Date post: | 16-Jan-2017 |
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Healthcare |
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Introduction to Patient Safety
Dr. Shailendra.V.L.Patient Safety Department
Al Bukeriya general hospital
Outline
• Introduction to the concept of Patient Safety• Occurrence Variance Report (OVR)– Adverse Events– Near Miss– Sentinel Events
• International Patient Safety Goals
SECTION-I
INTRODUCTION TO THE CONCEPTOF
PATIENT SAFETY
Patients and Medical Errors
• Healthcare errors impact 1 in every 10 patients around the world (WHO)
• Institute of Medicine, USA found in a study:-– Medical errors injure 1 in 25 hospital patients– Kills about 44,000 to 98,000 every year– Medical errors costs USA billions of dollars each
year
Risk Comparison• Less than one death per 100,000 encounters– Commercial airlines– Nuclear power generation– Off shore oil rigs
• One death in 1,000 – 100,000 encounters:– Motor vehicle driving– Chemical manufacturing
• More than one death per 1,000 encounters– Bungee jumping– Mountain climbing– Health care
Why Errors?“To err is human”
• Not always willful negligence but systemic flaws• Inadequate communication• Wide-spread process variation• Patient ignorance
Every error has a root causeEvery cause has a solution
Errors can be prevented with every one’s participation in the system
Here comes the role of the patient safety department
Patient Safety
• Patient safety is a new healthcare discipline that emphasizes on – Reporting– analysis, and– prevention ofmedical errors that may leads to adverse patient
outcomes
Patient Safety• Goals of Patient Safety– Detection of safety issues– Preventive & corrective actions– Processes to reduce risks
• Broad Strategies– Self reporting (OVR)– Safety oriented Leadership Walk Rounds– Communication / education– MOH – Patient safety standards monitoring– Promoting patient safety culture
SECTION-II
OCCURRENCE VARIANCE REPORT (OVR)
Sources of Errors
1. Individual made: Errors due to human factor in the process e.g. wrong calculations of dosage
2. System made: Holes in the system that allow to slip through e.g. no clear, detailed policy, no double checking systems
3. Environment made: Hazards that come from the environment of the hospital e.g. emotions, dangerous medicines, radiation hazards
How to Make it Safer
• Acceptance, not denial• Identifying the causes of the medical errors
and patient harm• Finding solutions• Improving systems
Identifying the Causes
• Significant patient harm• Patient complaints• Colleagues reporting• Management trying to detect• Self Reporting i.e. OVR
Occurrence Variance Report (OVR)
• Self Reporting – corner stone of improvement– Voluntary reporting of process variation by all
health care workers– Non punitive – no punishments– To improve the quality of services– To prevent recurrence of same errors – To target system, not individuals
Types of Events
1. Adverse Event: Any variation in the processes leading to unsafe situations in everyday working life
2. Near Miss: An event or situation that could have resulted in patient harm but did not, either by chance or timely intervention
3. Sentinel Event: Unexpected incident involving death or serious physical or psychological injury or the risk thereof
Example
• An inpatient received 2 (two) unit 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.
Examples of Reportable Events
• Eclampsia in booked patient• APGAR score less than 7 at 5 minutes• Unplanned blood transfusion• Wrong implant or prosthesis• Injury or unplanned repair or removal of an organ• Complications post ERCP• Complications post angiogram • Retinopathy of prematurity (ROP) needing laser
SECTION-III
INTERNATIONAL PATIENT SAFETY GOALS
International Patient Safety GoalsGoal 1: Identify patients correctlyGoal 2: Improve effective communicationGoal 3: Improve the safety of high-alert
medicationsGoal 4: Ensure correct-site, correct-procedure,
correct-patient surgeryGoal 5: Reduce the risk of health care–associated
infectionsGoal 6: Reduce the risk of patient harm resulting
from falls
Goal 1
• Identify Patients Correctly– Wrong-patient errors occur in virtually all aspects
of diagnosis and treatment – At least two patient identifiers• File number• Name
– Before• Administering medications, blood, or blood products • Taking blood and other specimens for clinical testing
Goal 2
• Improve Effective Communication– Verbal and telephone order or test result is• written down by the receiver• then read back by the receiver, and• confirmed by the giver
– Reporting back of critical test results and panic values
Goal 3
• Improve the Safety of High-alert Medications– Medicines with high risk of patient harm
– Policies to address the location, labeling, and storage of concentrated electrolytes
Goal 4
• Ensure Correct-site, Correct-procedure, Correct-patient Surgery– Mark surgical site identification and involve the
patient in the marking process
– Use time-out procedure before starting a surgical procedure
Goal 5
• Reduce the Risk of Health care–associated Infections– Implement an effective hand hygiene program
– Catheter associated infections
Goal 6
• Reduce the Risk of Patient Harm Resulting from Falls– Policies to reduce the risk of patient harm
resulting from falls – Implement initial assessment of patients for fall
risk and reassessment when indicated – Implement measures to reduce fall risk for those
assessed to be at risk
Conclusion
• Identification and prevention of patient harm
• Self reporting the events
• Adherence to the Six International Patient Safety Goals
THANK YOU