Patient Safety & Risk Management Staff Orientation

PATIENT SAFETY
AND
RISK MANAGEMENT
Ibn Al Gumahad, BSN-RN
Coordinator, Patient Safety
059 – 272 – 6391
894-5524 EXT 571
Quality Management-MDH

Safety Policy Statement
 Patient comes first.
 Most valuable resource:
STAFF
 Dedicated to a safe and
healthful environment
for employees, patients
and others;
 Preservation of company
assets and properties;
22 NOVEMBER 2014 / ibn_al07@yahoo.com

Safety Policy Statement
 Committed to aggressive
management of clinical
and non-clinical (operational)
risk;
 Control hazards, minimize
customer injuries, property
damage and/or loss;
 Promoting safety is every
MDH employee’s
responsibility.

Risk is EVERYWHERE !
is not an exception!

RISK MANAGEMENT PROGRAM
To develop and implement an integrated
system of assisting MDH employees in ensuring
the quality of services by:
 Identifying
 Managing
 Reducing hazards and risks of
undesirable or adverse events associated with
service delivery throughout the organization.

RISK MANAGEMENT PROCESS
1. Risk Identification
2. Risk Assessment
3. Risk Treatments
4. Review and Follow-
Up

RISK IDENTIFICATION
 Know the hazards or potential
risks.
 Risks when triggered, cause
problems.
 Can be internal or external
(SOURCE ANALYSIS).
 Events leading to a problem
are investigated (PROBLEM
ANALYSIS)

RISK ASSESSMENT
 Potential
severity of
damage, loss
and
recurrence.

RISK TREATMENTS
 Risk Avoidance
 Risk Reduction
 Risk Retention
 Risk Transfer

Risk REVIEW & FOLLOW-UP
 Incident Reporting System
 Hazards Surveillance Rounds
 Infection Control Surveillance
 Hospital Safety Committee
 Infection Prevention & Control
Committee
 Medication Safety
 Audits, focused studies

Occurrence Variance Reporting
System (OVRS)
VARIANCE – is anything that is
out of the STANDARDS
 Incidents are reported thru
OVR
 Processed by the Patient
Safety Coordinator
 Entered in the data base
where trends and patterns are
identified

Occurrence Variance Reporting
System (OVRS)
 Addressed and followed through with
appropriate individuals and entities.
SYSTEMS RATHER
THAN INDIVIDUALS
IS THE FOCUS OF THE
OVR.

What to REPORT?
 MEDICATION ERRORS
 Procedure/Practice
Variance
 Security-related
 Safety-related
 Patient Variance
 Miscellaneous

Sample of OVR Data

Patient-Related Incidents
UNKNOWN
Near Miss
Minor
Moderate
Major
Severe

Barriers in reporting incidents
 What’s in it for
me?
 Individuals
rather
than
systems/proces
ses
 Punitive
 No feedback

Proactive Safety Improvement
 Gather and analyze
information about risk-prone
processes
 Redesign high-risk
processes to reduce the
chance of patient harm
 Document the process
 Train people
 Monitor continuing safety
of the process

Steps to Improve Safety
 Basic Tenets of Human
Error
 Everyone commits errors
 Human error is generally the
result of circumstances that
are beyond the conscious
control of those committing
the errors.
 Systems or processes that
depend on perfect human
performance are fatally
flawed.

Common Causes of Medical Errors
and Sentinel Events
 Lack of staff orientation/training
 Communication failure
 Medication storage/access
problems
 Important information not available
to caregivers
 Staff competency/credentialing
problems
 Inadequate supervision
 Inadequate/improper labeling
 Staff distraction

Need to Increase Focus
on the Human Factors
Human errors occur because of:
 Inattention
 Memory lapse
 Failure to communicate
 Poorly designed equipment
 Exhaustion
 Ignorance
 Noisy working conditions
 A number of other personal and
environmental factors

Where to Start ?
 Consider safety improvement
recommendations made
during surveillance rounds
 Share safety improvement
ideas
 Focus attention on high-risk
processes
 Incident reports and other
info are used to identify risk-prone
patient-care processes
 Your help is needed – report
incidents and hazardous
situations.

REMEMBER:
People Are Set-Up to
Make Mistakes
Incompetent people are, at
most, 1% of the problem.
The other 99% are good
people trying to do a good
job who make very simple
mistakes and it's the
processes that set them
up to make these
mistakes.
Dr. Lucian Leape, Harvard School of Public Health

INTERNATIONAL PATIENT
SAFETY GOALS.
 TO PROMOTE SPECIFIC
IMPROVEMENT IN PATIENT SAFETY
 HIGHLIGHT PROBLEMATIC AREAS IN
HEALTHCARE
 DESCRIBE EVIDENCE AND EXPERT-BASED
CONCENSUS SOLUTIONS TO
THESE PROMBLEMS.
JOINT COMMISSION INTERNATIONAL

IPSG 1. IMPROVE THE
ACCURACY OF
PATIENT
IDENTIFICATION.
Use at least TWO (2)
PATIENT IDENTIFIERS:
1. Complete Name
2. Medical Record
Number
APPL ICABI L ITY OF PATI ENT IDENTI F ICATION:
1. Eme rg enc y Room
2. Ope r a t ing Room
3. L abor a tor y
4. Radiolog y
5. Be for e any proc edur e
6. Be for e prov iding any t r e a tment
7. At AL L Point s of Ca r e

IPSG 2. IMPROVE THE
EFFECTIVENESS
OF COMMUNICATION
1.Verbal and telephone order or
test resul t is WRITTEN DOWN
by the receiver of the order.
2. READ BACK is done by the
receiver of the order or test resul t .
3. The order or test resul t is CONFIRMED by the
individual who gave the order or test resul t .

IPSG 3. IMPROVE THE SAFETY
OF HIGH ALERT
MEDICATIONS
Take caution on:
LOOK-ALIKE /
SOUND-ALIKE
MEDICATIONS
Restricting access
to CONCENTRATED
ELECTROLYTES in
patient care areas.

IPSG 4. ENSURE CORRECT SITE,
CORRECT PROCEDURE,
CORRECT-PATIENT
SURGERY
1. MARKING THE SURGICAL SITE
for al l cases involving
lateral i ty, mul t iple st ructures or
levels.
2. PRE-OPERATIVE
VERFICATION PROCESS
3. TIME OUT is
held immediately
before the star t
of the procedure.

IPSG 5. REDUCE THE RISK OF
HEALTH-CARE
ASSOCIATED
INFECTIONS
• Surgical Site Infection Prevention
• Hand Hygiene Program
• Venti lator-Associated Pneumonia
Prevention
• C AU T I Prevention
• Central Line Infection Prevention

IPSG 6. REDUCE THE RISK OF
PATIENT HARM
RESULTING FROM
FALLS
• Fal l Risk Assessment Upon
Admission
• Fal l Risk Re-assessment
After Invasive Procedure
• Implementation of Patient
Fal l Management for those
assessed to be at risked.

THANK YOU
VERY MUCH !
Ibn Al Gumahad, BSN-RN
Coordinator, Patient Safety
059 – 272 – 6391
894-5524 EXT 571
Quality Management-MDH

Patient Safety & Risk Management Staff Orientation

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Patient Safety & Risk Management Staff Orientation