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Quality and Patient safety goals
- 1. Ms. Blessy Mathew M.ScNursing, QA officer.
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- 4. 1. Identify PatientsCorrectly 2. Improve Effective Communication 3. Improve the Safety of High Alert Medications 4. Ensure Correct-Site, Correct – Procedure, Correct-Patient Surgery 5. Reduce the Risk of Health Care Associated Infections 6. Reduce the Risk of Patient Harm Resulting from Falls
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- 6. IDENTIFICATION BAND 1. Patient’s1st 3 names 2. Hospital Identification Number 3. Date of Birth Shibu lijack
- 7. No procedureshall be conducted when the patient’s identity cannot be verified because ID band is illegible or missing. Patient should not be sent out of the unit without some form of ID Any clinician (doctor, nursing staff, health care professional) who removes ID band is responsible for ensuring another is applied. If limb is not available bands must be securely attached to the patient’s clothing
- 8. VERBAL ORDER Anoral order made by a physician during emergency/ life threatening situation TELEPHONE ORDER Made by physician who is physically unable to be present to write the order that requires immediate intervention *verbal and telephone orders should be limited
- 9. TELEPHONE ORDERS Write &“READ BACK” Example: 19-07-2015 @ 2000H: T.O. by Dr. A Paracetamol 1gm Infusion IV stat T.O. Dr. A/ SN B/ SN C
- 10. HIGH ALERT MEDICATIONS Medicationsinvolved in high percentage of errors and/or sentinel events, medications that carry a higher risk for adverse outcomes as well as look- alike/sound alike medications
- 11. Telephone orders arenot allowed when prescribing HIGH ALERT MEDICATIONS High Alert Medications are not allowed as ward stock All storage locations must be clearly labeled with a red high alert sticker An independent double check for high alert medications is done by two nurses before administering to the patient
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- 14. SITE MARKING When issite mark required? Involves laterality (left, right) Multiple structures (fingers, toes, lesions) Multiple levels (spine)
- 15. Physician performing surgery/procedure providessite marking prior to surgery Site mark is completed before patient enters the operating room/ procedure.
- 16. TIME OUT/PAUSE Averification process before surgical procedure TIME OUT OF REQUIRES CONFIRMATION : Correct patient Correct site Correct procedure Correct patient position Correct radiographs Correct implants and equipment
- 18. 5 MOMENTS OFHAND HYGIENE 1.Before touching the patient 2.Before aseptic procedure 3.After body fluid exposure risk 4.After patient contact 5.After contact with patient environment
- 21. Timed Get Upand Go test (OP) Humpty Dumpty (Peadia) MORSE FALL SCALE (IP) History of fall within 3 months Secondary Diagnosis Ambulatory Aid IV Therapy Gait Mental Status
- 22. Patients are assessedat the time of admission REASSESSMENT • Every 24 hours for Low and Moderate Risk • Every shift if HIGH RISK • Any Change in Patient Condition • Following a fall
- 23. PRECAUTIONS & PREVENTIVEMEASURES LOW FALL RISK •Educate patients •Create patient safe environment •Provide adequate lightning. •Maintain bed in low position •Lock movable transfer equipment •Encourage the use of non-slip footwear. •The re-assessment will be 24 hours and documented in the form.
- 24. MODERATE FALL RISK •Allstandard precautions. •Communicate patient's risk level to all members of the health care team •Communicate family and inform about all precautions available in the hospital. •Supervise or assist elimination/ toileting. Provide bedside commode as needed •Encourage use of assistive devices and mobility aids. •The re-assessment will be the same as low risk patients. PRECAUTIONS & PREVENTIVE MEASURES
- 25. PRECAUTIONS & PREVENTIVEMEASURES HIGH FALL RISK •All standard and Moderate Fall measures •A laminated sign of "Fall Alert“ will be hung on the overboard. •Remain with patient while toileting •Shift the patient to a room with a best visual access from nursing station. •Provide patient observer (family or a Watcher) •Re-assessment of patient with high risk is done every shift (8 hours) and document in the re-assessment form. •Fall alert stickers put on the medical file when sending the patients to other departments for investigations or procedures.
- 26. POST FALL MANAGEMENT Assess for injury Notify physician Use fall risk assessment Notify health care team & patient’s family Initiate OVR
- 27. OCCURRENCE VARIANCE REPORT (OVR) OccurrenceVariance Report (OVR) are internal forms used to document the details of the incident and the investigation of an occurrence and the corrective actions taken.
- 28. Purpose Occurrence Variance Reportis used to help identify areas needing improvement or recognition.
- 29. Who should reportsWhoshould reports Everybody
- 30. When to useWhento use Any incident which is not consistent to routine patient care. Injury to visitors or volunteers while on the hospital premises.
- 31. Miscommunication Accidentalneedle prick Absconded Blood extraction Problem in cleanliness Medicines not transcribed No response to call What to reportWhat to report
- 32. Violation instandard precaution Delays in:_______: Non-availability of supplies/forms Expired blood Wrong patient identification Other (specify: What to reportWhat to report
- 33. TYPES OF EVENTS SENTINELEVENT A “Sentinel Event” is an unexpected occurrence involving death or serious physical or psychological injury, not related to the natural course of a patient’s illness or underlying condition. Examples: • Unanticipated death unrelated to the natural course of the patient’s: suicide , homicide( • Hemolytic Blood Transfusion. • Wrong-site, wrong-procedure, wrong-patient surgery • Infant abduction or infant who was sent home with the wrong parents. NearMiss Events A near miss is defined as any process variation which did not affect the outcome but for which a recurrence carries a significant chance of a serious adverse outcome Adverse Events Any change in health or side effects that occurs while the patient is receiving the treatment
- 34. PolicyPolicy for OVRforOVR 1. Report the details of any occurrence, which has an impacts in the care of patient. 2. OVR Form will be initiated immediately after the incident. And submit it to your immediate supervisor within the current work shift.
- 35. 3. The reportwill NOT be used to CRITICIZE OR BLAME the actions of the staff involved. 4. Corrective actions shall be taken to minimize risk of injury and adverse outcomes. Corrective action(s) shall be documented.
- 36. Root Cause Analysis Thepurpose of the Root Cause Analysis is to understand how and why a Event occurred and to prevent the same or similar event from occurring in the future by analyzing the course and causes behind the event and working on defects.
- 37. QUALITY IMPROVEMENT METHODOLOGY (FOCUS –PDCA) •Find - an opportunity for improvement •Organize- a team •Clarify- The current process •Understand- the resources of the problem and the process variation •Select- The improvement •Plan - the improvement •Do- the improvement •Check- the results •Act- To hold the gain
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