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Semelhante a P8 INCIDENT REPORTING AND LEARNING FROM ERROR HOUSEMANSHIP MALAYSIA
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P8 INCIDENT REPORTING AND LEARNING FROM ERROR HOUSEMANSHIP MALAYSIA
- 1. 1 INCIDENT REPORTING & LEARNING FROM ERROR Patient Safety Unit Quality in Medical Care Section Ministry of Health Malaysia @ Secretariat, Patient Safety Council Malaysia In Collaboration with : Patient Safety Module Technical Committee
- 2. 2 • Understand the basic concept of incident reporting and learning system. • Understand the differences between error, violation and near miss • Understand the role of Junior Health Care Professional in improving Patient Safety through incident reporting and learning system 2
- 3. 3 1 in 10 patients is harmed while receiving hospital care ( Estimation in developed country ) -W.H.O Malaysia Hospital admissions in 2013 3,323,024 Estimated adverse events (10%) 332,302 3
- 4. 4 Medical error is the third leading cause of death in the United States which accounts for 10% of all US death Makary et al., BMJ, pg. 353; May 2016 4 10%
- 5. 55
- 6. 66 MEDICATION ERROR POOR HANDWRITING INCORRECT DOSE UNAWARE OF PATIENT ALLERGY TRANSFUSION ERROR INCORRECT SPECIMENT LABELING WRONG PATIENT WRONG SURGERY / PROCEDURE WRONG PATIENT / SITE / SIDE
- 7. 77 PATIENT FALL NOT AWARE OF FALL RISK RETAINED FOREIGN BODY E.g. POST PARTUM ( TAMPOON / GAUZE ) INFANT DISCHARGE TO THE WRONG PERSON WRONG PATIENT IDENTIFICATION ( SWITCHED PATIENT TAG) INJURY TO NEONATE POST DELIVERY ERB PALSY SHOULDER DYSTOCIA – NOT AWARE OF RED FLAGS AND UNASSISTED BEWARE!! IT COULD HAPPEN TO ANY PATIENT UNDER YOUR CARE!
- 8. 88 PATIENT SAFETY INCIDENTS VIOLATIONERROR NEAR MISS NON – INTENTIONAL DEVIATION FROM AN ACCEPTED PROTOCOL OR STANDARD OF CARE. “TAK SENGAJA” INTENTIONAL DEVIATION FROM AN ACCEPTED PROTOCOL OR STANDARD OF CARE. AGAINST THE LAW AN ERROR THAT HAS BEEN PREVENTED BEFORE IT OCCURRED
- 9. 99 ERROR ACCIDENTALLY wrote wrong unit on medication prescription e.g : 10mg instead of 10µg VIOLATION Take blood pre- and post- potassium correction but send the same sample INTENTIONALLY ( pre-sample ) twice and resulting in over- correction NEAR MISS Wrong dose of medication being prescribed but DETECTED BEFORE IT IS ADMINISTERED to the patient
- 10. 1010 ? WHEN AN INCIDENT OCCUR… X DON’T HIDE IT √ REPORT IT
- 11. 1111 DAMAGE CONTROL PREVENT WORSENING OF SITUATION IMPROVE QUALITY & SAFETY OF HEALTHCARE IMPROVE SYSTEM DEFECT LEARNING FROM MISTAKES
- 12. 12
- 13. 13 HOW TO REPORT AN INCIDENT?
- 14. 1414 Incident Reporting & Learning System 2.0 THE PRINCIPLES 1. Report 2. Respond 3. Share
- 15. 1515 SECTION A: FILLED BY H.O WHO IS INVOLVED / WITNESS THE INCIDENT
- 16. 16 • Medication error • Wrong transfusion • Wrong Surgeries/ procedures • Patient fall • Obstetric related incidents e.g neonatal injury during birth • Adverse outcome of clinical procedure • Patient suicide • ANY INCIDENTS RELATED TO PATIENT SAFETY 16 Example of Reportable Incidents
- 17. 1717 AS A JUNIOR HEALTH CARE PROFESSIONAL IMMEDIATE CORRECTIVE MEASURE/ DAMAGE CONTROL1 INFORM SUPERIOR ( e.g. MO , Specialist or other available experienced officer ) 2 PATIENT SAFETY INCIDENT OCCUR
- 18. 1818 FILL IN FORM I.R 2.0 ( AS WITNESS / PERSON INVOLVED )3 The incident will be investigated and action will be taken to prevent further occurrence of the incident. PATIENT SAFETY INCIDENT OCCUR AS A JUNIOR HEALTH CARE PROFESSIONAL
- 19. 19 Overview of Incident Reporting 19 INCIDENT OCCUR IMMEDIATE ACTION / DAMAGE CONTROL INFORM SUPERVISOR FILL IN INCIDENT REPORTING FORM (SECTION A) INCIDENT INVESTIGATED BY INVESTIGATION TEAM (e.g : Root Cause Analysis ACTION TAKEN & FURTHER OCCURANCE OF INCIDENCE PREVENTED MONITORING OF ACTION PLAN
- 20. 20 Examples of Improvement Achieved Through The Incident Reporting System 20 WRONG SURGERY ( DONE ON WRONG PATIENT/ SITE / SIDE ) PROBLEM1 • SAFE SURGERY SAVES LIVES PROGRAM • SSSL CHECKLIST IMPROVEMENT SAFE SURGERY SAVES LIVES PROGRAM SSSL CHECKLIST
- 21. 21 Examples of Improvement Achieved Through The Incident Reporting System 21 BCG VACCINE MISTAKENLY INJECTED TWICE TO BABY IN NICU PROBLEM2 • USAGE OF STICKER TO INDICATE BABIES THAT HAD RECEIVED THEIR VACCINATION IMPROVEMENT USAGE OF STICKER TO INDICATE BABIES THAT HAD RECEIVED THEIR VACCINATION
- 22. 22 Examples of Improvement Achieved Through The Incident Reporting System 22 GERIATRIC PATIENT FALLING FROM NORMAL HOSPITAL BED PROBLEM3 • USAGE OF ULTRALOW HOSPITAL BEDS FOR GERIATRIC PATIENT • PATIENT FALL PRECAUTIONS IMPROVEMENT USAGE OF ULTRALOW HOSPITAL BEDS FOR GERIATRIC PATIENT
- 23. 23 Take Home Message We need to take action to improve and prevent similar incident from happening again Incident reporting is not just about “paper work”, the aim is to improve our system and as a Junior Health Care Professional, you can play an important role in improving our system. 23
- 25. 25 DON’T HIDE IT REPORT IT!
- 26. 26
- 27. 27 Acknowledgement: Dr. Nor ‘Aishah bt Abu Bakar Dr. Mohd Suffian bin Mohd Dzakwan Dr. Khairulina Haireen bt Khalid Dr. Ahmad Muzammil bin Abu Bakar Pn. Sharmila Mat Zain Dr Fadzlinda Shaharuddin Dr Muhamed Faruqi Uzair Mohamed Sidek Dr Aida Amir Puan Wan Rahayu Wan Hasan