Chapter 1:Patient Safety inJurongHealth

JurongHealth & Patient Safety

Patient Safety:-defined as the freedom from accidental or preventable injuries produced by medicalcare. (AHRQ, Patient Safety Net)

JurongHealth ensures the safety of patients in accordance with the 6 dimensionsof quality of care, defined by the Institute of Medicine as :

1. Providing safe care through learning from Incident Reporting

2. Ensuring efficient care structured process of Specialist Outpatient Clinic visits

3. Ensuring timeliness through quality improvement projects

4. Ensuring Patient Centeredness through Patient Safety & Quality Assurance Committees

5. Providing effective care through policies and procedures

6. Providing equitable care

(IHI, Crossing the Quality Chasm: A New Health System for the 21st Century, 2001)

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Providing safe care through learning from Incident Reporting

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Providing safe care for patients meansto avoid harming patients from the carethat is intended to help them.

Learning from actual and near missPatient Safety incidents allowsimprovement in system processes,which benefit patients.

JurongHealth identifies Patient Safetyincidents through the electronic IncidentReporting Information System (IRIS).The management encourages all staff tovoluntarily report incidents. This isthrough the assurance that werecognise that errors are mostly due tosystem failure designs, and that errorsare rarely only the individual’s faults.This approach is known as the non-punitive approach.

By conducting review and analysis ofthese incidents, we can identify thematicissues through Root Cause Analysis.Appropriate corrective measures canthen be implemented to preventrecurrences. As such, we are able torectify issues immediately and alsoensure safer care for future patients.

Examples of Patient Safety incidentsinclude medication errors, patient falls,peripheral venous complications;pressure ulcers; treatment relatedincidents such as skin tear during patienttransfer; issues when diagnosingpatients; sharps injuries and body fluidsplash incidents, laboratory relatedincidents and conditions that are unsafe.

Since the launch of IRIS in February2013, reporting has increased from anaverage of 40 per month in 2012, toalmost 70 reports per month in 2014. Atotal of 193 improvements were alsocarried out from January 2013 to June2014!

In summary, ensuring safe care is anessential first step to improve quality ofcare.

Staff can access IRIS toReport a Patient Safetyincident by visitingJurongHealth intranet,under Quick Links, clickon Incident ReportingInformation System (IRIS)- Report an Incident.

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"When staff are willing to own up to their mistakes, they should not bepunished, but commended instead! This, however, does not mean thatwe condone wilful disregard of established processes and policies thatserve the purpose of protecting patients. Reporting incidents help ourhospital to improve processes and allows us to obtain feedback on ourown performance so that we can act fast (Do we really want them to actfast? We want them to be safe right?). It helps us identify risks so thatlearning can be carried out to prevent future occurrence"- Mr Foo Hee Jug JurongHealth CEO

“The main reason for reporting incidents is to improve patient safety bylearning from incidents and near misses. It stems from theunderstanding that the report will be analysed in a systematic non-punitive manner leading to enhanced learning regarding the root causeof the incident and systemic changes which will prevent it fromrecurring. The goal of feedback must be to learn from mistakes, and toensure that the systems are improved for better patient safety in thefuture. The feedback should be through multi- sources from the front-end clinical staff right to the high-level managerial staff. It is extremelyimportant that all staff can see something positive coming out of theincident reporting to encourage continued active participation in theprocess.”- Dr Chua Ai Ping Senior Consultant, Medicine

Ensuring efficient care structured process of SpecialistOutpatient Clinic visits

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In order to be efficient when providing medical care for patients, the use ofresources in the hospital has to benefit the patients a system is intended to help.

In JurongHealth, the structure of a Specialist Outpatient Clinic visit is designed insuch a way that optimises doctor/patient interaction. Before an outpatient visits adoctor, he or she is first engaged by the patient service associate to have heightand weight taken. The patient will then be brought to a room to have parametersand vital signs taken by a nurse. At this point, other basic questions to establishthe patient’s history will be asked. By the time the patient is brought into theconsultation room to see the doctor, all of the results taken previously would havebeen entered into the Electronic Medical Record, easily accessible for the doctor.A systematic structure like such allows for the patient to have an efficientencounter with the doctor.

Ensuring timeliness through quality improvement projects

Timeliness is an important characteristic in health care. Improving response topatients’ medical needs warrants attention and focus. However, long waits arethe norm in hospitals. In addition to emotional distress that patients could suffer,physical harm could result. A classic example is when a patient suffers frompreventable complications from a delay in diagnosis or treatment. (IHI, Crossingthe Quality Chasm: A New Health System for the 21st Century, 2001)

JurongHealth implemented to ensure timely care is provided for patients is thestandardisation of critical results routing rules. JurongHealth uses the Health careMessaging System (HMS) to alert clinicians on critical results that requireimmediate attention. If the doctor does not respond within a specific period oftime, HMS will escalate the notification to another clinician based on the routingrules provided by the specialty/department.

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Previously, the doctor alerted wasidentified based on the patient’s lastlocation. HMS followed the routing rulescreated and managed by eachdepartment responsible for that location.

A significant number of incidentsregarding the delay in communicatingcritical results were reported in 2014. Ateam was tasked to review theseincidents, and it was revealed that theissue was with following the rules basedon patient’s last location. An inpatientmay be transferred to anotherdepartment/specialty and location. Thedoctor activated by this routing rulewould not be the ordering doctor. As aresult, the ordering doctor would have tbe traced to act on the critical results.

In 2014, The Patient Safety Committeesaw the need to standardise the criticalresults routing rules and process. ThePatient Safety Officer worked withvarious clinicians and departments toimprove the critical results routing rulesand process

Now, a single routing rule with 3 tiers ofescalation applies within theorganisation:

With the standardisation of the routingrules, the ordering doctor and consultant-in-charge would always be informed oftheir patients’ critical results. They wouldbe able to make informed decisionsabout treating the patient based on theirexisting knowledge of the patientcurrently in their care. This improvementalso effectively eliminates the delay incommunicating critical results toappropriate doctors!

3 tiers of Escalation

1st Tier: Ordering Doctor

2nd Tier: Consultant-In-Charge ofthe patient

3rd Tier: Call Center

Ensuring Patient Centeredness through Patient Safety andQuality Assurance Committees

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The Patient Safety Committee andvarious sub-committees were set up toensure that care provided byJurongHealth is respectful of andresponsive to individual patient needs.These committees, as well as otherQuality Assurance Committees inJurongHealth,

- Have purview of clinical care processes that fall across departments or facilities of JurongHealth.

- Own the care processes for the areas within their purview and have the responsibilities to ensure compliance of the processes and policies in relation to their domain.

- Are also responsible for stipulated key performance indicators and will update the Medical Board regularly in this respect.

Some Patient Safety committees andsub-committees in JurongHealth include:

For the full lists of various committees,please visit JurongHealth intranet.

To ensure that Senior Management staysconnected to staff on the ground, walkrounds are conducted on a regular basis.Walk rounds are visits to various parts ofthe hospital grounds by the managementwith the intention to understand issuesthat staff are facing. Through thisplatform, Senior Management caninteract with the ground staff, gatherfeedback and show their support forPatient Safety.

Providing effective care through policies and procedures

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Providing effective care means to provide services (based on evidence basedknowledge) to all who could benefit, and to refrain from providing services to thoseunlikely to benefit.

In JurongHealth, process owners who are experts in various specialised fields conductresearch based on the best available scientific evidence of date and make referencesto other local hospitals and the Ministry of Health. Thereafter, they work with therespective workgroups and committees to develop internal policies, procedures andclinical practice guidelines for our doctors, nurses and allied health staff. Staff canmake reference to these policies when delivering care for patients.

We ensure that new staff are aware of these policies, procedures and guidelinesthrough organisational and departmental orientation courses.

Providing equitable care

Health care should be accessible to all, regardless of gender, language, race andreligion, or income. With regard to equality in health care, all individuals should betreated fairly, based on their unique clinical needs and not personal characteristicsunrelated to their health conditions.

JurongHealth provides accessible care to all individuals who seek medical attentionfrom us.

All in all, JurongHealth brings these dimensions of quality together by measuring andmonitoring Clinical Quality Indicators (CQIs). Measuring and monitoring indicatorsprovides an objective demonstration of the quality of care received by the patients.

CQIs are currently measured and monitored by clinical departments and QualityAssurance Committees (QACs).

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There are 4 domains of care being monitored in the Clinical Quality Dashboard:

On a monthly basis, data generated for each indicator will be uploaded into thedashboard. Subject matter experts will then conduct an analysis based on the datagiven and provide their comments. The information will also be presented to themanagement for an overview of how JurongHealth is performing. Where necessary,intervention can be made.

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Let us now follow through the journeys of patients Maria and Joseph in JurongHealth.

Hello, my name isMaria. I am 59 years old

this year. I will be thefirst inpatient whom

you will follow!

Hello, my nameis Joseph. I am 70 yearsold this year. Follow meon my inpatient journey

at JurongHealth!

Along the way, important issues related to Patient Safety will be highlighted by ourPatient Safety ambassadors, Elfie and Kelfie.

Hello, we are Elfie and Kelfie,JurongHealth's Patient Safetyambassadors. We will be yourPatient safety guides today!

Chapter 2: Maria'sInpatient Journey

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Maria's Profile

Name: Maria WongSex: FemaleAge: 59Medical History: Frequent Urinary Tract Infection, HypertensionDrug Allergy: AspirinHeight: 158cmWeight: 65kg

Summary of Stay in Hospital

Maria presented at the Emergency Department for complaint of severe pain at theright abdominal area and urine in blood for 3 days. She was admitted at the hospitalfor suspicion of kidney stone in the ureter. Patient has known drug allergy toAspirin.

A series of tests diagnosed Maria with Urinary Tract Infection and a large kidneystone at the right ureter.

Maria’s UTI and fever were resolved in two days.

Maria then had a Ureteroscopy done. Two days post-operation, incidental findingsof positive faecal occult blood required her to undergo a colonoscopy undersedation.

Patient was discharged well 5 days later.

a. Emergency Department

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One morning, a 59 year old femalenamed Maria, presents at EmergencyDepartment via walk-in. Maria isaccompanied by her husband,Frederick.

During triage, she complains of severe abdominal pain, fever and pain when urinatingsince two evenings ago.

Dr. Philip, the doctor on duty that morning, examines Maria. He asks for her medicalhistory and discovers that Maria had an episode of possible drug allergy to Aspirin, aNon-Steroidal Anti-Inflammatory Drug in The Philippines. This happened 2 years ago.

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After examining Maria, Dr. Phillip decides that Maria would require urine and bloodinvestigations.

Dr. Philip applies a tourniquet on Maria’s left arm for blood taking. However, due todifficulty in accessing the vein, Dr. Andie takes over. Dr. Andie successfully draws bloodfrom Maria on her second try.

Dr. Philip checks Maria’s left arm and removes the tourniquet.

After further investigations, Maria is diagnosed with Urinary Tract Infection and suspicionof kidney stone in ureter. Dr. Philip decides to admit Maria.

b. Admission

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3 hours later, Maria is admitted into the hospital, under Urology.

At this point, doctors, nurses and pharmacists should perform MedicationReconciliation upon Maria’s admission.

Medication Reconciliation ensures medication safety upon admission, transfer anddischarge through avoiding drug related problems such as drug use without indication,drug omissions and duplication of therapy amongst others.

IntensiveCare Unit

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At 7am during the MedicationRounds, Staff Nurse Clairechecks the Electronic MedicalRecord. Maria requires somemedications to beadministered.

Claire is a conscientious nursewho always observes the FiveRights of Drug Administration.

The Five Rights of MedicationAdministration include...

1. Identifying the Right Patient By checking Name and NRIC and scanning patient’s wristband2. Confirm the Right Medication By counterchecking the prescription listed in Medication Administration Record and what is prepared3. Confirm the Right Route By checking on the Medication Administration Record on how the medication is to be administered4. Confirm Right Dose By comparing the dose that has been ordered against the dose prepared5. At the Right Time

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Claire understands the importance of not being interrupted during medication preparationand administration. She therefore wears the “Do not Disturb” Medication Safety vest as asignal to others.

Claire finishes preparing the medication for Maria. She places all the parental and non-parental drugs into a tray and wheels the computer towards Maria.

Claire enters Maria’s environment and performs hand hygiene.

Why is Hand Hygiene Important?The most common mode of transmission

of germs is via our hands!

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The consultant in charge of Maria, Dr. Rexford, reviews Maria during the morningrounds. Maria complains of sharp pain originating from her lower abdominal area.Dr. Rexford orders for an urgent diagnostic test for kidney stone in the uterer.

A porter and nurse Claire wheel Maria to the MRI room for Magnetic ResonanceImaging (MRI) Scan.

They stop outside the MRI room. A radiographer, Kelvin, ensures that Maria doesnot possess any metallic item. Kelvin checks and confirms that all monitoringdevices are MRI Compatible.

Maria is being pushed into MRI room for her diagnostic procedure. Beforeperforming the radiological test, he remembers to perform Two Patient Identifier.After ensuring the right patient for the procedure, He then proceeds to scan Maria’sbarcode on her wrist tag into the EMR.

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Kelvin proceeds to perform MRI scan for Maria.

After the scan is completed, the porter pushes Maria back to her ward, accompanied byClaire.

Maria’s team of doctors comes to the ward and examines Maria. Her fever and UrinaryTract Infection are resolved and she is scheduled for Ureteroscopy at 9am the next day.

c. Surgery

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The next day, nurses Claire andJoanna in the ward prepare her forsurgery. All necessary pre-operativeinvestigations ordered by doctors andanaesthetists are in order.

They then conduct a pre-operationVerification with Maria.

Claire and the porter wheel Maria tothe Operating Theater reception andhand over Maria at the reception area.

Once again, the OT nurses, Phoebeand Farhana conduct a second roundof pre-operation verification.

The surgeon arrives and proceedswith site marking with reference toMaria’s kidney stone at her rightureter.

Phoebe and Farhana wheel Maria tothe Operating Room. At this point,Maria is still conscious. Sign in isbeing done with the surgeon,anaesthetist and an OT nurse.

The anasethetist puts Maria to sleep.Just before incision, the circulatingnurse conducts Time Out.

During the surgery, the surgeonsuccessfully removes the kidneystone one Maria’s right ureter. Justbefore dressing and sending Mariaout, the operating team once againconducts Sign Out.

Maria is being wheeled to theIntensive Care Unit for closemonitoring.

d. Intensive Care Unit

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In the ICU, Maria is restless due to the discomfort at her wound area. Dr Kennethprescribes an infusion, to dilute 200mcg of Precedex in normal saline.

ICU Nurse Rachel proceeds to prepare the infusion.

Rachel remembers during her trainingto always read the entire label whenpreparing IV medication. She thereforechecks both the concentration andvolume and notes that one vial of onevial of Precedex contains 200mcg in2ml.

Rachel conscientiously picks 1 vial andhands over the drugs for ICU NurseChristine to countercheck.

ICU Nurse Christine counterchecksthe Precedex infusion. ICU NurseRachel administers Precedex toMaria.

Maria’s restlessness resolves within30 minutes.

Shortly after, she is deemed stableenough to be transferred to thegeneral ward.

e. General Ward

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At the general ward, Maria’sphosphate level drops to 0.72mmol/L. This is below the normalreference range. Doctor Wendyorders 10mmol of PhosphateDihydrogen Phosphate Infusion tobe administered for 4 hours.

Upon checking of MedicationAdministration Record, Staff NurseRohaya misreads the order as10mmol of Potassium Chloride.Rohaya takes the premix 10mmolof Potassium Chloride to administerto patient.

Before administration, Rohaya asksStaff Nurse Farhana to counter checkand co-sign. Thankfully, Farhananotes the discrepancy in order andwhat has been prepared.

Maria is dispensed the rightmedication.

Two days post-operation, incidentalfindings of positive faecal occult bloodrequire Maria to undergo acolonoscopy under sedation.

Maria is dispensed the right medication.Maria is being pushed to the EndoscopySuite for colonoscopy by the porter,accompanied by Staff Nurse Rohaya.

In the suite, the endoscopist is about tosedate Maria. The endoscopist conductsa pre-sedation assessment to ensure thatMaria is optimised for Colonoscopy.

Throughout the entire procedure andpost-procedural care, the endoscopistand nurses monitor Maria vigilantly.

After the colonoscopy, Maria is beingwheeled back into the ward.

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Refer to JHS-CLN-MAF-PD-047 Guideline on Adult ProceduralSedation for more information!

f. Discharge

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After 3 days in the general ward, Maria is now being prepared for discharge. DoctorChristine ensures that all outstanding diagnostic and laboratory results have beenreviewed. She then proceeds to prescribe Maria her chronic medications.

Pharmacist Leon verifies the discharge prescription in EMR and processes themedication for dispensing.

While completing the dischargesummary, Dr Christine notes that shemissed out prescribing Atorvastatin forMaria. She quickly calls Pharmacist Leonto highlight the amendment and order forthe additional medication missed out.

Maria is being discharged well from thehospital!