Understanding the case Practice setting:

dr Arif private practice Hospital

Health problem: Spondylitis Spine Fracture

Understanding every new term in the case and your presentation

Public and private care Public and private practice Primary, secondary and tertiary care

Private/Individual Health Service Primary:

Private practice (FP/GP)

PHC (Puskesmas) Secondary

Specialist physician Hospital type C, D

Tertiary Sub specialist Hospital type A,B

Public Health Service Primary:

Public Health Comunity

Secondary DHO (Dinkes)

Tertiary: Provincial (Dinkes

Prop) National (Depkes)

(Patient) Inform Consent? Aim: Patient consent (aware, understand and

have full responsibility) about him/herself health condition and the treatment needed

Not merely asking permission for medical treatment

Parties: patient and health provider

Health Information System Information Form Procedures and flow chart Person behind the system Information operator

The Information System Flow

Hospital Admission Physician Patient &

Family

Patient-Doctor Communication

Referral Letter

Refer Back

Medical Record Admission Procedures

Referral Letter Physician Identity Patient Identity Summary of examination Working diagnosis Current treatment Type and Need for further examination or

treatment: Type of radiology examination needed

Case Analysis Describe the case: might use flow process

diagram Identify proximate factor: direct causing

factors: Patient could not proceed the laboratory

examination Proximate cause: referral letter not clear

Contributing factors: factors that lead to proximate cause:

Human resource issues: Was the staff adequately trained? Was the staffing adequate? Was there appropriate supervision?

Information availability: Was necessary information available, accurate, and complete?

Environmental issues: Did the physical environment contribute to the event? Are safeguards in place to minimize and address environmental risks?

Leadership and culture: Did the organizational culture impair safe care?

Communication among clinicians: Was communication among staff adequate?

The Final Patient Safety Incident Lab examination do not proceed Diagnosed not established Incomplete or inappropriate treatment Un-prevented complication:

Fracture : permanent disability, and cost

Process Proximate Cause Contributing Factors

Hospital admission

Admission and examination could not be proceed

Unclear referral letter:IncompleteHand writing

No clear information from doctor to patient

Unclear admission procedures for insurance patientNo refer back information to physician

What Happened Why Did this Happen

Prevention Action

Proximate Cause Contributing Factors

Admission and examination could not be proceed

Unclear referral letter:IncompleteHand writing

No clear information from doctor to patient

Standardized referral form using checklist

Provide : verbal ,written and repeat

Patient do not proceed the examination

Painful feeling:Long waiting timeUncomfortable waiting seat

Insurance Type

Private : No risk pooling and sharing between member Social

Service coverage (cakupan) General : all kind of health service Specific : specific health service as listed and agreed

Insurance Member (target) General Population Specific Population:

Vulnerable people (high risk) : woman, children, poor people

PATIENT SAFETY MANAGEMENT

A GUIDE FOR PRIMARY CARE PRACTICE

WHAT AND WHY

SOME BASIC TERM Error - “The failure of a planned action to be completed as intended or the

use of a wrong plan to achieve an aim.” Errors depend on two kinds of failure: • The correct action does not proceed as intended. (Referred to as error of

execution) • The original intended action is not correct. (Referred to as an error of

planning) Adverse (merugikan) Event – “an event that results in unintended harm by

an act of commission or omission (kelalaian) rather than by the underlying disease or condition of the patient.”

Near Miss - “an act of commission or omission that could have harmed the patient but did not cause harm as a result of chance, prevention, or mitigation (peringatan).” Near misses are also synonymous with potential adverse events and close calls.

Sentinel Event –a type of adverse event, defined by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) as an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof(dari padanya). Serious injuries specifically include a loss of limb or function.

Near miss tidak menimbulkan harmAdverse diakibatkan kelalaianSentinel diamsumsikan bukan kesalahan tapi

nasib

1) During an emergency resuscitation in an ICU, the physician running the resuscitation gives a nurse a verbal order to administer a dose of epinephrine. Instead of administering the dose the physician intended, the nurse administers a dose 10 times stronger. The patient dies.

2) A surgeon plans to amputate a diabetic patient’s left foot. During the actual surgery, however, the surgeon amputates the patient’s right foot.

3) A severely depressed patient who has denied being suicidal is placed on close observation in a psychiatric unit. Fifteen minutes after an observation is logged, the patient is found hanging from an exposed water pipe. The patient used his belt as a noose.

4) A rural surgeon advises a woman with breast cancer to undergo a radical mastectomy, even though a surgeon at a distant university hospital has assured her that a lumpectomy is indicated. Because the rural surgeon is closer to her home and his services are paid for by the woman’s HMO, the patient undergoes the radical procedure and develops extremely painful lymphedema.

5) A pharmacist can’t read a physician’s handwriting on a prescription and instead of filling a prescription for a stomach acid-controlling medication; she fills it with an antipsychotic. The patient notices that the pills in the prescription don’t look like the sample she got from the physician and asks the pharmacist about it.

TERMINOLOGY

GRADING

People Are Set-Up toMake Mistakes

Incompetent people are, at most, 1% of the problem. The other 99% are good people trying to do a good job who make very simple mistakes and it's the processes that set them up to make these mistakes.

Dr. Lucian Leape, Harvard School of Public Health

Need to Increase Focus on the Human Factors

Studies of adverse patient incidents have heightened our awareness of the need to redesign processes to prevent human errors.

It’s time for organizations to use cognitive ergonomics or human factors analysis to make health care services safer for patients.

How Can Safety be Improved?

Human errors occur because of: Inattention Memory lapse Failure to communicate Poorly designed equipment Exhaustion Ignorance Noisy working conditions A number of other personal and

environmental factors

Process Redesign Solutions Make mistakes impossible

Auto-shut off heating devices Circuit breakers Ready-to-administer medications Over-write protected computer disks

Can you think of other mistake-proofing techniques?

Process Redesign Solutions Design safer processes

Barriers or safeguards can prevent untoward events

X-ray confirmation of tube placementMandatory repeat-backsDoor alarmsSurgical site confirmation

Can you think of other barriers or safeguards?

Process Redesign Solutions Reduce harm caused by mistakes

People must be able to quickly recognize the adverse event and take action

Human interventionsResponse teamsBackupsAutomation

Can you think of other methods for reducing patient harm?

PATIENT SAFETY MANAGEMENT Patient Safety: Actions undertaken by

individuals and organizations to protect health care recipients from being harmed by the effects of health care services

STEPS

CASE SCENARIO

PROCESS PROBLEM PROXIMATE CAUSE

Family Physician practice:

No information how to use insurance

Do not knowAssuming patient knowLimited time

Unclear referral letter Hand writingIncomplete informationUn-standardized form

No information how to manage the disease at home

Assuming patient knowLimited time

PROCESS PROBLEM PROXIMATE CAUSE

Hospital Admission Officer :

Could not understand the referral letter

Unclear handwritingIncomplete informationNo clarification mechanism

Insurance card do not work for the hospital

The intended health service was not covered by insuranceNo collaboration between ins & hosp

Unclear information how to use the insurance card

Crowded patientNo standard proceduresNo standard information

No referral back to physician

PROBLEM PROXIMATE CAUSE

ACTION TO PREVENT

No information how to use insurance

Do not knowAssuming patient knowLimited time

Hand book how to use insurance

Unclear referral letter Hand writingIncomplete informationUn-standardized form

Standardized Form

No information how to manage the disease at home

Assuming patient knowLimited time

Provide written informationIncrease the doctor patient ratio

No follow up to patient

Take Action to Reduce Risk Reactive: Investigate significant patient

incidents (sentinel events). Proactive: Monitor patient safety and

redesign high-risk processes to prevent a sentinel event from occurring.

Root Cause Analysis A reactive (after-the-fact) activity

Example of sentinel event:An inpatient received 2 units of the incorrect type of blood. At the time the patient’s blood was drawn for a type/cross match, the sample was mislabeled with another patient's name. The transfusion was given to the patient whose name appeared on the type/cross match lab report, not the patient whose blood was in the lab specimen vial.

Results of the analysis: The root cause of the event was the poorly designed system for labeling laboratory specimens. If not corrected, this problem could cause other incidents.

Root Cause Analysis Steps

1. Gather the facts.2. Choose team.3. Determine sequence of events.4. Identify contributing factors.5. Select root causes.6. Develop corrective actions & follow-

up plan.

Examining the Safety of Processes Failure mode, effects and criticality analysis

(FMECA) What could go wrong? How badly might it go wrong? What needs to be done to prevent failures?

FMECA Steps Flow chart the process Brainstorm potential failures at each step

in the process Determine the criticality of each failure

(frequency x severity x detectability) Discover what causes critical failures