PATIENT SAFETY
INITIATIVE OVERVIEW



    DR LEE OI WAH
    MD(UKM), CMIA
Patient Safety Definition
• Healthcare
  organizations
  including hospitals
  were founded to give
  care to those who
  need it and to keep
  patients safe.
• It is generally agreed
  upon that the
  definition of patient
  safety is…
What is Patient Safety?
    The absence of the potential for patient
     harm
    Involves all Employees/Contract workers, All
     job descriptions
    Involves all Departments
    Time frame: 24/7
A model of patient safety
   1. Those who work in health care.
   2. Those who receive health care or have
       a stake in its availability.
   3. The infrastructure of systems for
       therapeutic interventions (health-care
       delivery processes).
   4. The methods for feedback and
       continuous improvement.
Methods: CQI on
                                          info, hardware,
                                          plant, policy




                                       Systems for therapeutic
                                       action designed to
Recipients of care




                                       preempt/rescue from failure
                     Preparation on:
                     illness
                     understanding,    Workers: teams
                     accessing care    trained to preempt /
                     systems,          rescue from /
                     advocacy          manage failure




                                          Methods: CQI
                                          on: competence
                                          communication,
                                                 A patient safety model of health care Emmanuel et al 2008
                                          teamwork
Avoidable confusion is everywhere…
Health care is increasingly
complex




                              Gaba
Traps in health care?
 • look-alike and sound-alike
   pharmaceuticals

 • equipment design
    ○ e.g. infusion pumps
Removing error traps
  • a primary function of an incident
    reporting system is to identify
    recurring problem areas - known as
    “error traps” (Reason)

  • identifying and removing these traps
    is one of the main functions of error
    management


                                            Error traps
What is being done to make healthcare
organizations safe for patients?
 • Joint Commission on Accreditation for
   Healthcare Organizations (JCAHO) first
   established patient safety goals in 2002.
 • Each year those goals are re-evaluated
   and revisions are published.
 • When healthcare organizations are
   accredited, they are given report cards and
   graded on their compliance with meeting
   the goals.
National Safety Goals
 • Improve the accuracy of patient
   identification.

 • Improve the effectiveness of
   communication among caregivers.

 • Improve the safety of using medications.
National Safety Goals
  • Reduce the risk of healthcare associated
    infections.

  • Accurately and completely reconcile
    medications across the continuum of
    care.

  • Reduce the risk of patient harm resulting
    from falls.
PATIENT SAFETY INITIATIVE
 OF HOSPITAL CHANGKAT
       MELINTANG
 Clean care is safer care
 Communication policy
 Patient identification
 Medication safety
 Notification of critical lab
  results
 Safe blood transfusion
 Patient fall
 Incident reporting and
   management
 Medical Officers
 Paramedics
 Pharmacists
 PPKs
 Allied health
  professionals
 HSS


WHO SHOULD KNOW?
 Reduce medical error
 Improve patient safety
 Requirement for
   Accreditation
 Protect from litigation
 Patient’s right




WHY???
What else is being done to promote
patient safety?
                • Committees to
                  investigate all aspects
                  of patient safety.
                • Employee training on
                  proper lifting and
                  transfer techniques
                  which benefit both
                  employees and
                  patients.
What else is being done to promote
patient safety?
            • Policies for safe disposal
              of contaminated articles
              and sharps
              – Syringes
              – Needles
              – Blades
What else is being done to promote
patient safety?
• Frequent Fire and Disaster drills
• Inspection and maintenance of all
  equipment…
  – Hospital beds
  – Patient Lifting equipment
  – Gas containers
  – Infusion pumps
  – Monitoring equipment
What can employees do to promote
 patient safety?
• Report any potentially dangerous patient
  situation to your supervisor.
• Know about and participate in performance
  improvement processes in your
  department or unit.
• Take your annual mandatory training
  seriously; it will help you to identify safety
  issues.
What can employees do to promote
patient safety?
 • Don’t take “shortcuts”.
 • Use check lists.
 • Ask co-workers to complete double
   checks.
Conclusion
 Be an advocate for our patients.

     Patient safety
               is

Intro to pt safety

  • 1.
    PATIENT SAFETY INITIATIVE OVERVIEW DR LEE OI WAH MD(UKM), CMIA
  • 2.
    Patient Safety Definition •Healthcare organizations including hospitals were founded to give care to those who need it and to keep patients safe. • It is generally agreed upon that the definition of patient safety is…
  • 3.
    What is PatientSafety?  The absence of the potential for patient harm  Involves all Employees/Contract workers, All job descriptions  Involves all Departments  Time frame: 24/7
  • 4.
    A model ofpatient safety 1. Those who work in health care. 2. Those who receive health care or have a stake in its availability. 3. The infrastructure of systems for therapeutic interventions (health-care delivery processes). 4. The methods for feedback and continuous improvement.
  • 5.
    Methods: CQI on info, hardware, plant, policy Systems for therapeutic action designed to Recipients of care preempt/rescue from failure Preparation on: illness understanding, Workers: teams accessing care trained to preempt / systems, rescue from / advocacy manage failure Methods: CQI on: competence communication, A patient safety model of health care Emmanuel et al 2008 teamwork
  • 6.
  • 7.
    Health care isincreasingly complex Gaba
  • 8.
    Traps in healthcare? • look-alike and sound-alike pharmaceuticals • equipment design ○ e.g. infusion pumps
  • 9.
    Removing error traps • a primary function of an incident reporting system is to identify recurring problem areas - known as “error traps” (Reason) • identifying and removing these traps is one of the main functions of error management Error traps
  • 10.
    What is beingdone to make healthcare organizations safe for patients? • Joint Commission on Accreditation for Healthcare Organizations (JCAHO) first established patient safety goals in 2002. • Each year those goals are re-evaluated and revisions are published. • When healthcare organizations are accredited, they are given report cards and graded on their compliance with meeting the goals.
  • 11.
    National Safety Goals • Improve the accuracy of patient identification. • Improve the effectiveness of communication among caregivers. • Improve the safety of using medications.
  • 12.
    National Safety Goals • Reduce the risk of healthcare associated infections. • Accurately and completely reconcile medications across the continuum of care. • Reduce the risk of patient harm resulting from falls.
  • 13.
    PATIENT SAFETY INITIATIVE OF HOSPITAL CHANGKAT MELINTANG
  • 14.
     Clean careis safer care  Communication policy  Patient identification  Medication safety  Notification of critical lab results  Safe blood transfusion  Patient fall  Incident reporting and management
  • 15.
     Medical Officers Paramedics  Pharmacists  PPKs  Allied health professionals  HSS WHO SHOULD KNOW?
  • 16.
     Reduce medicalerror  Improve patient safety  Requirement for Accreditation  Protect from litigation  Patient’s right WHY???
  • 17.
    What else isbeing done to promote patient safety? • Committees to investigate all aspects of patient safety. • Employee training on proper lifting and transfer techniques which benefit both employees and patients.
  • 18.
    What else isbeing done to promote patient safety? • Policies for safe disposal of contaminated articles and sharps – Syringes – Needles – Blades
  • 19.
    What else isbeing done to promote patient safety? • Frequent Fire and Disaster drills • Inspection and maintenance of all equipment… – Hospital beds – Patient Lifting equipment – Gas containers – Infusion pumps – Monitoring equipment
  • 20.
    What can employeesdo to promote patient safety? • Report any potentially dangerous patient situation to your supervisor. • Know about and participate in performance improvement processes in your department or unit. • Take your annual mandatory training seriously; it will help you to identify safety issues.
  • 21.
    What can employeesdo to promote patient safety? • Don’t take “shortcuts”. • Use check lists. • Ask co-workers to complete double checks.
  • 22.
    Conclusion Be anadvocate for our patients. Patient safety is