Patient Safety II Presentation PDF

PATIENT SAFETY II DR\ SHAIMA HAMED ALBELWI MD,MSC, CPHQ ,CPPS , FISQUA,teamstepps master trainer, internal assessor of king AbdulAziz award quality& patient safety director at tabuk healthcare affair  CONTENT OUTLINE *RCA. *FMEA. *Differences between RCA&FMEA. *organiza...

PATIENT SAFETY II DR\ SHAIMA HAMED ALBELWI MD,MSC, CPHQ ,CPPS , FISQUA,teamstepps master trainer, internal assessor of king AbdulAziz award quality& patient safety director at tabuk healthcare affair  CONTENT OUTLINE *RCA. *FMEA. *Differences between RCA&FMEA. *organizations. Healthy kidney Removed by mistake 2015 patient with suspected kidney cancer had the wrong kidney removed. Instead of the right kidney that showed suspected renal cell carcinoma in a CT scan, the healthy left kidney was removed. A second surgery was then performed to remove the right kidney and the patient was left dependent on dialysis after losing both kidneys. The patient wasn’t a candidate for a kidney transplant  ROOT CAUSE ANALYSIS  A root cause is the approach, tools and techniques utilized to determine what the root cause of a problem is. WHEN : *after an adverse event occurs, and occasionally when there is a near miss. *every time there is a sentinel event without exception. WHERE: *close to the event occurrence *interviewed individually or to write what HOW: *uses the '5 Whys' approach to identifying the root cause. With this approach, the team asks 'Why' five successive times. *it is important not to leave any loose ends. *The time to stop asking Why is clear RCA PROCESS : *define the problem *collect data *identify possible causal factors *identify the root causes *recommended and implement solution  Report and Define the evaluate action problem plan Action plan Form team Multivoti Flow ng char pareto t Analyze the Determine root process cause Ask Fish Ideal 5 bon Flow why e chart Determine Perform causes safeguard analysis  Multi voting  Report the finding and evaluate to administration/management, all involved parties, and regulatory agencies as relevant.Evaluate effectiveness of action implementation and efficiency of RCA. : Failure mode effective analysis(FMEA) a tool designed to proactively and systematically evaluate a process: 1) determine where and how it might fail. 2)the effects of those failures. 3)identify the portion of the process the most in need of change Step 1 : identify a process Step 2 :entails establishing an interdisciplinary team. The team should include everyone involved in the process being studied. Step 3 : developing a flowchart of all the steps in the process to be studied.Every step in the process should be numbered from top to bottom. Step 4 the team will list all possible 'failure modes'. Failure mode & causes is defined as anything that could go wrong Step 5: the team will determine how likely it is the occurrence will occur, detected, and how severe the failure would be. (The resulting numbers of these rankings is called the Risk Priority Number RPN). Step 6: The failure modes with the highest numbers are the ones the team should begin to work on improving first step 7 : develop an action plan for improvement for the high priority failure mode  The FMEA tool prompts teams to review, evaluate, and record the following: Steps in the process Failure modes (What could go wrong?) Failure causes (Why would the failure happen?) Failure effects (What would be the consequences of each failure?) Likelihood of Occurrence: 1–10 [10 = very likely to occur] Likelihood of Detection: 1–10 [10 = very unlikely to detect] Severity: 1–10 [10 = most severe effect] Risk Priority Number (RPN): Likelihood of Occurrence × Likelihood of Detection × Severity One of the main differences between the FMEA and the RCA is the FMEA is proactive (before an adverse event occurs) and the RCA is reactive (after an adverse event occurs).  The World Health Organization (WHO) In 2009, the WHO developed a 19-item Surgical Safety Checklist to.decrease errors and adverse events during surgery  National Quality Forum (NQF) One of its charges was identifying a core list - of preventable, serious adverse events. -identified measures for medication safety, healthcare- associated infections, falls, pressure ulcers, surgical complications,.workforce issues, and other subjects The Centers for Medicare and Medicaid Services (CMS) Began withholding Medicare reimbursement October 2008 for 10 healthcare-acquired conditions (HACs) (CMS - HACs, 2017). These conditions were not present on admission (POA), but developed during the time the patient was under the care of the hospital, nursing home. The Joint Commission In 2003, The Joint Commission established National Patient Safety Goals for all healthcare organizations that they accredited. Soon after, other entities established patient safety goals or safety practices. IN 2014 moved all of their patient safety into a chapter entitled patient safety  AHRQ patient safety indicators (PSIs) a set of risk-adjusted measures that screen for potential in hospital complications and adverse events following surgeries, procedures. Two domain , hospital level indicators and area-level.  The Institute for healthcare Improvement (IHI) The IHI's goal for patient safety is to work with others- "to build safety into every system of care, ensuring that patients receive the safest, most reliable care across the continuum". -focuses on innovations which will create the system level changes across organizations at all levels to build measures and early warning systems for patient safety,. as well as for transparency The Patient Safety and Quality Improvement Act of 2005The PSQIA also established Patient Safety Organizations (PSOs) to standardize event data collection and reporting to the PSO without the fear of legal discovery or disciplinary action. -PSOs were approved by ARHQ beginning in 2008 and began accepting data in 2009 (Clancy, 2009). ‫معًا‬ ‫نبدع‬