Patient safety

1. PREPARED BY :- DR. M. RAMZY ER RESIDENT-QUALITY COORDINATOR-MGH 1

2. Patient Safety Definition The working to avoid, manage and treat unsafe acts within the health-care system, through the use of best practices lead to optimal patient outcomes.

3. The GOAL  Hospitals should provide an environment that ensures safety of all individuals  By promoting a proactive and non- punitive Culture to facilitate reporting of hazards, errors, near-misses, concerns and otherwise unsafe conditions within the Hospital.

4. What Should Be Reported?  Unanticipated death or permanent loss of function  Healthcare acquired infection  Unanticipated patient outcome  Any adverse event involving patient care &/or pt. environment.  Any near miss  Any safety concerns

5. FIRST DO NO HARM NOW DO IT SAFE 5

6. Patient Safety Terms  Adverse Event  Medical Error  Sentinel event  Near Miss  Retrospective Analysis  Prospective Analysis  Identifying risks and processes before they happen  Bad outcome from care  Major and enduring loss of function  An examination of past events  Deficient process of care  Could have resulted in loss, injury or illness, but did not

8. SOME REASONS WHY ERRORS OCCUR System Factors  Complexity of healthcare processes  Complexity of health care work environments  Lack of consistent administration practices  Deferred maintenance  Clumsy technology Human Factors  Limited knowledge  Poor application of knowledge  Fatigue  Sub-optimal teamwork  Attention distraction  Inadequate training  Reliance on memory  Poor handwriting ‫تناغم‬

9. What is a culture of safety? Components of a safety culture include:  Commitment to safety as the primary priority  Availability of the necessary resources  Incentives, and rewards for safety  Openness about errors and problems  Commitment to organizational learning  Unity, loyalty, and teamwork among staff  Non Punitive Environment (culture of safe reporting) leads to increase number of reported errors 9

10. Just culture  3 basics: 1. It doesn’t reduce the personal accountability and discipline. It emphasizes the learning from the errors and near misses to reduce errors in the future. 2. The greatest error not to report a mistake. Thereby prevent learning. 3. All in the organization to serve as safety advocates. Both providers and consumers will feel safe and supported when they report medical errors, near misses and voice concerns about patient safety. IT HAS ZERO TOLERANCE FOR RECKLESS BEHAVIOR.

11. BEHAVIORS  Human error – inadvertent action: doing other than what should have been done. ‫غفلة‬-‫مقصود‬ ‫غير‬ Manage through change in processes, procedures and training.  At risk behavior: behavioral choice that increase risk , where risk is not recognized or is believed to be justified. Manage through increase awareness, and providing incentives for healthy behaviors and disincentives for risky behaviors.  Reckless behavior: consciously disregard substantial and unjustifiable risk. Manage through Remedial and punitive action.

12. 12 ‫قلعة‬‫قايتباى‬ ‫ية‬‫ر‬‫ـكند‬‫ـ‬‫ـ‬‫ـ‬‫ـ‬‫ـ‬‫ـ‬‫ـ‬‫ـ‬‫ـ‬‫س‬‫اال‬

13. The most common cause of medical errors is miscommunications 13

14. MISCOMMUNICATION  Breakdowns in communication can result in the wrong treatment, a lack of treatment, or incorrect self-care by the patient.

15. 4 6 1 3 25 Patient Safety Goals

16.  IPSG.1 Identify Patients Correctly  IPSG.2 Improve Effective Communication  IPSG.3 Improve the Safety of High-Alert Medications  IPSG.4 Ensure Correct-Site, Correct-Procedure, Correct-Patient Surgery  IPSG.5 Reduce the Risk of Health Care–Associated Infections  IPSG.6 Reduce the Risk of Patient Harm Resulting from Falls International Patient Safety Goals IPSG I CAN MEMOR IZE EVERY THING I FANCY

17. Patient Safety Goals Identify patient correctly by two identifiers before: 1 Providing treatments and procedures Administering medications, blood, or its products Taking blood and other specimens uses Patient’s NAME and DATE of BIRTH Label specimen containers in presence of patient

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19.  IPSG.1 Identify Patients Correctly  IPSG.2 Improve Effective Communication  IPSG.3 Improve the Safety of High-Alert Medications  IPSG.4 Ensure Correct-Site, Correct-Procedure, Correct-Patient Surgery  IPSG.5 Reduce the Risk of Health Care–Associated Infections  IPSG.6 Reduce the Risk of Patient Harm Resulting from Falls International Patient Safety Goals IPSG

20. Improve effective communication through: 2 Patient Safety Goals con.. The most common cause of medical errors is miscommunications

21. Documentation a major form of Communication. 21

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26. SBAR  A structured communication technique designed to convey a great deal of information in an organized & brief manner.  This is important as we all have different styles of communicating, varying by profession, culture, and gender.

27. SBAR Situation A concise statement of the problem What is going on now Background Pertinent and brief information related to the situation What has happened Assessment Analysis and considerations of options What you found/think is going on Recommendation Request/recommend action What you want done S B A R

28. Example SBAR briefing Situation: Dr. Jones, I have a 55 Y/O Man who looks pale, sweaty and is complaining of chest pressure. • Background: He has a history of HTN, admitted for GI Bleed received 2 units, last crit two hours ago was 31 vital signs are: BP 90/50, Pulse 120 • Assessment: I think he’s got an active bleed and we can’t rule out an MI but we don’t have a troponin or a recent H&H. • Recommendation: I’d like to get an EKG and labs and I need for you to evaluate him in right away.

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31. Patient Safety Goals con.. Improve the safety of high alert medication 3 Double check Why ? Labeling? To prevent medication errors

32. 32  Medication reconciliation: document meds on admission  Medication brought in by family members  Herbals, supplements, OTC drugs  Develop a process for communicating patient medications to all providers  Provide list of medications to patient upon discharge from facility.

33.  Standardizing drug concentrations  Reducing potential for error related to look-alike and sound alike meds. – Insulin – all types – Chemotherapy – Ambulatory medications  Label all medications and med containers or other solutions on or off the sterile field in operative and procedural areas. 33

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37. Patient Safety Goals con.. ENSURE • Marking the surgical site • Preoperative verification: • Correct site, patient, and procedure • All relevant documents, images and studies are available and properly labeled • Time out immediately before starting procedure Ensure correct-site, correct procedure, and correct-patient surgery through: 4

39. Patient Safety Goals con.. Reduce the risk of health care associated infections by Hand hygiene 5 After exposure to body fluid

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42. Patient Safety Goals con.. Reduce the risk of patient harm resulting from falls by: ◦ Initial assessment for fall risk at the time of admission ◦ Reassessment when change in patient condition, medication , etc. ◦ Implement fall prevention measures 6

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44. Thank you 44

Patient safety

Patient safety

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Patient safety