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Patient safety
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- 2. What is PatientSafety? Patient Safety is the absence of preventable harm to a patient during the process of health care. Improving patient safety means reducing patient harm. It emerged with the evolving complexity in health care systems and the resulting rise of patient harm in health care facilities. Most times, fault is not wilful negligence, but systemic flaws, inadequate communication and wide-spread process variation and patient ignorance. Patient safety is fundamental to delivering quality essential health services.
- 3. Patient Safety Concerns Adverse Event: Bad outcome from care. Event or omission arising during clinical care and causing physical or psychological injury to a patient. Medical Errors: Major and enduring loss of function. Failure to complete a planned action as intended, or the use of an incorrect plan of action to achieve a given plan Medication Error: Any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of health professional, patient or consumer. Near Miss: Could have resulted in loss, injury or illness, but did not. Situation in which an event or ommission arising during clinical care fails to develop further, whether or not as the result of compensating action, thus preventing injury. Focus on near miss: no patient harm, therefore no blame; no guilt, no fear of litigation, focus on future prevention Adverse Drug Reaction: Any response to a drug which is noxious
- 4. Sentinel Event:Deficient process of care. Surgery on wrong body part, surgery on wrong patient, patient administered wrong medication. Hospital Acquired Infections: Nosocomial Infections. An infection acquired in hospital by a patient who was admitted for a reason other than that infection. An infection occurring in a patient in a hospital or other health-care facility in whom the infection was not present or incubating at the time of admission. Unsafe Injections Practices: in health care settings can transmit infections, including HIV and hepatitis B and C, and pose direct danger to patients and health care workers. Unsafe transfusion practices expose patients to the risk of adverse transfusion reactions and the transmission of infections. Radiation errors involve overexposure to radiation and cases of wrong-patient and wrong-site identification. Sepsis is frequently not diagnosed early enough to save a patient’s life. Because these infections are often resistant to antibiotics, they can rapidly lead to deteriorating clinical conditions. Venous thromboembolism (blood clots) is one of the most
- 5. Burden of Harm Everyyear, millions of patients suffer injuries or die because of unsafe and poor-quality health care. The occurrence of adverse events due to unsafe care is 1 of the 10 leading causes of death and disability in the world. In high-income countries, it is estimated that 1 in every 10 patients is harmed while receiving hospital care. The harm can be caused by a range of adverse events, with nearly 50% of them being preventable. Each year, 134 million adverse events occur in hospitals in low and middle income countries (LMICs), due to unsafe care, resulting in 2.6 million deaths. Another study has estimated that around two-thirds of all adverse events resulting from unsafe care, and the years lost to disability and death (known as disability adjusted life years, or DALYs) occur in LMICs.
- 6. Globally, asmany as 4 in 10 patients are harmed in primary and outpatient health care. Up to 80% of harm is preventable. The most detrimental errors are related to diagnosis, prescription and the use of medicines. In OECD countries, 15% of total hospital activity and expenditure is a direct result of adverse events. Investments in reducing patient harm can lead to significant financial savings, and more importantly better patient outcomes. An example of prevention is engaging patients, if done well, it can reduce the burden of harm by up to 15% . According to WHO (2005), On average, 8.7% of hospital patients suffer health care- associated infections (HAI). In developed countries: 5-10% In developing countries: – Risk of HAI: 2-20 times higher – HAI may affect more than 25% of patients At any one time, over 1.4 million people worldwide suffer from infections acquired while in hospital.
- 7. Globally, thecost associated with medication errors has been estimated at US$ 42 billion annually . Health care-associated infections occur in 7 and 10 out of every 100 hospitalized patients in high-income countries and low- and middle-income countries respectively. Unsafe surgical care procedures cause complications in up to 25% of patients. Almost 7 million surgical patients suffer significant complications annually, 1 million of whom die during or immediately following surgery. Unsafe injections practices account for a burden of harm estimated at 9.2 million years of life lost to disability and death worldwide (known as Disability Adjusted Life Years (DALYs)). Diagnostic errors occur in about 5% of adults in outpatient care settings, more than half of which have the potential to cause severe harm. Most people will suffer a diagnostic error in their lifetime. Data on adverse transfusion reactions from a group of 21 countries show an average incidence of 8.7 serious reactions per 100 000 distributed blood components . A review of 30 years of published data on safety in radiotherapy estimates that the overall incidence of radiation errors is around 15 per 10 000 treatment courses. Sepsis have affected an estimated 31 million people worldwide and causing
- 8. Principles of PatientSafety Proper identification of patient and matching to their care elements Prevention of patient handover error and safety during transition Assessing medical accuracy while giving care to a patient Performance of correct procedure at a correct bodysite Take appropriate precautionary measures to avoid infection Principle of Patient Safety: Right Drug Right Patient Right dose Right Route
- 9. International Patient SafetyGoals Goal 1 Identify Patients Correctly Goal 2 Improve Effective Communication Goal 3 Improve the Safety of High-Alert Medications Goal 4 Ensure Correct-Site, Correct- Procedure, Correct-Patient Surgery Goal 5 Reduce the Risk of Health Care- Associated Infections Goal 6 Reduce the Risk of Patient Harm Resulting from Falls
- 10. Goal 1: IdentifyPatients Correctly Use at least two patient identifiers whenever collecting laboratory samples or administrating medications or blood products. Acceptable identifiers may be the individual’s name, an assigned identification number, telephone number, photograph or other person-specific identifier. (e.g. birth date) Prior to the start of any invasive procedure, conduct a final verification process (such as a “time out”) to confirm the correct patient, procedure and communication techniques. Problems associated with surgical safety in developed countries account for half of the avoidable adverse events that result in death or disability.
- 11. Goal 2: ImproveEffective Communication Effective communication, which is timely, accurate, complete, unambiguous, and understood by the recipient, reduces error and results in improved patient/client/resident safety. Simply repeating back the order or test result is not sufficient. Whenever possible, the receiver of the order or test result enter it into a computer, then read it back, and receive confirmation from the individual who gave the order or test result. Standardize a list of abbreviations, acronyms, symbols, and dose designations that are not be used throughout the organization. Implement a standardized approach to “hand over” communications, including an opportunity to ask and respond to questions. Measure, assess, and if appropriate, take action to improve the timeliness of reporting, and the timeliness of receipt by the caregiver, of critical tests and critical results. A complete list of the patient’s medications is communicated to the next provider of service when a patient is referred or transferred to another setting, service, practitioner or level of care within or outside the
- 12. Goal 3: Improvethe Safety of High- Alert Medications Remove concentrated electrolytes (like potassium chloride, potassium phosphate) from patient care units. Standardize & limit the number of drug concentrations available in the organization. Identify and at a minimum, annually review a list of look-alike/sound-alike drugs used by the organization, and take action to prevent errors involving the interchange of these drugs. Label all medications, medication containers (for example, syringes, medicine cups, basins) or other solutions on and off the sterile field.
- 13. Goal 4: EnsureCorrect-Site, Correct- Procedure, Correct-Patient Surgery Ensure Correct-Site, Correct- Procedure, Correct- Patient Wrong-site, wrong-patient, wrong-procedure surgery can be prevented if appropriate processes are in place. “Preoperative verification process”: The checklist is an example of one approach-the most common one. Ensure that all of the relevant documents are available prior to the start of the procedure & that they have been reviewed & consistent with each other & with staffs’ understanding of the intended site, patient, & procedure.
- 14. Goal 5: Reducethe Risk of Health Care- Associated Infections Reduce the Risk of Health Care-Associated Infections Rationale. Compliance with the CDC hand hygiene guidelines will reduce the transmission of infectious agents by staff to patients/clients/residents thereby decreasing the incidence of healthcare associated infections.
- 15. Goal 6: Reducethe Risk of Patient Harm Resulting from Falls Falls account for a significant portion of injuries in hospitalized patients, long-term care residents, and home care recipients. In the context of the population it serves, the services it provides, and its environment of care, the organization should assess, its patient risk for falls and take action to reduce the risk of falling and to reduce the risk of injury, if a fall occur.
- 16. TYPES OF PATIENTSAFETY ENVIRONMENTAL SAFETY MEDICAL SAFETY SURGICAL SAFETY EQUIPMENT INSTALLATION SAFETY ELECTRICAL SAFETY BLOOD SAFETY LABORATORY SAFETY INFECTION CONTROL SANITATION BMW DISPOSAL
- 17. ENVIRONMENTAL SAFETY Thereis a direct link between work environment and patient safety. If we do not have a formal program in place addressing work environment issues, little will change. Creating healthy work environments requires changing long-standing cultures, traditions and hierarchies Therefore, though everyone must be involved in the creation of healthy work environments, the onus is on organizational, departmental and unit
- 18. Adequate light Adequate ventilation, exhaust fan Stairs with hand rails Window-door-closer Slip preventing floors Fire extinguishers and fire alarms Prevent noise pollution Heavy and fixed beds Safe wheel chairs and trolleys No water logging in bathrooms Call bell system for patients Adequate no. of bed screens to maintain privacy of the patient.
- 19. MEDICAL SAFETY IllegibleWriting prescription by doctors. Wrong medicines or wrong does or wrong patient. Wrong injection, wrong does or wrong patient, wrong route of administration. Drip sets: air bubbles, over hydration, drip speed. Oxygen flow: check empty gas cylinders. Clear, written medication guidelines. Identification of each patient with Similar patient names Proper handing taking over during change of shift. Look alike and Sound Alike “LASA”
- 20. A- Medication ordersshould be written legibly in ink and should include: Patient’s name and location (ward, room No, and bed No) . Medication Generic Name. Dosage, frequency and route of administration. Signature of the physician. Date and hour the order was written. B- Any abbreviations used in medication orders should be agreed to and jointly adopted by the medical, nursing, pharmacy, and medical records staff of the institution. Lately, in the interest of patient safety, “Do Not Abbreviate” Is the new practice nowadays. C- Before dispensing the drug: The pharmacist must receive the physician’s original order or a direct copy of the order (except in emergency situations).This permits the pharmacist to Resolve questions or problems with drug orders before the drug is dispensed and administered. Eliminate errors which may arise when drug orders are transcribed into another form for use by the pharmacy. D- to check at least two patient identifiers before providing care, treatments or services, likr Patient name and medical record number
- 21. Methods of sendingthe Physician’s orders to the pharmacy are: 1. Self-copying order forms: This method provides the pharmacist with a duplicate copy of the order and does not require special equipment. There are two basic formats: a. Orders for medications included among treatment orders. b. Medication orders separated from other treatment orders on the order form.` 2. Electromechanical: Copying machines or similar devices may be used to produce an exact copy of the physician’s order. Provision should be made to transmit physicians’ orders to the pharmacy in the event of mechanical failure. 3. Computerized: Computer systems, in which the physician enters orders into a computer which then stores and prints out the orders in the pharmacy or elsewhere.
- 22. SURGICAL SAFETY Consentof the patient/ relative in writing Proper identification of patient: wrist band Proper identification mark of parts to be operated Pre- anesthetic check-up Anesthetic Safety Ensure no foreign body left inside Safety measures from ward to OT & coming back (Safety check list) Prevention of surgical wound infections Use of Surgical safety proforma in all operations Check Safety code if available WHO SURGICAL SAFETY CHECKLIST The primary benefit of the checklist may be to engage the medical team. By using the checklist, we may be gaining the ability to open communication by the medical team, to encourage teamwork
- 23. EQUIPMENT INSTALLATION SAFETY Regularchecking of equipments Proper earthling to avoid shock Regular maintenance & repair Training of nurses & technical staff How do you control hazards?: Preventing inadvertent harm to patients requires use of human factors engineering principles. The “hierarchy of hazard control:” Eliminate hazard Guard against hazard Train to avoid hazards Warn against hazards
- 24. ELECTRICAL SAFETY Safetyfuses with each equipment No loose wires or connection Properly plugged and fixed If short circuit call electrician Electricity back up battery/ generator Use of CVT/UPS
- 25. FIRE SAFETY UseFire proof material for construction Have Fire Exit in all Buildings. Smoke detectors and water sprinklers on the roof of all Floors. Fire Extinguishers in all areas. Fire Hydrants in all buildings. Training in Fire management Mock drills
- 26. BLOOD SAFETY Propergrouping & cross matching Tests of HIV, Inf. hepatitis & VDRL Proper labeling of group, name of the patient Standard operating procedure Screening against HIV, Hepatitis. VD, Malaria. Control blood transfusion reactions
- 27. SANITATION- INFECTION CONTROL- BMWDISPOSAL Proper segregation & transportation of biomedical wastes Sanitation & hygiene of different parts of hospital to avoid infection Use of sterile procedures Safety in use of incinerator, autoclave, shredder, needle destroyers and proper disposal of biomedical waste. Formation of hospital infection control committee Investigation of all hospital infections Use of proper antibiotics in right doses in right time
- 28. LABORATORY SAFETY Avoidneedle stick injuries & spilling of blood Safety measures in Radiology & Radiotherapy departments Safety norm guide lines for different areas of hospitals. Regular pest control measures Care in handling acids, reagents, inflammable substances. BMW segregation and disposal
- 29. PRACTICE OF PATIENTSAFETY ( WHO ) Be aware of Look-Alike, Sound-Alike Medication Names. Proper Patient Identification. Explain in Detail During Patient Hand/Take- Overs. Performance of Correct Procedure at Correct Body Site. Careful About Electrolyte Imbalance. Assuring Proper Treatment During Shifting. Avoid Catheter and Tubing, Wrong Connections . Single Use of Injection Syringes. Improved Hand Hygiene to Prevent Health Care- Associated Infections Proper Disposal of BMW and Good House Keeping. Practice Surgical Safety Guide Lines.
- 30. TIPS FOR IMPROVINGPATIENT SAFETY Constitution of Patient Safety Committee. Develop clear policies and protocols for patient safety. Discuss regularly patient safety initiative within hospital staff. Orientation, Re-orientation hospital staff on patient safety Encourage transparency in the regular death review. Incident reporting by staff. Each department to devise their own patient safety protocols. Investigate each accident/ incident reported and take remedial measures.
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- 32. Errors can involve: Medicine Surgery Diagnosis Equipment Labreports Radiology reports Dietary dept
- 33. What are theseerrors Errors: Failure of planned action to be completed as intended (error of execution) or use of wrong plan to achieve an aim (error of planning); accumulation of errors result in accidents. Active Errors: An error that occurs at the level of front line operator and whose effects are felt almost immediately. At point of human interface with complex system. Latent Errors: Errors in design, organisation, training or maintenance that lead to operator errors and whose effects typically lie dormant in system for lengthy period of time. (system design)
- 34. Classification Human errors Errorof omission Error of commission Interpretation/evaluation System Errors Inadequate staffing or untrained staff Poor communication between providers, facility and pharmacy Poor coordination between pharmacy and facility for drug ordering and delivery Poor documentation and reporting system of patient specific concerns and human errors
- 35. Process framework fora safer health care Core elements Identify risk Measuring the identified risk in terms of magnitude and frequency of occurrence Prioritizing and controlling the risk Constantly monitoring the effectiveness of control measures
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- 37. Steps Step 1: Identifyrisk Step 2: Determining the Cause Step 3: Considering the consequences Step 4: Assessing the likelihood of an adverse incident Step 5: Determining the risk Step 6: Identifying and reviewing controls Step 7: Action Plan