DR. ASHFAQ AHMED BHUTTOM B B S, M B A , M A S, D C P S, M R C G P, ( P h D )

SUNDAY, FEBRUARY 19 , 2012

Hospital ManagementSession VIII

Patient Safety Friendly Hospital Initiative (PSFHI)

Acknowledgement

The slide depicted here are taken from WHO resource CD provided by WHO EMRO region with permission.

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The risk of Dying is:

If some one is admitted to a Hospital in USA for one day only

It is equal to travel

8800 hour in an Air plane or 460 trip from Pakistan to USA

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Adverse Events in Health Care

■ 10% of hospital patients suffer an adverse event■ 16.6% of hospital patients suffer an adverse event

(Australia)■ ≈100,000 hospital deaths/year through medical

error (USA)■ Unsafe Surgery:

o234m case globally/year: 7 m complications, 1 m death

■ Patient Handoverso15% of adverse events or errors (USA study)

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Common Types of Error

A nurse gives a patient a 4 X overdose of methotrexate; the patient dies

A physician removes the wrong kidney A patient receives a 10 X overdose of

insulin, goes into shock, is resuscitated, but has persistent brain damage.

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Case

64 year old woman is admitted to hospital with fevers. Presumed diagnosis of pneumonia, treated for that with penicillin. On day 2, she develops a severe rash, felt to be caused by her infection. Involves entire body. Service is very busy. No senior doctor available. Penicillin continued. Rash progresses. On day 4 she is confused, gets out of bed at night, floor is wet, and she slips and falls, fracturing hip. Dies on day 7.

What happened?

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Causation

Individuals made errorsJunior doctor didn’t know what was causing rashSenior doctor wasn’t availableNurse wasn’t there when patient got out of bed

However, the system also allowed errors to slip through

No good approach for dealing with very busy periodInsufficient nurse staffing at nightOperating room was too full and no surgeon available

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The Burden of Unsafe Care

Adverse events due to medical devices & medications: Good data from developed nations Very little data from developing / transitional nations

Surgical errors, health-care associated infections Common sources of harm in all nations Preliminary data from developing / transitional nations

Unsafe blood products Likely major cause of harm in some developing nations Reasonably good data from select nations (WHO)

Patients safety among pregnant women and newborns Better data needed from developing / transitional nations

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The Burden of Unsafe Care: Developing Countries

Mothers and newborns

Maternal mortality rates: North America:

Asia (some countries):

Africa (some countries):

Afghanistan

1 in 3700

1 in 65

1 in 16

1 in 6

% deliveries in developing countries attended by health professional: 53%

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The Burden of Unsafe Care: Unsafe Injections

16 billion injections a year in developing countries

39.6% with syringes and needles reused non sterilized (70% in some countries)

Unsafe disposal can lead to re-sale of used equipment on the black market. The extent of harm caused by unsafe injections is unknown

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Unsafe Blood, Counterfeit Drugs

5–15% of HIV infections in developing countries are due to unsafe blood

Unsafe blood risks transmission of: hepatitis B & C syphilis, malaria, Chagas disease and West Nile fever

Counterfeit drugs account for up to 30% of medicines consumed in developing countries

The extent of harm caused by unsafe blood and medications are unknown

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Deficit of Qualified Health-care Providers

The deficit in 57 countries is estimated to be 2.4 million doctors, nurses and midwives

Fatigue, production pressures cause high risk of mistakes

Medical Record Review Study Results

Study Adverse event rate

No. of records

Permanent disability

Percent deaths

Percent AE preventable

EMR 8.1%(2.5-18%)

15,548 0.9% 1.86% 83%

Australia 16.6% 14,210 2.2% 0.79% 50%

Canada 7.5% 3,745 0.4% 1.2% 37%

New York 3.7% 30,195 0.24% 0.51% NA

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Wilson RM. Unpublished data, Regional Patient Safety Research Meeting, Amman, Jordan, August 2008

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THE SWISS CHEESE MODEL

SUCCESSIVE LAYERS OF DEFENCES

ProceduresPhysical barriers

Information

Decisions

Adapted from Professor James Reason

THE SWISS CHEESE MODEL

Patient harmed

DEFENCESProcedures

Physical barriers

Information

Decisions

THE HOLES

Poor protocols

Faulty equipment

Missing information

Inadequate supervision Adapted from Professor James Reason

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II Assess Scope

V Organizing & Running

PS programs

I Awareness

III Understanding the Causes of Error

IV Developing & Testing Methods

For Prevention

EMR Patient Safety

Strategy

Regional Strategy for Patient Safety 5 Axes to enhance the safety of patients

Patient Safety Friendly Hospital Initiative (PSFHI) – (1)

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Promote safe practices in hospitals by assessing adherence to PS guidelines developed - EMRO/WAPS/IIRO

Develop standards for assessing patient safety and guidelines for implementation Patient safety assessment manual 7 hospitals identified as pilot sites for PSFHI – EGY,

JOR, MOR, PAK, SUD, TUN, YEM

Patient Safety Friendly Hospital Initiative (PSFHI) – (2)

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PS Assessment manual developed Review of literature Internally reviewed Externally reviewed Pre-piloted Piloted

Baseline Assessment of 7 hospitals completed between July-October 2009

Five Domains for Measurement of Performance of a PSF Hospital

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2121

PSFHI Assessment Manual

Domains Critical Core DevelopmentalLeadership andManagement

9 20 7

PatientCenteredness

2 16 10

Evidence based Practice

7 29 8

Environment 2 19 0

Lifelong learning 0 6 5

Total score 20 90 30

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Baseline assessment of pilot hospitals in 7 countries

Standards EGY JOR MOR PAK SUD TUN YEM

Critical (20)

15.5 12 10.5 13 8 11 5

Core (90) 41 34 25.5 34 22 32.5 16.5

Developmental (30)

0.5 4 1 3.5 1 3 1

Total 57.5 50 37.5 50.5 32.5 47.5 22.5

Domains Patient Safety Subdomain Critical Standards

Core Standards

Developmental Standards

A. Leadership and Management Domain

A.1. The leadership and governance are committed to patient safety

3 3 2

A.2. The hospital has a patient safety program.

2 5 2

A.3. The hospital uses data to improve safety performance.

0 2 2

A.4. The hospital has essential functioning equipment and supplies to deliver its services.

3 3 1

A.5. The hospital ensures staff safety for safer patients and availability of staff round the clock to deliver safe care.

1 5 0

A.6. Hospital has policies, guidelines, and standard operating procedures (SOP) for all departments and supporting services.

0 2 0

9 20 723

Examples of Critical Standards:

The hospital has Patient Safety as a strategic priority. This strategy is being implemented through a detailed action plan.

All patients are identified and verified with at least 2 identifiers including full name and date of birth.

The hospital maintains clear channels of communication for urgent critical results.

The hospital conforms to guidelines on management of sharps waste.

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Examples of Core Standards :

The hospital has a set of process and output measures that assess performance with a special focus on patient safety.

The patient rights statement exists in the hospital and is visible to patients.

The hospital ensures that each and every patient has a single completed medical record with a unique identifier.

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LEVELS OF COMPLIANCE WITH PATIENT SAFETY STANDARDS

Hospital level Critical Standards

Core Standards

Developmental Standards

Level 1 100% Any Any

Level 2 100% 60-89% Any

Level 3 100% ≥ 90% Any

Level 4 100% ≥ 90% ≥ 80%

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How to Develop a PS Program in your Hospital?

1-Leadership Commitment

Embrace a blame free CultureStrategic planAccountabilityLeadership PS walk rounds

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2-Establish a PS Organizational Structure

Human Resources: PS leader PS Coordinator PS Departmental focal points

PS CouncilPS Sub committees:

Infection prevention and control Environment safety Medication safety Research and ethics Patient and public involvement

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3-Adopt PSFH Standards

Start learning about PSFH standards and how to comply with them

Self assessment on ongoing basisAction plan : develop and monitor its

implementation

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4- Train , Train, Train

Involve as many as possible:PS ConceptsPS assessmentPS reporting PS SOPs , plansRisk Management

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5- Work to Overcome Resistance

What are they going to gain?Let them compete and be proud of their

accomplishmentsCommunicate to all staff

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6- Develop Systems, Procedures that support PS

Risk ManagementADE ReportingClinical AuditingPS Performance ManagementPatient Safety Tour

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Thank You

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