MEDICAL ERRORS & QUALITY TOOLS

Views:
 
Category: Education
     
 

Presentation Description

this presentation outlines the medical errors , quality tools and risk management

Comments

Presentation Transcript

MEDICAL ERRORS & QUALITY TOOLS 2013:

MEDICAL ERRORS & QUALITY TOOLS 2013 Dr.Waleed Fawzy Specialist Surgeon

PowerPoint Presentation:

HUMAN IS TO ERR كل إبن آدم خطاء و خير الخطائين التوابون

Important definitions:

1- Adverse Event: Error occurs and causes harm to the patient 2- Near Miss : Error occurs without harm to the patient but was about to cause harm. 3- Sentinle event : Error occur which cause death or loss of an organ or loss of multiple organs Important definitions

A SENTENCE THAT SHOULD BE REMOVED FROM OUR LIFE:

A SENTENCE THAT SHOULD BE REMOVED FROM OUR LIFE

Legal Liability:

Health care professional is liable legally if he commits an error and the error caused harm المادة 27 من مزاولة المهن الصحية كل خطأ مهني صحي صدر من الممارس الصحي و ترتب عليه ضرر للمريض, يلتزم بالتعويض و تحدد الهيئة الصحية الشرعية مقدار التعويض Legal Liability

Common Causes Of errors:

Meds Errors Bad communication Infection Falls Surgical Poor Patient Identification Common Causes Of errors

SITE MARKING:

SITE MARKING

PowerPoint Presentation:

80% Of Medical Errors Are System-Driven (IHI )

PowerPoint Presentation:

First Do No Harm Epocrates The assumption of safety is the provision of healthcare, it is as fundamental as care itself

For the sake of patient safety:

Risk Management Infection Control FMS Qualified staff Credentialing & privileging Performance appraisal Practice guidelines Policies & procedures Medication safety For the sake of patient safety

Safe Healthcare How?:

Because Health system is complex. Stepwise correction of the problems in the system and process Patient Practitioners System Safe Healthcare How?

Learning from mistakes:

Near miss , adverse event and sentinel event are symptoms of a pathology in the organization So , we must collect data about errors to learn from it. Learning from mistakes

How can we collect data about medical errors and adverse events:

Prospective Direct observation of patient care Retrospective Voluntary incident report system (OVR) Record review (global trigger tools for adverse event) Malpractice claim analysis All complaints should be tackled positively How can we collect data about medical errors and adverse events

رحم الله إمرئ أهدى لي عيوبي (عمر بن الخطاب رضى الله عنه) GOD BLESS PERSON DEDICATE TO ME MY DRAWBACKS :

رحم الله إمرئ أهدى لي عيوبي (عمر بن الخطاب رضى الله عنه) GOD BLESS PERSON DEDICATE TO ME MY DRAWBACKS

Using Patient Safety Data:

The challenge is converting these data into real system changes How? Analyzing the incident to reach its root causes Suggesting remedies Testing remedies (pilot study) Implementing remedies Using Patient Safety Data

PowerPoint Presentation:

Redesigning systems & Process

SAFE GUARDS / BARRIERS:

SAFE GUARDS / BARRIERS

PowerPoint Presentation:

Redesigning systems and processes to make it more safe. Safe guards/barriers are not present Design new barriers Examples of barriers; Physical : Locks , safety equipment , electrical ground protection , poka yoke . Natural: Distance Information Barriers: caution signs and alarms

Poka yoke:

Poka yoke

Poka yoke:

Poka yoke

PowerPoint Presentation:

Knowledge Barriers ( check lists ,Barcode identification) Administrative Barriers Safety policies and procedures Regulations Supervised practices Design specifications Training education PPM Documentation Clinical pathways

QUALITY DAY:

1 ST WEDNESDAY IN THE 1 ST WEEK OF NOVEMBER PATIENT SAFETY IMPROVEMENT PROJECTS ARE REQUESTED . QUALITY DAY

QUALITY TOOLS:

QUALITY TOOLS

QUALITY TOOLS:

QUALITY TOOLS

QUALITY TOOLS:

Tools used to: Organize work Generate Ideas Prioritize work Measure execute QUALITY TOOLS

Organize Work:

Flow Chart Affinity Diagram Problem Statement Organize Work

Flow Chart:

Flow Chart

Generate Ideas:

Brain storming Structured Unstructured The provision is not to criticize any idea Cause & Effect Generate Ideas

RCA Root Cause Analysis :

Team formation Hospital Director Quality Director Head of departments From dep’t physician or nurse It should be not less than 4 and not more than 10 Definition of the problem Problem statement ( specific, measured, objective, do not include solutions) RCA Root Cause Analysis

Problem statement:

e.g 60% of healthcare providers in ICU from month 1 to month 6 /1433 did not follow properly the protocol of hand hygiene. Problem statement

Cause & effect:

Patrons Place Material Equipment Environment Process management Cause & effect

Fishbone Analysis:

Fishbone Analysis

Tools to prioritize:

Prioritization matrix Pareto Chart Multivoting Tools to prioritize

Prioritization Matrix :

Prioritization Matrix

Prioritization matrix:

Ford Toyota Chevrolet Hyundai Low price 30% Post sale service 25% safety 15% specifications 30% Motor power 5% Fuel consumption 10% Prioritization matrix

PARETO PRINCIPLE:

The Pareto principle is used in occupational health and safety to underline the importance of hazard prioritization. Assuming 20% of the hazards will account for 80% of the injuries and by categorizing hazards, safety professionals can target those 20% of the hazards that cause 80% of the injuries or accidents. Alternatively, if hazards are addressed in random order, then a safety professional is more likely to fix one of the 80% of hazards which account for just 20% of the injuries PARETO PRINCIPLE

PARETO PRINCIPLE:

for many events, roughly 80% of the effects come from 20% of the causes. 80% of your sales come from 20% of your clients 80% of your complaints come from 20% of your customers 80% of your profits come from 20% of the time you spend 80% of your sales are made by 20% of your sales staff PARETO PRINCIPLE

Pareto Chart:

Pareto Chart

Tools to measure:

Histogram Control chart Tools to measure

Histogram:

Histogram

Control Chart:

Control Chart

Control Chart:

Control Chart

Tools to execute:

Action Plan Gantt Chart Tools to execute

Action Plan:

Action Plan

Gantt Chart:

Gantt Chart

RISK MANAGEMENT:

RISK MANAGEMENT

DEFINITIONS:

HAZARD الخطر RISK القابلية للإيذاء EXPOSURE التعرض HAZARD + EXPOSURE = RISK DEFINITIONS

Risk Assessment:

1- PREDICT POTENTIAL ADVERSE EVENTS 2- RISK PRIORITIZATION HIGH VOLUME HIGH RISK PROBLEM PRONE EXPOSURE TO HAZARDOUS EFFECT Risk Assessment

Risk management process:

Risk management process

Risk Identification:

OVR Surveillance of practices that may create liability (High Risk Procedures) Generic screening OR Key Exposure Area Analysis Risk Identification

RISK MANAGEMENT PLAN:

List of procedure , behavior and situations that may potentially cause harm List of statistics estimated likelihood of each occurrence List of severity of each occurrence. RISK MANAGEMENT PLAN

Risk control:

Risk avoidance Risk prevention Risk shifting Risk transfer Risk control

RISK ASSESSMENT TOOLS:

FMEA (Failure Mode Effective analysis) SAC (Safety Assessment Code) HVA (Hazard Vulnerability Analysis) SAC IS THE ONE ASKED BY SBAHI RISK ASSESSMENT TOOLS

FMEA (FAILURE MODE EFFECTIVE ANALYSIS):

FMEA (FAILURE MODE EFFECTIVE ANALYSIS)

SAC (SAFETY ASSESSMENT CODE):

SAC (SAFETY ASSESSMENT CODE)

HVA:

HVA

Thank you:

Thank you

authorStream Live Help