Patient Safety L PDF

# **CH4 Patient Safety** - Dr: Amira Salah - Together Everyone Achieves Much - The shortest way to be board certified ## **Definitions** - Patient safety practice is a type of process or structure whose application reduces the probability of adverse events resulting from exposure to healthcare sy...

# **CH4 Patient Safety** - Dr: Amira Salah - Together Everyone Achieves Much - The shortest way to be board certified ## **Definitions** - Patient safety practice is a type of process or structure whose application reduces the probability of adverse events resulting from exposure to healthcare system. - Mistake-proofing is the use of process or design features to prevent errors or the negative impact of errors. ## **Developing Framework for Patient Safety** 1. Develop a patient safety committee. 2. Integrate the patient safety-related efforts within a coordinating council. 3. Assign one person to coordinate patient safety various areas. 4. Expand the scope of current committee responsibilities and accountability to include patient safety various areas. ## **What is a patient safety committee?** A patient safety committee is a multidisciplinary team that takes a proactive approach to patient safety; It provides coordination and oversight to advance an organizations safety program and implement safety-related policies and procedures. ## **What is a patient safety committee do?** The patient safety committee coordinate (role of QP) the following: 1. The risk management. 2. The environmental safety. 3. The infection control. 4. & the quality improvement. ## **7 Steps to Patient Safety** 1. Build a safety culture. 2. Lead and support your staff. 3. Integrate your risk management activity. 4. Promote reporting(no blame). 5. Involve and communicate with patients and the public. 6. Learn and share safety lessons(Learning culture). 7. Implement solutions to prevent harm. ## **Leadership related standards on patient safety:** The leadership is to build an environment that recognize the importance of safety. ## **Leadership Focus** 1. Create & maintain a culture of safety. 2. Encourage decision making. 3. Implement patient safety program throughout the organization. 4. Ensure that the processes are designed well, using available information from internal or external sources about potential risks to patient and successful practices. ## **Responsibilities of Governing body to enhance patient safety** - Setting aims - Monitoring system-level measures. - Change the environment, policies and cultures. - Establish accountability. ## **Take Action to Reduce Risk** **Reactive:** - Investigate significant patient incidents(sentinel events). - RCA using(brainstorming, fishbone, flowchart) **Proactive:** - Monitor patient safety and redesign high-risk processes to prevent a sentinel event from occurring. - FEMEA using(brainstorming, affinity, fishbone, flowchart) ## **Patient Safety: Challenges and Concerns** - Difficulty recognizing errors. - Lack of information systems to identify errors. - Relationship of trust with providers. - Shortages of clinical professionals. - Concern about liability. - Limited capacity on how to use quality improvement tools such as PDSA. - Culture of patient safety is lacking. ## **Important Issues facing healthcare organizations** - Establishing culture of patient safety and just culture. - Identifying organizational champions. - Deploying patient safety strategies. - Adoption of safety-related technologies. ## **Patient Safety Plan** 1. Should standardize the definitions and categorize medical errors. 2. Establish or enhance an error, near miss reporting mechanism. 3. Identify data collection plan, reporting structure, as well as performing scheduling.  ## **Patient Safety Terms** | Term | Description | |---------------------|--------------------------------| | Adverse Event ADE | Injury or illness | | Medical Error | Deficient process of care | | Sentinel event | Major loss of function | | Near Miss | Could have resulted in loss, injury or illness, but did not | ## **Patient Safety Terms** - ADR: unpredictable, no preventable - Malpractice is normal in PS culture. ## **Some Reasons Why Errors Occur** **System Factors:** - Complexity of healthcare processes - Complexity of health care work environments - Lack of consistent administration practices **Human Factors:** - Limited knowledge - Fatigue - Sub-optimal teamwork - Attention distraction - Inadequate training - Reliance on memory - Poor handwriting ## **Not Who caused the accident but What caused the accident?** - “We cannot change the human condition, but we can change the conditions under which human works." - Adoption of this paradigm by leaders is the beginning for culture change. ## **The "Swiss Cheese” Theory of System Error**  ## **Patient Safety The Anatomy of Errors in Healthcare** - **Active Failures:** - Highly visible errors with immediate consequences - By first contacting staff (nurse) - **Latent Failures:** - may be hidden for years ## **The Anatomy of Errors in Healthcare**  ## **A safety culture** Is an atmosphere of mutual trust in which all staff? Members can talk freely about safety problems and how to solve them without fear of blame or punishment. ## **A safety culture** A. Senior management provides a climate that promotes patient safety. B. My supervisor/manager says a good word when he/she sees a job done according to established patient safety procedures. C. Discussion around major events focuses mainly on systems-related issues, rather than focusing on the individual(s) most responsible for the event. ## **Just Culture** - 3 basics: 1. It doesn't reduce the personal accountability and discipline. It emphasizes the learning from the errors and near misses to reduce errors in the future. 2. The greatest error not to report a mistake. Thereby prevent learning. 3. All in the organization to serve as safety. Both providers and consumers will feel safe and supported when they report medical errors, near misses and voice concerns about patient safety. ## **Psychological Safety** Psychological safety is a belief that one will not be punished or humiliated for speaking up with ideas, questions, concerns, or mistakes. - **No Blame Culture** A non-punitive encouraging voluntary reporting of adverse events. ## **Red Rules** - cannot be broken. - few in number. - easy to remember. - associated only with processes that can cause serious harm to employees, customers, or the product line. - Every worker, regardless of rank or experience in the company, is expected to stop the work or production line if the red rule is violated. ## **Highly Reliable Organizations Patient Safety** - Highly Reliable Organizations: - Risk monitoring: monitoring of activities to identify both expected and unexpected risks. - Appropriate reward systems that encourage safety-related behavior. - System quality standards. - Acknowledgment of risk to learn from error. - Flexible management model to promote teamwork and communication. ## **Communication and Teamwork Challenges** - led to development of SBAR - Addressed with other patient safety initiatives - Simulation training - Rapid Response Teams (RRT) - Walk-arounds - (PS communicate - before accreditation. for continuous. readiness - Patients participating on committees/RCAs ## **Miscommunication** - Miscommunication: Breakdowns in communication can result in the wrong treatment, a lack of treatment, or incorrect self-care by the patient. - Miscommunication can be the result of faulty systems (poor methods of reporting critical test results, for example); lack of attention to the health literacy of patients; or a lack of cultural competency on the part of the healthcare team. ## **Disclosure** - Implement a formal (transparent) policy and process of disclosure of adverse events to patients/families, including support mechanisms for patients, family, and care/service providers. - **Reasons to Disclose** - Earn trust. - Supports patient safety initiatives. - Required by The Joint Commission. ## **Barriers to Disclosure** - **Personnel Barriers to Disclosure** - Fear of legal liability - Fear of loss of licensure - Fear of punishment or loss of job - Feelings of vulnerability - **System Barriers to Disclosure** - Struggle with accepting even most well trained and competent can make mistakes - Conflict of Interest ## **Improve Patient Safety** - **Human Factors:** - Simplification - Standardization - Use of constraints and forcing functions - Reduce reliance on memory - Use of protocols and checklists - Avoid or reduce fatigue - Heighten awareness of error prevention through communication and training ## **Forcing Functions** - An aspect of a design that prevents a target action from being performed or allows its performance only if another specific action is performed first. - For EXAMPLE, one of the first forcing functions identified in healthcare was the removal of concentrated potassium from general hospital wards. ## **Resilience** - The capability of anybody to recover its size and shape after deformation caused especially by compressive stress. - An ability to recover from or adjust easily to or change. ## **Improve Patient Safety** - **Technology to Improve Patient Safety:** - CPOE Computerized physician order entry - Barcoding(BSMA) - Robotics - Electronic medical records ## **Technology to Improve Patient Safety**  ## **Barcode Medication Administration (BCMA)** - Provides a system of checks and balances to ensure medication safety. - Nurse scans name badge thus logging in as the person responsible for medication administration. - patient's barcode on the patient's ID bracelet is scanned prompting the electronic system to pull up the medication orders. - the bar code on each of the medications to be administered is scanned. This technology checks to ensure that the 5 rights of medication administration—right patient, right med, right dose, right route and right time—are met. ## **CPOE Advantages** - Direct entry of orders into EMR. ­ - Replaces handwritten orders. - Cross reference for potential drug-interactions or allergies. ­ - Reduces wait times for patients. - Improves compliance with best practices. - Ready access to patient data. ## **Electronic Medical Records**  ## **International Patient Safety Goals** Meeting the Joint Commission on accreditation of healthcare Organization (JCAHO) patient safety goals is the current trend in enhancing patient safety. ### **Patient Safety Goals**  ## **Requirement Goal 1 patients correctly** Use at least two patient identifiers whenever collecting laboratory samples or administering medications or blood products. Acceptable identifiers may be the individual's name, an assigned identification number, telephone number, photograph or other person-specific identifier. (e.g. birth date) ## **Requirement Goal (1) patients correctly** - Prior to the start of any invasive procedure, conduct a final verification process, (such as a “time out”) to confirm the correct patient, procedure and communication techniques. - Problems associated with surgical safety in developed countries account for half of the avoidable adverse events that result in death or disability. ## **Goal 2: Improve Effective Communication** **Rationale:** Ineffective communication is the most frequent cited category of root causes of sentinel events. Effective communication, which is timely, accurate, complete, and understood by the recipient, reduces error and results in improved patient/client/resident safety. ## **Requirement Communication** Simply repeating back the order or test result is not sufficient. Whenever possible, the receiver of the order or test result enter it into a computer, then read it back, and receive confirmation from the individual who gave the order or test result. ## **Requirement Communication** o Implement a standardized approach to abbreviations, symbols, and dose designations. Implement a standardized approach to “hand off” communications, including an opportunity to ask and respond to questions. **Reconcile Medications** ## **Reconcile Medications** o Reconcile Medications: Accurately and completely reconcile medications across the continuum of care. o Requirement: A complete list of the patient's medications is communicated to the next provider of service when a patient is referred or transferred to another setting, service, practitioner or level of care within or outside the organization. The complete list of medications is also provided to the patient on discharge from the facility ## **Requirement Communication** o Identify and, at a minimum, annually review a list of look-alike/sound-alike drugs used by the organization, and take action to prevent errors involving the interchange of these drugs. ## **Requirement Goal 3 high-alert medications** - Label all medications, medication containers (for example, syringes, medicine cups) or other solutions on and off the sterile field. ## **Goal 4: Ensure Correct-Site, Correct-Procedure, Correct-Patient Surgery** **Rationale:** Wrong-site, wrong-patient, wrong-procedure surgery can be prevented if appropriate processes are in place. The intent is to establish and implement processes to always identify the correct site, correct person and correct procedure. ## **SURGICAL SAFETY CHECKLIST**  ## **Goal 5: Reduce the Risk of Health Care-Associated Infections** Compliance with the CDC hand hygiene guidelines will reduce the transmission of infectious agents by staff to patients/clients/residents thereby decreasing the incidence of healthcare associated infections. ## **Summary**  ## **WHO collaborating centre for patient safety solutions** reporting to PSO without fear of legal discovery or disciplinary .action WHO collaborating centre for patient safety solutions identify, evaluate, adapt, coordinate, disseminate, accelerate .improvements in PS worldwide - Collaborating centre built international network composed of key - organizations and individuals with expertise in patient safety as accrediting bodies, national patient safety agencies, professional :societies - In 2009 WHO developed 19-item surgical safety checklist to .decrease errors and adverse events during surgery .increase teamwork and communication These checklists decreased morbidity and mortality, being used - for many types of surgery, customized to meet specific needs ## **National Quality Forum** - National Quality Forum: - nonprofit organization, focus on patient safety. - one of its charges was identifying core list of preventable, serious adverse events, sentinel events. - NQF identified measures for medication safety, healthcare associated infections, falls, pressure ulcers, surgical complications. - Endorsed patient safety measures: ## **Institute for Healthcare Improvement (IHI)** - provide website for their PS resources. - GOAL: to work with others to build safety into every system of care, ensure that patients receive safest most reliable care across the continuum. - Trigger tools - IHI focus on : - (innovations which will create the system level changes across organizations at all levels. - (System level reliability for patient safety. - (Build measures and EARLY WARNING SYSTEMS for PS. - (TRANSPARENCY. ## **IHI Interventions to reduce urinary catheter infections** Interventions to reduce urinary catheter use, ▪ Reminders to stop orders ▪ .removal protocols ## **AHRQ Team STEPPS:** - Team strategies and tools to enhance performance and patient safety. - teamwork system developed by AHRQ to help HC teams increase patient safety and make QIs. - Classify the 2 types of patient safety indicator to: provider(hospital) indicators and area level indicators (country ,state). ## **What are the 2 types of patient safety indicator?** - 1- pediatric and prevention. - 2- pediatric and inpatient. - 3- provider(hospital) indicators and area level indicators. - 4- safety and quality. ## **Leapfrog**  - One of the key principles behind the development of Leapfrog was to support value-based purchasing. - Leapfrog's mission is to reward healthcare providers that provide excellent care. ## **Policy on Patient Safety** **Safety standard policies:** - **Staff qualification and education** Policies: - Hiring - Training needs analysis - Continuing professional training ## **Policy on Patient Safety** **Safety standard policies:** - **Access to care and continuity of care (ACC)** Policies: - Admission - Networking - Transport - Discharge - Referral ## **Policy on Patient Safety** **Safety standard policies:** - **Patient and family rights** Policies: - Information - Patient care - Confidentiality - Security - Patient and family education ## **Policy on Patient Safety** **Safety standard policies:** - **Care of patients** Policies: - Clinical pathways - clinical practice - Medication preparation, storage - Periodic clinical monitoring and evaluation - Special care/Intensive care ## **Policy on Patient Safety** **Safety standard policies:** - **Anesthesia and surgical care** Policies: - pre-anesthetic evaluation - Surgical site preparation - Post-anesthetic care ## **Policy on Patient Safety** **Safety standard policies:** - **Medication Management and use** Policies: - Storage/dispensing - Preparation - Medication errors/near misses - Adverse drug reaction ## **Policy on Patient Safety** **Safety standard policies:** - **Quality improvement and patient safety** Policies: - Sentinel event reporting and handling or processing ## **Policy on Patient Safety** **Safety standard policies:** - **Prevention and control of infection** Policies: - Hand washing - Disinfection - Handling of infectious waste, sharps, specimens - Personal protective equipment (PPE) - Rational use of antibiotics ## **Policy on Patient Safety** **Safety standard policies:** - **Governance, Leadership and direction** Policies: - Organizational mission - Monitoring and evaluation - Periodic review of policies and procedures - Handling of complain - Patient survey - Accountability ## **Policy on Patient Safety** **Safety standard policies:** - **Facility Management and safety** Policies: - Safe Environment - Equipment maintenance - Building and environment maintenance - Patient transport maintenance - Other facility maintenance such as electricity, generator, water, gas management - Waste segregation and disposal - Others ## **Thank You**