing the problem Slide 19: ISBAR The ISBAR (Introduction, Situation, Background, Assessment, Recommendation) framework, endorsed by the World Health Organisation, provides a standardised approach to communication which can be used in any situation. Slide 20: Example of inappropriate communication between doctors Slide 21-24: Role Play: Use ISBAR for the example below Facilitating role play scenarios using the ISBAR communication format. Identifying weaknesses in communication through interactive role-playing exercises. Slide 25: Do and Don’t for Junior Health Care Professional in Effective Communication The slide outlines best practices for junior healthcare professionals on effective communication practices. Importance of proper documentation, avoiding non-standard abbreviations, and seeking help when needed. Slide 26: Communicating Patient Safety Incident for Junior Health Care Professional Responding to incidents: Patient safety incidents require immediate action. Report them promptly through the designated channels, such as the Incident Reporting System. Never attempt to conceal these situations. Seek Support and Communicate Effectively: Inform your immediate supervisor as soon as possible. Don't handle the matter alone. Involve senior staff, especially when communicating with patients or family members during these difficult situations. Always prioritise empathy and document all communication related to the incident. Slide 27: Take Home Messages Emphasising the vital role of communication in patient safety and quality healthcare delivery. Slide 28: Acknowledgement 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 KEY POINTS FOR PRESENTATION SLIDE 1: Infection Prevention & Control (IPC) SLIDE 2: Content of the presentation SLIDE 3: Objectives; by the end of this lecture, junior healthcare professionals will be able to explain the effects of poor infection prevention and control (IPC) practices and describe methods to prevent and minimize healthcare-associated infections (HCAIs). SLIDE 4: The principle of Infection Prevention & Control is to stop transmission by breaking the chain of infection. Portal of exit – body opening of an infected person – nose, mouth, eyes, skin wounds, urethra, anus Mode of transmission – how the pathogen travels from one person to the next – air, hands, surfaces Portal of entry – body opening of uninfected person – noes, mouth, eyes, skin wounds, urethra, anus Susceptible host – the uninfected person Causative agent – pathogen or infectious microorganism – bacteria, viruses, mold, fungi Reservoir – place where the pathogen lives – lungs, blood, tissues, GI tract.. SLIDE 5: Definition of Healthcare Associated Infection SLIDE 6: Pneumonia is the most common type, Followed by BSI CLABSI = central line associated blood stream infection SLIDE 7: Reference: https://www.who.int/publications/i/item/report-on-the-burden-of-endemic-health- care-associated-infection-worldwide 88  KEY POINTS FOR PRESENTATION SLIDE 8: HCAIs can be caused by bacteria, viruses and fungi from human or environmental sources. Transmission through direct contact: Person-to-person transmission can occur when microbes present in blood or other bodily fluids of a patient are transmitted to a health-care worker (or vice versa) through contact with a mucous membrane or breaks (cuts, abrasions) in the skin. Indirect transmission: Infections can be transmitted indirectly through devices such as thermometers, stethoscopes, other inadequately decontaminated equipment, medical devices or toys, which health-care workers pass from one patient to another. This is probably the most common mode of transmission in health-care settings. Droplet transmission: Respiratory droplets carrying pathogens are generated when an infected person coughs, sneezes, or talks, as well as during procedures such as suctioning or intubation. Airborne transmission of infectious diseases occurs through the dissemination of either airborne droplet nuclei, 10 days Less Common Mechanisms Hematogenous seeding from another source Contaminated infusates SLIDE 30: How to prepare for Central Venous Catheter (CVC) insertion SLIDE 31: Hand Hygiene has been explained earlier We will go through the rest of the bundle components in the next slides Step 1, 2, 3 are actually part of the Aseptic Non-touch technique which I will explain later. SLIDE 32: Barrier precautions for operator SLIDE 33: Barrier precautions for patient SLIDE 34: It is important to scrub & not just wipe to effectively reduce the bacterial burden on the skin. Remember to select the appropriate skin antisepsis – 2% chlorhexidine in 70% alcohol SLIDE 35: Where is the optimal catheter site insertion? SLIDE 36: This will prevent unnecessary delays in removing lines that are clearly not needed. Many times, central lines remains in place because they provide reliable access and medical personnel have not considered removing them. SLIDE 37: How to maintan catheter venous catheter (CVC). Decontamination Flushing SLIDE 38: Example of how to do “scrub the hub” 92  KEY POINTS FOR PRESENTATION SLIDE 39: What to do if you suspect your patient has CLABSI? Send culture tip ONLY if clinically suspect infected/CRBSI. Do not send routinely for non-infected/non-CRBSI patients. SLIDE 40: Review question 4 Answer: Look for any signs and symptoms of infection over the CVC insertion site: redness, swelling, pus or serous discharge, pain. Observe condition of the dressing for any soaked or soiled dressing , date of the last dressing change: OCCLUSIVE DRESSING ≤48H , TRANSPARENT DRESSIGN ≤7 DAYS. Check for daily review form of patient’s CVC. Review temperature chart for any spike of temperature. Check for indication and continuity of the line. SLIDE 41: Review question 5 SLIDE 42: Reference Wang, Y., Cai, B., Ni, D. et al. A novel antibacterial and antifouling nanocomposite coated endotracheal tube to prevent ventilator-associated pneumonia. J Nanobiotechnol 20, 112 (2022). https://doi.org/10.1186/s12951-022-01323-x SLIDE 43: Avoid intubation & prevent reintubation: Use high-flow nasal oxygen or noninvasive positive pressure ventilation (NIPPV) as appropriate whenever safe and feasible Minimize sedation Avoid benzodiazepines in favor of other agents Use a protocol to minimize sedation Implement a ventilator liberation protocol Maintain and improve physical conditioning Elevate the head of the bed to 30–45° Provide oral care with toothbrushing but without chlorhexidine Provide early enteral vs. parenteral nutrition Change the ventilator circuit only if visibly soiled or malfunctioning (or per manufacturers’ instructions) SLIDE 44: Definition of Catheter Associated Urinary Tract Infection (CAUTI) 93 KEY POINTS FOR PRESENTATION SLIDE 45: Source of microorganisms may be endogenous (meatal, rectal, or vaginal colonization) OR exogenous, usually via contaminated hands of healthcare personnel during catheter insertion or manipulation of the collecting system (refer to the figure) SLIDE 46: In the next slides we will elaborate on number 1, 4, 5, & 6 SLIDE 47: Incontinence alone is not an appropriate indication to have an indwelling urinary catheter SLIDE 48: Insert by properly trained person Perform hand hygiene before and after insertion Effective cleansing with sterile water. Properly secure catheters SLIDE 49: If breaks in aseptic technique, disconnection, or leakage occur, replace catheter and collecting system using aseptic technique and sterile equipment. If urine sample collection indicated, appropriate and aseptic technique must be observed (refer to next slides). SLIDE 50: How to maintain closed drainage system when collecting urine samples? SLIDE 51: Proper way to collect urine specimen from continuous bladder drainage (CBD) SLIDE 52: Strictly no urine specimen from urine bag SLIDE 53: Flow of urine must not be obstructed SLIDE 54: Review question 6 SLIDE 55: You may have notice a trend among the preventive care bundles for CABSI & CAUTI, where proper insertion procedure is important to prevent infection. These devices (CVL, CBD) are placed in a sterile area of the body (bloodstream, urinary bladder). Hence when inserting devices into these area we should ensure that sterility in maintained. This is achieved by implementing the aseptic non-touch technique. 94  KEY POINTS FOR PRESENTATION SLIDE 56: Purpose of aseptic and clean technique SLIDE 57: Examples of clean technique SLIDE 58: Examples of aseptic technique SLIDE 59: ANTT – Aseptic Non Touch Technique SLIDE 60: Review question 7 SLIDE 61 & 62: Everyone has a role to play in SLIDE 63: In the next talk , you will find out the impact of Antimicrobial Resistance (AMR) & how else we can prevent escalation of this problem (by implementing Antimicrobial Stewardship (AMS)) SLIDE 64: Acknowledgement 95 96 97 98 99 100 101 102 103 104 105 106 107 KEY POINTS FOR PRESENTATION SLIDE 1: Antimicrobial Resistance (AMR) SLIDE 2: Content of the presentation SLIDE 3: Objectives By the end of this lecture, junior healthcare professionals will have been educated about the concept of antimicrobial resistance and their roles in combating it. SLIDE 4: What are antimicrobials? Antimicrobials – including antibiotics, antivirals, antifungals and antiparasitics – are medicines used to prevent and treat infections in humans, animals and plants. They are critical tools for fighting diseases in humans, terrestrial and aquatic animals and plants, but they are becoming ineffective. SLIDE 5: What is AMR? Antimicrobial Resistance (AMR) occurs when bacteria, viruses, fungi and parasites change over time and no longer respond to existing antimicrobials. AMR occurs naturally over time, usually through genetic changes. However, the misuse and overuse of antimicrobials is accelerating this process. As a result, the medicines become ineffective and infections persist in the body, increasing the risk of spread to others. SLIDE 6: Why is AMR a global concern? WHO has declared that AMR is one of the top 10 global public health threats facing humanity. Researchers estimated that AMR in bacteria caused an estimated 1.27 million deaths in 2019. The emergence and spread of drug-resistant pathogens that have acquired new resistance mechanisms, leading to AMR, continues to threaten our ability to treat common infections. Alarming levels of resistance have been reported in countries of all income levels, with the result that common diseases are becoming untreatable, and lifesaving medical procedures riskier to perform. The cost of AMR to national economies and their health systems is significant as it affects productivity of patients or their caretakers through prolonged hospital stays and the need for more expensive and intensive care. The clinical pipeline of new antimicrobials is dry. In 2019 WHO identified 32 antibiotics in clinical development that address the WHO list of priority pathogens, of which only six were classified as innovative. Without harmonized and immediate action on a global scale, the world is heading towards a post-antibiotic era in which common infections could once again kill. Many people around the world still do not have access to antimicrobials. Ensuring equitable and affordable access to quality antimicrobial agents and their responsible and sustainable use is an essential component of the global response to antimicrobial resistance. 108  KEY POINTS FOR PRESENTATION SLIDE 7: Impact of AMR: A growing crisis worldwide AMR is happening RIGHT NOW, across the world The full impact is unknown. There is no system in place to track antibiotic resistance globally Without urgent action, many modern medicines could become obsolete, turning even common infections into deadly threats. In the EUROPEAN UNION, antibiotic resistance causes 25,000 deaths per year and 2.5m extra hospital days. In INDIA, over 58,000 babies died in one year as a result of infection with resistant bacteria usually passed on from their mothers In THAILAND, antibiotic resistance causes 38,000+ deaths per year and 3.2m hospital days In the UNITED STATES, antibiotic resistance causes 23,000+ deaths per year and >2.0m illnesses SLIDE 8: Impact of AMR Drug-resistant diseases already cause at least 700,000 deaths globally a year, including 230,000 deaths from multidrug-resistant tuberculosis. It could increase to 10 million deaths globally per year by 2050 under the most alarming scenario if no action is taken. The cost of AMR to the economy is significant. In addition to death and disability, prolonged illness results in longer hospital stays, the need for more expensive medicines and financial challenges for those impacted. In a high-impact scenario, AMR will reduce global annual GDP by 3.8 percent by 2050. Left unchecked, by 2030, AMR could result in a GDP shortfall of US$ 3.4 trillion annually and push 24 million more people into extreme poverty. SLIDE 9: How does AMR spread? Because the drivers and impact of antimicrobial resistance lie in humans, terrestrial and aquatic animals, plants, food, feed and the environment, and are interconnected, a One Health approach is essential to addressing it on multiple fronts “One Health” refers to designing and implementing programmes, policies, legislation and research in a way that enables multiple sectors and stakeholders engaged in human, terrestrial and aquatic animal and plant health, food and feed production and the environment to communicate and work together to achieve better public health outcomes. SLIDE 10: The contributing factors of AMR in the healthcare setting are: Misuse and overuse of antimicrobials among healthcare workers and patients Lack of awareness and knowledge on AMR Poor infection and disease prevention and control in health-care facilities Lack of access to clean water, sanitation and hygiene (WASH) 109 KEY POINTS FOR PRESENTATION SLIDE 11: How does AMR happen? The principles of how AMR happens are the same, but we will now focus on antibiotic use and antibiotic resistance as it the most common antimicrobial used in the healthcare setting. Firstly, we need to be aware that our body is colonized with a lot of organisms whereby most are sensitive organisms. For example, our urinary tract is colonized by E.coli which is mostly sensitive to the commonly used antibiotics. When an antibiotic is given for whatever reason, this antibiotic will kill all the sensitive bacteria in our body. When all the sensitive bacteria are killed, only the resistant bacteria remains. This will lead to the antibiotic resistant bacteria multiplying and taking over as the predominant organism. Some of these resistant bacteria which we are colonized with can become pathogenic and cause an infection. This mechanism is known as selection pressure. Resistance can also occur by transmission of resistant genes from one bacteria to another. Antibiotics resistance occurs when they are misused and overused. SLIDE 12: How are antibiotics misused and overused by healthcare workers? Given when they are not needed Wrong antibiotic is given to treat infection Broad spectrum antibiotic e.g. Carbapenem or Vancomycin is used to treat susceptible bacteria Given at the wrong dose Continued when no longer necessary SLIDE 13: How does AMR happen in the healthcare setting? Inappropriate antibiotic use can refer to two types of antibiotic misuse: When an antibiotic is prescribed, but not needed, or When the wrong antibiotic, dose, or duration is chosen SLIDE 14: The treatement options for Multidrug Resistant Organisms (MDROs) is limited and less effective. For example, in this slide, it shows the treatment options available in resource limited settings. For common bacterial infections, including urinary tract infections, sepsis, sexually transmitted infections, and some forms of diarrhoea, high rates of resistance against antibiotics frequently used to treat these infections have been observed world-wide, indicating that we are running out of effective antibiotics. Colistin is the only last resort treatment for life-threatening infections caused by carbapenem resistant Enterobacteriaceae (i.e. E.coli, Klebsiella, etc). Bacteria resistant to colistin have also been detected in several countries and regions, causing infections for which there is no effective antibiotic treatment at present. 110  KEY POINTS FOR PRESENTATION SLIDE 15: The two main strategies to contain AMR in the healthcare setting are: A comprehensive infection prevention and control program to prevent the spread of organism and infections. To have an AMS programme to optimise antimicrobial use and prevent antimcrobial selection pressure As IPC has been covered in depth in the previous Module on Infection Prevention and Control, we will now focus on Antimicrobial Stewardship (AMS). SLIDE 16: Antimicrobial management or stewardship programme has been developed as a response to AMR. Antimicrobial Stewardship (AMS) is a coordinated systematic approach to improve the appropriate use of antimicrobials by promoting the selection of the optimal antimicrobial drug regimen; right diagnosis, right choice of antimicrobial, right duration, right route of administration, right dose, right time, and minimise harm to the patient and future patients. SLIDE 17: National Antibiotic Guideline (3rd edition, 2019) Antimicrobial guidelines support the clinical decision-making based on evidence and local epidemiology to tackle relevant disease problems. The adoption of guidelines targeting antibiotic prescribing has been associated with significant benefits, encompassing: improvements in morbidity, mortality, healthcare utilization, costs as in some cases even in resistance rates. contribute to control AMR by producing necessary, appropriate and specific recommendations to optimise the use of antibiotics and inviting health professionals to adhere to them. SLIDE 18:The role of junior doctors in promoting judicious antibiotic use SLIDE 19: To make the right diagnosis, a doctor should take a thorough history and perform a physical examination to identify the site and cause of infection. The history should also include past exposure to any antibiotics, hospital admission, as well as recent procedures done. Eliciting an allergy history is also vital. It is also important for the junior doctor to differentiate if the signs and symptoms that patient presents with is due to either an infective or non-infective cause. If it is a possible infection, the doctor must determine if it is likely a bacterial or viral infection. SLIDE 20: How to ensure it is the appropriate culture 111 KEY POINTS FOR PRESENTATION SLIDE 22: How to initiate right antimicrobial choice and dose SLIDE 23: WHO's Essential Medicines List (EML) in 2017 provided guidance on antibiotic use for common clinical infections and classified the included antibiotics into Access, Watch, and Reserve (AWaRe) groups. Antibiotics in the Access and Watch groups were selected on the basis of their indication as first-choice or second-choice treatments, spectrum of activity, and potential for inducing antimicrobial resistance. Whereas Reserve antibiotics were selected as last-resource treatments for multidrug-resistant infections. SLIDE 24: At 72 hours, antibiotics should be reviewed. Trace the cultures and review clinical progress. Based on these two factors, decide: 1. To stop antibiotics if there is no evidence of bacterial infection; 2. Based on the culture results, to change from broad spectrum to narrow spectrum antibiotics; 3. To change from IV to oral antibiotics; or 4. To continue the same antibiotic and review daily 5. To decide on duration of antibiotics based on site of infection and organism SLIDE 25: Examples of source control to fight AMR SLIDE 26: Antibiotic prophylaxis before surgery, how to give it. SLIDE 27: The pledge to join the fight against AMR SLIDE 28: Infection prevention and control measures are designed to reduce the spread of pathogens including resistant ones within healthcare facilities and to the wider community. This can prevent further infections and AMR spread. Standard precaution is the minimum infection prevention practices that should be used in the care of ALL patients, ALL the time. Transmission based precaution is applied when treating patients who are known or suspected of being infected or colonised with infectious agents based on its mode of transmission IPC has been covered in depth in the Module on Infection Prevention and Control. SLIDE 29: Take home message SLIDE 30: Acknowledgement 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130  KEY POINTS FOR PRESENTATION SLIDE 1: Title: Medication Safety Teaser: Unsafe medication practices and medication errors are a leading cause of injury and avoidable harm in healthcare systems across the world. In the session, I as a pharmacist will be sharing with all newcomer doctors the strategy, contributing factors, and examples of good prescribing practices. SLIDE 2: Learning Objective Understand the importance of medication safety Understand factors related to medication error Understand good prescribing practices including in computerised system SLIDE 3: Definition of Medication Error (ME) A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is under the control of health professionals, patients, or consumers. (Emphasise the keywords) Why is Medication Safety being Important? 1. Medication use has become increasingly complex – more medications have been developed by the industry, use of multiple medications by one patient, and various available routes can lead to error. Look-alike sound-alike (LASA) medication can lead to confusion. 2. ME is a major cause of preventable patient harm compared to other incidents 3. As healthcare practitioners, we can ensure safer medication use and prevent ME from happening. SLIDE 4: Goals in Malaysian Patient Safety Goals 2.0 Medication Safety is under Goal No. 3, KPI 5 If there is an error with patient identification, it will also report in goal 6 under patient identification. SLIDE 5: Statistics related to ME The cost associated with medication errors has been estimated at $42 billion USB annually Around 1 in 1000 prescriptions received contributes to medication error each year. Do we want to see the ME occur more frequently for instance 1 error in 100 prescriptions received? This indicates our quality as health care professionals. SLIDE 6: Statistics related to Medication errors from 2018 to 2022 for the medication use process. There are 3 indicators where prescribing in the green line shows the highest number of ME reported and an increasing trend compared to dispensing and administration processes. Where most prescriptions are written by doctors. From this data, it is important for newcomer doctors to pay attention because this is related to doctors’ routine jobs. 131 KEY POINTS FOR PRESENTATION SLIDE 7: Statistics related to Medication Safety in Malaysia from Medication Error Reporting System, MOH from 2020 to 2022 data The data is divided into 2 categories which are actual errors, where the error already reaches patients, and near-misses, where the error didn’t reach patients. Target is Zero for actual error and harm which falls from category F to I Numbers of Medication Errors (Actual) in Hospitals and Clinics. Meanwhile, the data shows actual errors from category C to I. The trend fluctuated decreasing in the year 2021, this could be due to the pandemic covid and underreporting, however the trend slightly up in the year 2022. Meanwhile, the number of Medication errors (Near-misses) in hospitals and clinics is increasing trend from 2020 to 2022. This could enhance or sustain awareness in reporting near-misses thru MERS. SLIDE 8: Medication Use Process Errors can happen at any step: prescribing, dispensing, administering, and during patient monitoring. Example of monitoring error includes omission of blood glucose monitoring for patients on insulin and omission of potassium monitor for a patient on furosemide Errors also can be contributed from one process to another. Mostly, the errors are related to Wrong dose, Wrong drug, Wrong route, Wrong dosage form, Wrong time, Wrong patient and Omission SLIDE 9: Strategy to Close the Loop These are a few strategies to reduce errors in each process. It is important during prescribing to evaluate patients on establishing the need for medicine, selection of right medicine, interactions and allergies, and prescribe the correct medicine regime. It is also crucial during the administering of a drug to review the prescription order to identify any warnings, interactions and allergies. Ensure 7R in all steps and finally administer the correct medicine. In the monitoring process, a doctor should assess the patient’s response to the medicine and should report and document any result/patient progress. SLIDE 10: Contributing Factors These are the common contributing factors related to medication error. Staff factors include lack of knowledge, fatigue and lack of safe behaviour Work and environmental factors include heavy workload, distraction and physical environmental issues For product, mainly look alike and sound alike (LASA) and product packaging Tasks and technology factors include lack of SOP/Protocol and IT system issues Team Factor includes communication and problem in seeking help And lastly Patient factor which includes language barrier and miscommunication 132  KEY POINTS FOR PRESENTATION SLIDE 11: Good Prescribing Practice SLIDE 12: 5R Always practice 5R to ensure safe medicine administration SLIDE 13 & 14: Outpatient Prescription These are the requirements for writing an outpatient prescription. Preferably written in BLOCK LETTERS, legible, has the patient's full name, IC No. MRN and age and date of prescription. For children below 12 years old, body weight in kg is required to be written on the prescription. Correct and full diagnosis must be written. No Abbreviation is allowed. For the drug regime, it must be written in a full and correct drug name Use a generic name and not the brand name. Correct medication dosage form, dose, routes, frequency and duration. Do not use abbreviations or acronyms. Patient’s allergy information While prescribing, importance should be given to using a leading zero before the decimal point and avoid trailing zero after the decimal point Limit the number of medications in one prescription to five and make sure to write the page number on every prescription if it is more than a page Use mcg or microgram and not using symbol (μg) Write clear instruction Put an initial when a correction is made on the prescription with a stamp. Finally prescriber should sign and stamp on the prescription. SLIDE 15: Inpatient Prescription These are the requirements for writing an inpatient prescription. Two patient identifiers are required in this prescription which is the name of the patient (compulsory) and either the registration number or IC No. Other details required are ward/bed number and diagnosis. For children below 12 years old, body weight in kg is required to be written on the prescription. Additional orders e.g. infusion rate or to be given on specific dates should be clearly mentioned on the prescription. Patient’s allergy information Sign and stamp on the prescription by the prescriber And if it is a controlled medicine requiring a specialist’s signature, then it should be signed and stamped as well by a specialist. SLIDE 16: Allergy Information in Computerised System This is how allergy information is notified in the facility which has a computerised system to prescribe medication. 133 KEY POINTS FOR PRESENTATION SLIDE 17: What should I do before prescribe? Well prescribers should always remember these 3 words: KNOW, CHECK and ASK KNOW – patient medical history and medication history, allergies, current illness and diagnosis, medication side effects, contraindication and safe dosage CHECK – patient identification and medication information ASK – advice from multi-discipline SLIDE 18: Do and Don’ts during Prescribing using Manual Prescription and Computerised Prescription SLIDE 19: Use Generic Name instead of a brand name Do not use ‘ARIXTRA’ which is a brand name, instead use the generic name, FONDAPARINUX. SLIDE 20: Use leading zero BEFORE decimal point. HAVE to write clearly the zero, to avoid confusion between 0.5mg and 5mg doses. In this case can mistakenly read the dose as 5mg rather than 0.5mg, which is 10 times higher than the required dose. SLIDE 21: Do not use trailing zero AFTER decimal point. DO NOT write the zero, to avoid confusion between 5mg and 50mg doses. In this case, can mistakenly read the dose as 50mg rather than 5 mg which is 10 times higher than the required dose. SLIDE 22: Use mcg OR microgram instead of using symbol μg DO NOT use symbols, must write units in full. This symbol can be misunderstood as mg. In this case, can mistakenly read the dose as 500mg rather than 500 mcg which is 1000 higher than the required dose. (1mg = 1000mcg) SLIDE 23: Illegible prescription Prescribers must make sure their writing is readable. The handwriting must be clear and concise. Illegible handwriting can lead to errors. This is very dangerous, especially for HIGH ALERT MEDICATION. SLIDE 24: DO NOT use ABBREVIATION or ACRONYM Must write the generic name of a medication and it must be written in full name. SLIDE 25: For drugs to be administered only on specific days of the week, please specify the day. MUST write specifically if the medication is to be taken on certain days of the week. Please avoid general orders to make sure the medications are supplied accordingly. SLIDE 26: Clearly state dilution and infusion rate of the medications MUST provide dilution and infusion rate if the medication needs to be infused. This information will help in the supply of the right amount of medications and in the administration of the medication. 134  KEY POINTS FOR PRESENTATION LIDE 27: To OFF or WITHHOLD must be accompanied by DATE & Doctor’s SIGN and STAMP Every prescription to be off or withheld must be signed and stamped by the doctor with the date for valid documentation. SLIDE 28: Ensure that prescriptions and signatures are legible, and include the prescriber’s name next to the signature. Every prescription must be signed and stamped by the prescribing doctor with the date for valid documentation. SLIDE 29: All modifications/changes made to a prescription must be done in one sentence/line of regimen and signed with name/stamp Every amendments to the prescriptions must be done in one line with doctor’s sign and stamp with date for valid documentation. SLIDE 30: Interactive Session 1: Spot The Error(s)? Can u spot the errors? SLIDE 31: Interactive Session 1: Spot The Error(s)? The prescriber must write the diagnosis in full sentence Drug name is recommended to write in capital letters Prescribers need to initial (simple signature) on each cancellation SLIDE 32: Interactive Session 2: Spot The Error(s)? Seebri & Berodual are brand names – supposed to use the generic name Dose of Seebri must be written in full 1 puff OD, not 1/1 No Age Dose of MDI Berodual must be written in full 2 puff, not 2p Diagnoses should be written in full No allergy information SLIDE 33: Interactive Session 3: Case Scenario In this case scenario, the error happened through the system. Pharmacists contacted the prescriber regarding duplicate prescriptions. Therefore, the prescriber canceled one of the prescriptions while the pharmacist ‘On Hold’ another prescription without communicating to each other what action they have taken towards the duplicate prescription. At the end of the day, the patient did not receive the medicine. SLIDE 34: Interactive Session 3: Case Scenario The error happened due to both the prescriber and pharmacist assuming that the other prescription is valid. SLIDE 35: Interactive Session 3: Case Scenario The nurse noticed the prescription was ‘On Hold’ so they didn’t serve the medicine. The nurse also assumed the decision ‘On Hold’ is correct without clarifying with the pharmacist or prescriber. 135 KEY POINTS FOR PRESENTATION SLIDE 35: Interactive Session 3: Case Scenario The nurse noticed the prescription was ‘On Hold’ so they didn’t serve the medicine. The nurse also assumed the decision ‘On Hold’ is correct without clarifying with the pharmacist or prescriber. SLIDE 36: Interactive Session 3: Case Scenario Factors contributing to the error was the team factor in which there was miscommunication among staff and the task and technology factor in which there was an issue with the IT system, whereby staff was not familiar with the system. SLIDE 37: Look Alike Medication This is an example of Look Alike Medication. Healthcare workers must be very careful, especially for drugs with 2 strengths. It is recommended to put the drugs separately and stick the caution label on the bin or container in which the drug is placed. SLIDE 38 It is also recommended to read the drug name on the label carefully. Do not identify a drug by using its colour or package size. SLIDE 39: Examples of Look Alike Medication Look Alike Medications are not only common in syrup but also with tablets. Here, we can see the colour and the information written on the blister look alike. SLIDE 40: How to Prevent Error With LASA Medications? This slide showed 4 common methods to prevent Medication Errors with LASA Medication. Tall Man Lettering (e.g. ATORVAstatin, SIMVAstatin) Medication with different strength stored apart from each other (e.g. Losartan 50mg, 100mg) Put Extra Cautionary labels (e.g. Cautions! I have 2 strengths) Best Practice is counter-checking by other colleagues. SLIDE 41: High Alert Medications (HAM) & Categories of HAM Medications HAM are medications that bear a heightened risk of causing significant patient harm when these medications are used in error. All drugs listed in this category are considered HAM. This list may be edited at the individual health facility based on localized medication error reports. These ME may be related to labeling and/or packaging of drugs, proprietary and generic names, and/or misleading nomenclature How to Prevent Error with HAMs? High Alert Medications are medications that have a high risk of causing significant patient harm when these medications are used in error. Refer to HAM Drug List from each facility. 136  KEY POINTS FOR PRESENTATION SLIDE 42: Safe Administration of Medicines in the Wards These are the example of sources of references we used to refer if there is any query of drug information. Please check references whenever in doubt. SLIDE 43: Interactive Session 4: unit → ml Guide the audience to read the concentration of Insulin Actrapid and perform the cross-multiple calculations. SLIDE 44: Interactive Session 4: unit → ml (Answer) The answer is C 0.1ml. SLIDE 45: Interactive Session 5 Guide the audience on which reference to refer to. (e.g. Product leaflet, Drug Dilution Protocol at each facility, Lexicomp etc) SLIDE 46: Interactive Session 5 (Answer) By referring to the information provided in Ceftriaxone Product Leaflet, the correct answer should be B. If using the option in C, only half dose is administered (500mg) SLIDE 47: How to Reduce the Risk Of Medication Error? In summary, as a healthcare practitioner, these are the ways to reduce the risk of medication error especially prescribing errors that usually involved doctors. SLIDE 48: Video Medication Safety SLIDE 49: Acknowledgment Key Take-Home Messages “MEDICATION ERROR: SIMPLE MISTAKE CAN BE LETHAL” “PLEASE CHECK/VERIFY WITH YOUR SUPERIOR IF IN DOUBT BEFORE PRESCRIBING OR ADMINISTERING MEDICATION, IF IN DOUBT, DO NOT ASSUME. PLEASE DOUBLE CHECK” “SAFETY BEGINS WITH YOU, DON’T WAIT FOR SOMEONE ELSE” 137 138 139 140 141 142 143 144 145 146 147 148 149 150  KEY POINTS FOR PRESENTATION SLIDE 1:Incident Reporting and Learning System. SLIDE 2: Objectives By the end of this lecture, Junior Health Care Professionals should grasp the basic knowledge on incident reporting and learning systems and be aware of their role in preventing Patient Safety Incidents as Junior Health Care Professionals. SLIDE 3: In recent years, we saw a lot of patient safety incidents occurring in local newspapers. It not only causes loss of time and money… It even causes loss of lives. SLIDE 4: The graph shows the trending of patient safety incident reporting in the Ministry of Health Hospital and Institutions from 2018 to 2022. SLIDE 5: The graph shows top 10 patient safety incidents reported in 2022 SLIDE 6: It is a system of reporting Patient Safety Incidents that occur in healthcare Investigate or review why the incident happened. Learn from the incident. Take appropriate action to prevent similar incidents from happening. Share with others. SLIDE 7: Patient Safety Incident Reporting Guidelines in Malaysia can be traced back since 1999. SLIDE 8: Policy Implementation of Incident Reporting 2.0 SLIDE 9: The Incident Reporting and Learning System 2.0 was implemented in the Ministry of Health Hospitals and Institutions starting on January 1, 2018, following Pekeliling Ketua Pengarah Kesihatan Malaysia Bil. 9 Tahun 2017. SLIDE 10: Patient Safety Incident Definition and Explanation. SLIDE 11: Differences between adverse events and sentinel events. SLIDE 12: Definition of actual and near miss patient safety incident. 151 KEY POINTS FOR PRESENTATION SLIDE 13: Examples of actual and near miss patient safety incidents. SLIDE 14: The outcome of the patient safety incident, as defined in the Guidelines on Implementation Incident Reporting & Learning System 2.0 for Ministry of Health Malaysia Hospitals. It refers to the direct impact of the incident on the patient's health. SLIDE 15 & 16: The outcome of the patient safety incident. SLIDE 17: DON’T HIDE IT, REPORT IT SLIDE 18: Importance of Incident Report For DAMAGE CONTROL: Prevent worsening of situation. To LEARN from the mistakes To IMPROVE Quality & Safety of our Healthcare System SLIDE 19: All incidents related to patient safety, including near misses, must be reported regardless of the outcome. SLIDE 20 & 21: Examples of patient safety incidents SLIDE 22: As a house officer, you have a responsibility to act if a patient safety incident occurs. SLIDE 23: In the event of a patient safety incident, take immediate action to help the patient, remove the danger, and then call for help. Subsequently, inform your superiors about the incident. SLIDE 24: Once the patient is safe, you can complete the IR 2.0 form. This form can be filled out by the person involved in the incident or by a witness. SLIDE 25: This slide shows the IR2.0 Form (IR 2.0/2007), currently used to report patient safety incidents. SLIDE 26: Act, report, formulate, execute and monitor action plan SLIDE 27: Key steps in managing patient safety incidents 152  KEY POINTS FOR PRESENTATION SLIDE 28 - 30: Examples of action plans and improvements implemented through the incident reporting system. SLIDE 31: Guidelines on Implementing the Incident Reporting & Learning System 2.0 for Ministry of Health Malaysia Hospitals, which is currently in use. SLIDE 32: Thank you SLIDE 33: Acknowledgement 153  PATIENT SAFETY UNIT MEDICAL CARE QUALITY SECTION MEDICAL DEVELOPMENT DIVISION MINISTRY OF HEALTH MALAYSIA