Patient Safety

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Patient Safety:

1 Patient Safety

MEDICAL ERRORS Magnitude of the Problem:

2 MEDICAL ERRORS Magnitude of the Problem In the U.S., death from medical errors is now considered to be a national epidemic, based on the report To Err is Human: Building a Safer Health System (Kohn, Corrigan, and Donaldson, editors) released by the Institute of Medicine (lOM) in November 1999. The report synthesizes the results of numerous studies on medical errors and, based on data collected from two hospitals in New York that were extrapolated nationally, estimates that medical errors result in 44,000 to 98,000 deaths annually. The lOM also estimated that medical errors account for as much as $29 billion annually in lost income, disability, and healthcare costs.

First do no harm:

3 First do no harm The assumption of safety in the provision of healthcare is as fundamental as care itself. " Safety is the most basic dimension of performance necessary for the improvement of healthcare quality. Safety is the underlying reason for risk management, infection control, and environmental management programs. It is the reason we insist on qualified clinical practitioners and support staff, validating education, expertise, and other credentials; providing appropriate orientation and continuing education; and performing periodic appraisal.

The Healthcare Environment:

4 The Healthcare Environment The healthcare environment that is most effective in identifying and reducing those errors and risk factors contributing to unintended adverse patient outcomes:. Has leaders who foster commitment to safety through personal example, communication, and strategic planning;. Establishes a vision of the desired patient safety culture that is communicated throughout the organization on a focused, ongoing basis;. Provides a strategy for change and improvement and allocates financial, personnel, educational, and time resources; Encourages patients, families, organization staff, and leaders to identify and manage actual and potential risks to patients, staff, and visitors;

The Healthcare Environment:

5 The Healthcare Environment Encourages error management and intervention:- Recognition and acknowledgment of risks and errors; Initiation of actions to reduce risks and errors;- Safe communication and/ centralized internal reporting of findings, actions, successes, failures;- A focus on processes and systems and minimization of individual blame for errors;.- Organizational learning and sharing knowledge to effect behavioral

What is a culture of safety?:

6 What is a culture of safety? Components of a safety culture include: Commitment to safety as the primary priority Availability of the necessary resources Incentives, and rewards for safety Openness about errors and problems Commitment to organizational learning Unity, loyalty, and teamwork among staff Non Punitive Environment

Challenges of Creating a Culture of Safety:

7 Challenges of Creating a Culture of Safety Internal Factors: Over Self-confidence of Healthcare providers Routine work/Work Load Lack of resources Lack of Information about the magnitude of the problem Lack of commitment from Hospital leaders Lack of effective supervision Competency of Staff

Challenges of Creating a Culture of Safety:

8 Challenges of Creating a Culture of Safety External Factors: External Environment Lack of supportive Infrastructure Community Awareness Individual behavior Culture of Fear Medico-Legal Practice

Improving Safety Culture :

9 Improving Safety Culture Leadership: Hospital leaders must establish safety as a priority. A learning and improvement cycle: Analysis focuses on systems rather than individuals and is non-punitive. Analysis should include trend and aggregate data. Accountability: Improvement team members must be held accountable for identifying effective solutions. Timely feedback: The system must feed back useful information to front-line workers, especially those who report the problem, and must do so in a timely manner.

Improving Safety Culture:

10 Improving Safety Culture Incentives and rewards for pursuing safety: A simple, but powerful reward implemented by one hospital was a formal letter of thanks from the Chief Executive. Reporting For Learning Use education and communication strategies to broaden the “circle of believers” new employee orientation, mandatory patient safety training, just-in-time root cause analysis participant training, as well as informal interactions. Employee newsletters and email “safety-grams” can be used to discuss lessons learned and to share improvements and recommended practices.

2006 National Patient Safety Goals:

11 2006 National Patient Safety Goals #1) Improve the Accuracy of Patient Identification Use at least two patient identifiers (neither to be the patient's room number) whenever administering medications or blood products; taking blood samples and other specimens for clinical testing, or providing any other treatments or procedures. #2) Improve the effectiveness of Communication among Caregivers For verbal or telephone orders or for telephonic reporting of critical test results, verify the complete order or test result by having the person receiving the order or test result "read-back" the complete order or test result. Standardize a list of abbreviations, acronyms and symbols that are not to be used throughout the organization. Measure, assess and, if appropriate, take action to improve the timeliness of reporting, and the timeliness of receipt by the responsible licensed caregiver, of critical test results and values. Implement a standardized approach to “hand off” communications, including an opportunity to ask and respond to questions.

2006 National Patient Safety Goals:

12 2006 National Patient Safety Goals #3) Improve the safety of using medications Standardize and limit the number of drug concentrations available in the organization. Identify and, at a minimum, annually review a list of look-alike/sound-alike drugs used in the organization, and take action to prevent errors involving the interchange of these drugs. Label all medications, medication containers (e.g., syringes, medicine cups, basins), or other solutions on and off the sterile field in perioperative and other procedural settings. # 4) Eliminate wrong-site, wrong-patient , wrong-procedure surgery: (1) preoperative verification process/checklist for available documents/studies; (2) surgical site marking process involving the patient [now in a Universal Protocol

2004 National Patient Safety Goals:

13 2004 National Patient Safety Goals #5) Improve the safety of using infusion pumps Improve the safety of using infusion pumps: Ensure free-flow protection of all intravenous infusion pumps #6) Improve the effectiveness of clinical alarm systems Specific recommendations: Implement regular preventive maintenance and testing of alarm systems. Assure that alarms are activated with appropriate setting and are sufficiently audible with respect to distances and competing noise within the unit. #7) Reduce the risk of healthcare-acquired infections Comply with current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines. Manage as sentinel events all identified cases of unanticipated death or major permanent loss of function associated with a health care-associated infection.

2006 National Patient Safety Goals:

14 2006 National Patient Safety Goals #8) Accurately and completely reconcile medications across the continuum of care Implement a process for obtaining and documenting a complete list of the patient’s current medications upon the patient’s admission to the organization and with the involvement of the patient. This process includes a comparison of the medications the organization provides to those on the list. 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. #9) Reduce the risk of patient harm resulting from falls Implement a fall reduction program and evaluate the effectiveness of the program.

The Patient Safety Program:

15 The Patient Safety Program All healthcare organizations are expected to implement specific patient safety programs that include at least the following components:. A designated, qualified individual or interdisciplinary group to manage the program (typically individuals may include directors of quality/performance improvement, risk managers, safety officers, or clinical leaders);. A defined scope of program activities, including ongoing proactive efforts to both identify and reduce risk, as well as to respond to errors (from patterns of "no harm" errors to "near misses" to sentinel events); Mechanisms to ensure that all applicable functions of the organization are integrated into and participate in the program;

The Patient Safety Program 2:

16 The Patient Safety Program 2 Procedures for immediate response to medical errors, including care of affected patients, containment of risk to others, and preservation of facts for analysis; Internal and external medical error reporting processes; Defined intervention mechanisms, e.g., proactive risk reduction activities, systematic tracking of identified risks, root cause analysis for sentinel events; Defined mechanisms for support of staff involved in a sentinel event; Reporting to the governing body.

The specific patient safety program includes at least::

17 The specific patient safety program includes at least: Policies, procedures, and education mechanisms to reduce and control risk to patients (and staff); An occurrence/event reporting system; Proactive activities to identify high-risk processes and implement actions to reduce avoidable risk; A process for immediate response to medical errors and sentinel events; Mechanisms to incorporate all related functions and safety programs; Performance measurement; Documentation and reporting

Related Safety Programs A. Environment and equipment :

18 Related Safety Programs A. Environment and equipment All health care organizations have inherent environmental hazards and safety risks. Therefore the organization needs to identify those risks and implement processes to minimize them:- A written environmental management plan and designated leader to coordinate activities and respond to immediate threats; components include management! coordination of:- Safety-- Security– Staff education Hazardous materials and waste— Emergency power: maintenance, testing, and inspection— Fire safety: drills, equipment, building features— Medical equipment: maintenance, testing, and inspection– Utilities: maintenance, testing, and inspection–

Related Safety Programs A. Environment and equipment 2:

19 Related Safety Programs A. Environment and equipment 2 Standards and process to measure organization and staff performance Proactive risk assessments of buildings, grounds, equipment, and physical systems, with procedures implemented to reduce risk potential;- Establish safety policies and procedures, including smoking prohibition;- Maintain grounds and equipment and respond to product recalls;- Reporting; measuring, assessing, and improving; and annually evaluating the environment of care.

Related Safety Programs B. Employees:

20 Related Safety Programs B. Employees Staff, licensed independent practitioners, students, and volunteers should be able to describe their roles and responsibilities relative to safety, based on their specific job responsibilities and education received. They should be able to participate in safety drills, should know and comply with all applicable safety policies and procedures, and should report adverse occurrences/events upon first observation or first knowledge. Participates and respond to safety rounds

Physician Participation:

21 Physician Participation Specific ways in which physicians and other practitioners can facilitate patient safety/clinical risk management efforts:. Identify general areas of potential risk in the clinical aspects of patient care and safety;. Help design programs to reduce risk in clinical aspects of patient care;. Develop criteria for identifying specific cases with potential clinical and safety risk; . Evaluate specific cases identified as having potential or real clinical risk;. Participate on teams to correct problems in the clinical aspects of patient care and safety identified through performance improvement and risk management activities;

Role of the Quality Management Professional:

22 Role of the Quality Management Professional Patient safety must be #1 priority Facilitate appropriate integration of the appropriate organization functions, including infection surveillance, control, and prevention, and all safety processes;. Minimize duplication of effort in policy/procedure development, education of staff and patients, data collection and aggregation, and communications;. Prioritize and coordinate performance measurement and the data and information available for analysis, reporting, and decision making;

Role of the Quality Management Professional:

23 Role of the Quality Management Professional Ensure that reactive activities such as root cause analysis (RCA) and proactive activities such as failure modes and effects analysis (FM EA) are conducted timely, efficiently, and effectively.. Coordinate the flow of information to all who need to know and respond, including results of occurrence/event reporting, performance measurement, reactive and proactive activities, educational content, and safety policies and procedures.

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