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Patient safety
- 1. Pune Adventist Hospital Training:Patient Safety Programme
- 2. Why is Safetyof importance? • A hospital is a people- intensive place • Provides services round the clock • Free access to enter at any time • Hospital atmosphere is one full of emotions of excitement, life, happiness, death, sorrow • A hospital operated under continuous strain. It gives rise to irritation, confrontation, conflicts and aggression
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- 5. Safety of place FireInfrastructure Electrical/ Mechanical
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- 7. Current scenario • Repeatederrors and system failures • Action on known risks very slow • Detection system in its infancy • Many events not reported • Understanding of causes is limited • Limited measurement of impact • Blame culture alive • Defensiveness and secrecy
- 8. Medical errors • Onein 10 patients is harmed while receiving hospital care https://www.who.int/features/factfiles/patient_safety/en/ • Upto 10 in 100 admitted patients contract HAI • Unsafe care is likely one of the 10 leading causes of death and disability across the world • Nearly 5.2 million witness harm due to medical errors every year in India • More than 1 mn. patients die annually from surgery complications
- 9. Whose error? Sales By patient Byhospital staff Both Physical, mechanical, electrical 66 % 4 % 14 % 16%
- 10. Why do errorshappen? • In most cases it is not wilful negligence but systemic flaws, inadequate communication, wide – spread process variation and ignorance
- 11. Types of Errors •Adverse health care event – during clinical care and causing physical or psychological injury to the patient • Error – use of incorrect plan of action • Near miss – an event that might have resulted in harm • Medication errors • Sentinel errors – unexpected events that result in death or serious physical or psychological injury
- 12. Medical Safety Patient safety Surgicalsafety Electrical safety Laboratory safety Infection control Blood safety Equipment safety Environment safety
- 13. Patient Safety Goals •Improve accuracy of patient identification • Improve the effectiveness of communication among caregivers • Improve safety of using medication • Reduce risk of HAIs
- 14. • Reduce riskof patient harm resulting from falls • Special emphasis on dangerous abbreviations, infection control, LASA medication, time outs
- 15. Medication Safety • Medicationorders should be written legibly and should include: a) Patient name b) Medicine generic name c) Dosage, frequency and route of administration d) Name and signature of physician, and e) Date and time the order was written. i.e. SNDT format and in ALL CAPITALS
- 16. • Any abbreviationsused in medication orders should be agreed upon and jointly adopted by the medical, nursing, pharmacy and medical records staff
- 17. ... Cont’d MedicationSafety • Before dispensing the drug, the pharmacist must receive the physician’s original order or a direct copy of the order (except in emergency situations) • To check at least 2 patient identifiers before administering medication; Patient name and Medical Record Number
- 18. ... Cont’d MedicationSafety • Discourage telephonic orders. Do not accept verbal orders
- 19. Surgical Safety • Consentof patient/ relative in writing • Proper identification of patient with name, wrist band • Proper identification mark of parts to be operated
- 20. Cont’d.. SURGICAL SAFETY •Pre – anaesthetic check up • Anaesthetic safety • Ensure no foreign body left inside • Safety measures when transferring patients • Prevention of surgical wound infections • Use of surgical safety checklist
- 21. Environment safety • Adequatelight • Adequate ventilation • Stairs with hand rails • Slip preventing floors • Fire extinguishers and alarms
- 22. Cont’d... Environment Safety •Prevent noise pollution • Heavy and fixed bed • Safety belt on wheelchairs and trolleys • No water logging in bathrooms • Call bell system for all patients • Adequate screens for patient privacy
- 23. Installation Hazards • Regularchecking of equipment • Proper earthing to avoid shocks • Regular maintenance and repair • Training of nurses and technical staff
- 24. When to report? •When you think a device has or may have caused or contributed to the following outcome for patient, staff member or visitor 1. Close calls or other potential harms 2. Minor injury 3. Serious injury 4. Death
- 25. Your role • Identifyactual and potential problems, adverse events and close calls with medical services • Report the problem or adverse event to your supervisor according to policy and procedure • Make sure your report includes details • Remove the device, keep all affected items
- 26. Electrical safety • Safetyfuses with each equipment • No loose wires or connection • Properly plugged and fixed • Electricity backup battery/ generator • If short circuits happen, inform immediately
- 27. Fire safety • Usefire proof material • Fire exits, fire extinguishers, fire hydrants in all buildings • Smoke detectors and water sprinklers on all floors • Fire drills
- 28. Blood safety • Propergrouping and cross matching • Test HIV, hepatitis and VDRL • Proper labelling • Control of mismatch reaction • Screening against HIV, hepatitis, VD, malaria • Inform and report adverse reactions
- 29. Infection control • Properdisposal, segregation, transportation and disposal of BMW • Sanitation of different parts of the hospital • Use of sterile procedures • Safety in use of autoclave, needle destroyers
- 30. cont’d... Infection Control •Formation of hospital infection control committee • Investigation of all hospital infections • Use of proper antibiotics in right doses given at the right time • Reorientation of RMOs and nurses
- 31. Laboratory safety • Carefulnessto avoid needle prick and blood spill • Regular pest control measures • Care in handling acids, reagents, inflammables
Editor's Notes
- #12 Every error has a root cause, every cause has a solution. One unintentional error-miss, repeated error-crime. Error can be prevented with one’s initiative in the system
- #24 For new devices, have safety inspection, compatibility, education and keep manual and appropriate purchasing documents. When in doubt, have certified equipment (CE) check. Incident reporting