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Chapter 9Chapter 9[1][1]
Patient Safety
Introduction Introduction Patient safety comprises the reporting,
analysis and prevention of adverse healthcare events and medical error.
Scary Facts:
– Patient-Safety related incidents cause harm in between 3% and 17% of hospital inpatients [4]
– At least 50% of medical equipment in most developing countries is not in usable condition [3]
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AgendaAgenda
In Chapter 9:
– Current patient safety goals – Objectives from the assessment of safety
cultures– How to implement a patient safety program– How to develop patient safety measures– Common safety analysis methods
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Current Patient Safety GoalsCurrent Patient Safety Goals [2][2]
Enhance the accuracy of patient identification
Improve the safety of using medications
Minimize patient slips, trips and falls
Minimize surgical fire risks
Minimize health care-related infections
Enhance communication between caregivers
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Objectives From the Assessment Objectives From the Assessment of Safety Culturesof Safety Cultures
Profiling
Benchmarking
AwarenessEnhancement
MeasuringChange
Accreditation
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How to Implement a Patient Safety How to Implement a Patient Safety Program (8-Step Process)Program (8-Step Process)
Step 1: Perform safety climate survey Step 2: Educate staff members about safety education Step 3: Survey staff members in regard to safety concerns Step 4: Take an in-depth look Step 5: Plan and implement necessary improvements Step 6: Document the results Step 7: Share the stories Step 8: Repeat step 1 (safety climate survey)
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How to Develop Patient Safety How to Develop Patient Safety Measures (6-Step Process)Measures (6-Step Process)
Step 1: Conduct a systematic literature review
Step 2: Choose specific types of outcomes for evaluation
Step 3: Choose pilot measures
Step 4: Write design specifications for the measures
Step 5: Assess data validity and reliability
Step 6: Pilot test the measures
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Common Safety Analysis MethodsCommon Safety Analysis Methods
Technic of Operation Review (TOR)
Fire Drill Seat Belt Checks
Seeking Feedback
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Common Safety Analysis MethodsCommon Safety Analysis Methods
Root Cause Analysis (RCA)
Also known as:“The 5 Why’s”
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Common Safety Analysis MethodsCommon Safety Analysis Methods
Root Cause Analysis (RCA)
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Common Safety Analysis MethodsCommon Safety Analysis Methods
Hazard Operability Analysis (HAZOP)
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A HAZOP study is usually carried out by a team, Lead by an experienced member that is versed in both in the use of the HAZOP technique and the system under investigation.
* Human Element is NOT the focus!
Common Safety Analysis MethodsCommon Safety Analysis Methods
Hazard Operability Analysis (HAZOP)
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Common Safety Analysis MethodsCommon Safety Analysis Methods
Failure Modes and Effect Analysis (FMEA) Per System:
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•Item(s) •Function(s) •Failure(s) •Effect(s) of Failure •Cause(s) of Failure •Current Control(s) •Recommended Action(s)
Common Safety Analysis MethodsCommon Safety Analysis Methods
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Common Safety Analysis MethodsCommon Safety Analysis Methods
Fault Tree Analysis (FTA)
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Common Safety Analysis MethodsCommon Safety Analysis Methods
Fault Tree Analysis (FTA)
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SummarySummary
– Current patient safety goals
– Objectives from the assessment of safety cultures
– How to implement a patient safety program
– How to develop patient safety measures
– Common safety analysis methods
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Where to Get More InformationWhere to Get More Information
http://jama.ama-assn.org/cgi/content/full/280/16/1444 http://jama.ama-assn.org/cgi/content/full/jama
%3B287/15/1993 http://muse.jhu.edu/journals/
journal_of_health_care_for_the_poor_and_underserved/v020/20.1.dingham.html
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Where to Get More InformationWhere to Get More Information
Dr. Joan Burtner – burtner_j@mercer.edu
Jason Coggins Jermaine Early Eric Hudnall Joshua Smith
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ReferencesReferences
[1] Dhillon, B.S., (2008). Patient Safety. Reliability Technology, Human Error and Quality in Health Care (pp 129 – 139). Boca Raton, FL: CRC Press
[2] National Patient Safety Goals. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO), 1 Renaissance Blvd., Oakbrook Terrace, Illinois, 2007. Also available online at www.jointcommission.org/patientsafety/nationallpatientsafetygoals/07_npsg_facts.htm
[3] Patient Safety, Fact Sheets. World Health Professions Alliance, April 2002. www.whapa/factptsafety.htm.
[4] Sary, A.F., Sheldon, T.A., Cracknell, A., Turnbull, A. Sensitivity of Routine System for Reporting Patient Safety Incidents in an NHS Hospital: Retrospective Patient Case Note Review. British Medical Journal 327 (2006): 432-436.
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Questions?Questions?
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