Patient Safety Management - 20150406

Patient Safety Management
Reynaldo O. Joson, MD, MHA, MHPEd, MSc Surg
UNILAB SHARING PROGRAM
April 6, 2015

share
my thoughts, perceptions, opinions, and
recommendations (TPOR)
on
Patient Safety Management Program

Patient Safety Program
Outline / Topics
• Patient Safety Program and Safe
Hospital Initiative
• Status and Practices of Patient Safety
in the Philippines
• ROJoson’s TPOR on Patient Safety
Program

Patient Safety Program and Safe Hospital Initiative
in Medical Centers / Hospitals
Questions are:
1) Are they the same?
2) If not, what are the differences?
3) Do they have something in common?

Are they the same?
Patient safety program and safe hospital
initiative are not exactly the same.

If not the same, what are the differences?
Patient safety program is focused on safety
of patients inside the medical center in the
aspect of medical management.
Safe hospital initiative is focused on safety of
patients inside the medical center in the
aspect of disaster risk reduction and
management.

Do they have something in common?
Safety of patients
is what patient safety program and safe
hospital initiative have in common.

Safe Hospital Initiative in Medical Centers /
Hospitals
The ultimate goal of safe hospital initiative is
that the medical center has a safety level
that is sufficient to protect patients during
and after a disaster event and is likely to
continue functioning in disaster situations.

Hospitals
There are three standard indicators being
used in safe hospital initiative, namely,
structural, non-structural, and functional.

Hospitals
Safe in Structural Component means the
hospital will not collapse thereby
protect patients, staff, and properties;
being safe to accommodate patients from
external mass casualty incidents;
continue to function during disasters.

Hospitals
Safe in Non-Structural Component means
the hospital non-load bearing structures and
facilities will not be destroyed / swept away,
thereby protect patients, staff, and
properties;
continue to function effectively and safely
during disasters for current patients and
external mass casualty incident patients.

Hospitals
Safe in Functional Component means the
hospital services will continue to function at
its maximum capacity
for its current patients;
for surge of patients; and
will remain accessible to patients from
external mass casualty incidents during
disasters.

Patient Safety Program in Medical Centers /
Hospitals
The ultimate goal of patient safety program
is that the medical center has a safety level
that is sufficient to protect patients from
harm and preventable complication,
disability and mortality during medical
management.

Status and Practices of Patient Safety in the
Philippines
Philippines has a
National Policy on Patient Safety
(Administrative Order 2008-0023)
issued in 2008.
June 25 – National Patient Safety Day
July 25 – World Patient Safety Day

Status and Practices of Patient Safety in the Philippines
PH National Policy on Patient Safety
Program Framework

Goal:
to ensure that patient safety is
institutionalized as a fundamental
principle of the health care delivery
system in improving health outcomes.

Objectives:
• To establish a comprehensive patient
safety program in all levels of the
health care delivery system thru
effective governance.

Objectives:
• To develop the critical capacity of the
health care workers in the health
facilities for the implementation of
standards, guidelines, systems,
training programs, relative to patient
safety.

Objectives:
• To sustain and continuously improve
mechanisms that nurtures a culture
of safety thru appropriate strategies.

General Policy Statements:
• The establishment and maintenance
of a culture of patient safety in an
organization is the responsibility of
its leadership.
• Enabling / support mechanisms /
strategies shall be in place to ensure
patient safety in the health facilities.

• The implementation of the Patient
Safety Program for all facilities shall
be anchored on both DOH licensing
and PHIC accreditation standards.

• The key priority areas in patient
safety include but not limited to
• proper patient identification
• assurance of blood safety
• safe clinical and surgical procedures

• The key priority areas in patient
safety include but not limited to
• provision and maintenance of safe
quality drugs and technology
• strengthening of infection control
standards
• maintenance of the environment of
care standards and
• energy / waste management standards

Could not get adequate and reliable data
and information on (as of April 5, 2015)
• What are the programs in place and what
are the status of these programs so far?
• Are there consolidated national data on
patient safety from 2008 to 2014?

My two general observation and
perception:
• All hospitals or medical centers
somehow have a patient safety
program.
• The patient safety programs vary in
the extent of development, a few are
well-developed, majority are
underdeveloped.

• All hospitals or medical centers somehow have
a patient safety program.
To pass and maintain their licensure
requirements, all hospitals must show
they have a patient safety program.

All hospitals are being assessed by the DOH using
a tool that contains the following requirements
related to patient safety:
• Policies and procedures and implementation
evidences on
• Safe Practice and Environment including
Patient and Staff Safety
• Maintenance of Environment of Care
• Infection Control
• Energy and Waste Management

Required presence of hospital committees (directly
and indirectly related to Patient Safety)
• Blood Transfusion
• HIV/AIDS Core Team
• Waste Management
• Patient Safety
• Infection Control
• Pharmacologic/Therapeutics
• Health Emergency/Crisis Management
• Tissue

Every year, all hospitals have to submit to the
DOH an annual hospital statistical report which
include among other things that will force them
to have somehow a patient safety program -
• Quality management program
• Healthcare Associated Infection (HAI)

• The patient safety programs vary in the extent
of development, a few are well-developed,
majority are underdeveloped.
If I were to use the following criteria:
1) design and development blueprint;
2) deployment, education and training and
implementation;
3) evaluation, review and continual
improvement;
4) documentation and archiving; and
5) management review and independent
audits.

• The patient safety programs vary in the extent
of development, a few are well-developed,
majority are underdeveloped.
• Those hospitals with relatively well-developed
are usually those hospitals which sought and
have been given international accreditation
such as the Joint Commission International and
Accreditation Canada International (and there
are 7 hospitals in the Philippines).
• These accreditation bodies have more comprehensive
and stringent requirements on patient safety
compliances.

International Patient Safety Goals
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 risk of health care-associated infections
Goal 6 - Reduce the risk of patient harm resulting from
fall

Surgical Safety Checklist

Hand Hygiene

Infection Precaution

Infection Precautions

ICU Infection Safety Precaution Posts

Department of Surgery

Patient Safety in Health Science Schools
WHO Patient Safety
Curriculum Guide – Multi-
Professional Edition - 2011

ROJoson’s TPOR on Patient Safety Program
• For a medical center to be completely safe for
patients, it must have an excellent patient
safety program and safe hospital initiative in
place and which are aligned and integrated
with each other.

• To achieve alignment and integration of all
patient safety initiatives and projects, there
must be a medical-center-wide body to
coordinate and supervise them.

• SAFETY PROMOTION AND DISASTER
PREPAREDNESS COMMITTEE (SPDPC)
• Natural Disaster and Fire Safety Program
• Security and Man-made Disaster Program
• Environmental Safety Program
• Infection Safety Program
• Patient Care Safety Program
• Occupational Health and Safety Program
• Search, Rescue, and Evacuation Program
• Medical Resuscitation Program
• Surge of Patients Program
• Emergency and Disaster Information Program
• Media and Risk Communication Program

Other medical centers in the Philippines have
committees or groups with the following names:
Quality and Patient Safety Group or Committee
integrating safety and quality or simply Patient
Safety Committee as indicated by DOH.
Note: The name is not as important as the
authorized functions, responsibilities and
authorities which must be comprehensive and
integrative as far as patient safety initiatives are
concerned.

For all patient safety programs that may be
established in the medical centers, to be judged as
excellent, they must have the following key result
areas fully developed, aligned, integrated and
institutionalized, namely:
1) design and development blueprint;
2) deployment, education and training and
implementation;
3) evaluation, review and continual improvement;
4) documentation and archiving; and
5) management review and independent audits.

They must be able to show consistently excellent
results in the key performance indicators of
patient safety,
with a level that is sufficient to constantly and
continuously protect patients from harm and
preventable complication, disability and mortality
during medical management.

I have seen a lot of approaches in establishing and
developing patient safety program in medical
centers.
Most of them just try to comply to the letter
whatever are stated in the requirements of
accrediting standards (DOH-PHIC, JCI, ACI, etc.).
This is most probably the easiest way to start the
ball rolling.

However, what I would like to propose,
in order for a patient safety program in a medical
center to be more systematic, comprehensive,
aligned, and integrated,
will be to do a strategic planning ending with a
comprehensive design and development
blueprint.

In the strategic planning,
there must be a comprehensive identification of
all potential, common, and critical hazards related
to patient care safety.
After a comprehensive list of potential hazards is
drawn up, the next step is to formulate strategies
in prevention, mitigation, preparedness, response,
and recovery.

In formulating the strategies,
use the principles of all-hazards approach,
meaning look for generic critical measures or
package of generic critical measures in prevention,
mitigation, preparedness, response and recovery
that can be used for all types of hazards regardless
of the cause.
This contributes to cost-effectiveness and efficient
education of staff compared to formulating
strategies for each type of hazard.

Put simply,
start macro and gradually go micro or
start with concepts and principles and processes
then gradually go particulars until a generic critical
package of strategies have been identified.
Specific and contingency strategies may be
included as indicated but only after the generic
critical package of strategies have been
established.

Aside from the identification of hazards and
formulation of all-hazards approach strategies in
prevention, mitigation, preparedness, response
and recovery that should be contained in the
design and development blueprint,

there should also be blueprints for
• deployment, education and training and
implementation;
• evaluation, review and continual improvement;
• documentation and archiving; and
• management review and independent audits.

EDUCATION and COMMITMENT of all staff (top-
down) are the critical success factors of a Patient
Safety Program in a medical center.

EDUCATION of all staff (top-down) as a critical
success factor of a Patient Safety Program in a
medical center.
ALL staff shall understand the what, why, and
general how of patient safety
• Concept
• Principles
• Processes
• General safety precautions and measures
• General contingency responses

EDUCATION of all staff (top-down) as a critical
medical center.
SOME staff (because of their specialty) shall
understand
• Specific safety precautions and measures
• Specific contingency responses

COMMITMENT of all staff (top-down) as a critical
medical center.
ALL staff shall commit themselves to
• Achieve the goals of patient safety in all patients they are
managing
• Work as a team (with proper communication,
coordination, collaboration) in promoting patient safety
• Practice the principles, processes, and safety precautions
on patient safety
• Vigilance against harms and adverse events
• Continual improvement in processes and safety
precautions

GOALS in the Management of any Patient:
RESOLUTION OF THE PATIENT’S HEALTH PROBLEM
OR CONCERN IN SUCH A WAY HE DOES NOT END
UP
• DEAD;
• WITH DISABILITY;
• WITH COMPLICATION;
AND IN SUCH A MANNER
• THAT HE IS SATISFIED AND
• THERE IS NO MEDICOLEGAL SUIT.

SAFETY GOALS in the Management of any Patient:
OR CONCERN IN SUCH A WAY THAT THERE IS
• NO HARM;
• NO PREVENTABLE COMPLICATION;
• NO PREVENTABLE DISABILITY; AND
• NO PREVENTABLE DEATH.

SAFETY GOALS (corporate and staff) in the
Management of any Patient:
OR CONCERN IN SUCH A WAY THAT THERE IS ZERO
INCIDENCE OF
• HARM;
• PREVENTABLE COMPLICATION;
• PREVENTABLE DISABILITY; AND
• PREVENTABLE DEATH.

Identification of HAZARDS (threats) in the
management of any patient:
(potential, common, and critical)
ROJoson’s Categorization:
• HARM (blatant physical injuries to patients)
• ADVERSE EVENTS
• PREVENTABLE COMPLICATION;
• PREVENTABLE DISABILITY; AND
• PREVENTABLE DEATH.

ROJoson’s Categorization:
• HARM (blatant physical injuries to patients)
I put in a separate HARM category to bring out the
importance of avoiding blatant physical injuries to
patients as these are outright res ipsa loquitur (the
thing speak for itself) and constitute medical
negligence and therefore, should be given priority
and avoided at all cost.

• HARM
• Fall (from inpatient beds, stretchers)
• Burns
• Unnecessary procedures (diagnostic and
treatment)
• Blatantly wrong diagnosis which lead to harm
• Blatantly wrong procedure (wrong patient; wrong
side; wrong medication; wrong diagnostic
procedure; wrong treatment procedure)
• Wrong reports which lead to harm
• others

• ADVERSE EVENTS
• PREVENTABLE COMPLICATION; DISABILITY; AND
DEATH
• Also produce “harm” but usually inconspicuous, at
least initially

• ADVERSE EVENTS
• Those medical events considered as preventable
complication, disability, and death by medical
standards (internal at least, may be by the
community or international) and after an audit in
patients who underwent an indicated procedure.

• ADVERSE EVENTS
• The medical center will have to put up such a list
and the processes to determine which
complications, disabilities, and deaths are
preventable.
• The list can contain two subcategories: surgery-
related and non-surgery-related complications,
disabilities, and deaths.

After the identification of hazards,
the next thing to do is
to identify the more common and critical causes,
general then specific, and in terms of vulnerability
and capacity.

In both the HARM and ADVERSE EVENTS
categories,
the general cause of the occurrence of the hazards
consists basically of
INADEQUATE LEVEL OF SAFETY PRECAUTIONS OR
MEASURES in 5 Ms and 1 S, namely,
• Man
• Method
• Machine
• Monument
• Money
• Systems

The more specific causes are related to the
• competency of staff (inclusive of leaders) on
patient safety, particularly on safety culture;
• safety in methods of delivering medical services
(formulating clinical diagnosis; diagnostic
procedures; treatment procedures; giving
advices);
• safety of machines in delivering medical
services;

The more specific causes are related to the
• infrastructure needed for safe services;
• money to establish, develop and sustain a
patient safety management system;
• and safety systems (such as communication
system; coordinating systems; policies and
procedures; clinical practice guidelines and
clinical pathways).

After spelling out the goals, identifying the
potential patient safety related hazards and
putting them into 2 categories (based on
commonality); and identifying the more common
and critical causes,
the next thing to do is
to formulate strategies using principles of all-
hazards approach.

Examples of all-hazards-approach strategies that
can be used:
• Common framework of prevention-mitigation-
preparedness-response-recovery (with policies
and procedures, clinical practice guidelines, and
clinical pathways) that can be used for all
hazards related to patient care safety regardless
of specific cause or types.

can be used:
• Common framework of prevention-mitigation-
preparedness-response-recovery (with policies
and procedures, clinical practice guidelines, and
clinical pathways) (with policies and
procedures, clinical practice guidelines, and
clinical pathways) (with policies and
procedures, clinical practice guidelines, and
clinical pathways) for each of the two
categories of hazards, namely, HARM and
ADVERSE EVENTS.

can be used:
The approaches in these two categories (HARM
and ADVERSE EVENTS) may be different but within
the category, the approach may be the same for
all specific types of hazards.

can be used:
Whether it be HARM or ADVERSE EVENTS, there
must be
a) design and development blueprint;
b) deployment, education and training and
implementation;
c) evaluation, review and continual improvement;
d) documentation and archiving; and
e) management review and independent audits.

After formulating the strategies using the
principles of an all-hazard approach, as indicated,
specific action and contingency plans are
formulated.

5-step strategic planning
• Formulation of Goals
• Identification of Hazards
• Identification of Common Causes of Hazards
• Formulation of Strategies for P-M-P-R-R using
All-Hazard Approach
• Formulation of Specific Action and Contingency
Response Plans
*PMPRR – Prevention, Mitigation, Preparedness,
Response, Recovery

As mentioned, the foremost advantage of these 5-
step strategic planning is that it is more
systematic,
comprehensive,
aligned, and
integrated,
that ends with a comprehensive design and
development blueprint.

Using the principles of all-hazards approach
contributes to cost-effectiveness and efficient
education of staff compared to formulating
strategies for each type of hazard.

Let me end my sharing with two vignettes that I
have observed over the years.

In the management of surgical patients, patient
safety in the operating room, just using the
surgical patient checklist, is not enough.
Surgical patient care safety precautions and
measures should be present in the inpatient floors
and other parts of the medical centers where the
patient may have to be sent for needed diagnostic
and other treatment procedures.

Fall, burns, wrong diagnosis, wrong reports, delay
in needed intervention for adverse events, and
inadequate safety precaution in other procedures
done to the patient outside the operating room
should be prevented.
Thus, the patient care safety must be vigilantly
and comprehensively carried out anywhere and
everywhere in the medical center and by all
members of the medical team.

In the management of non-surgical patients in the
inpatient floors,
fall, burns, wrong diagnosis, wrong reports, wrong
patient, wrong side, wrong diagnostic procedure,
wrong treatment procedure, wrong medication,
unnecessary procedures, delay in intervention,
and other instances of inadequate safety
precautions
are common challenges and should be avoided.

Patient care safety measures should also be
present in other parts of the medical center where
the patient will be sent for needed diagnostic and
other treatment procedures.
Thus, the patient care safety must be vigilantly
and comprehensively carried out anywhere and
everywhere in the medical center and by all
members of the medical team and all staff.

These two vignettes emphasize the benefits that
can be derived from the systematic and
comprehensive approach that I share with you,
better than the single-shot approach of patient
safety by a specialty and by a sector in the
hospital.

April 6, 2015
rjoson2001@yahoo.com
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Patient Safety Management - 20150406

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