patient safety and staff Management system ppt.pptx

Patient Safety is a health care discipline that emerged with the evolving complexity in health care systems and the resulting rise of patient harm in health care facilities. It aims to prevent and reduce risks, errors and harm that occur to patients during provision of health care.

1. DR.ANJALATCHI MUTHUKUMARAN VICE PRINCIPAL ERA COLLEGE OF NURSING SARFRAZGANJ, ERA UNIVERSITY LUCKNOW-226003 PATIENT AND STAFF SAFETY MANAGEMENT SYSTEM

2. Introduction

3. Key facts about patient safety by WHO report The occurrence of adverse events due to unsafe care is likely one of the 10 leading causes of death and disability in the world (1). In high-income countries, it is estimated that one in every 10 patients is harmed while receiving hospital care (2). The harm can be caused by a range of adverse events, with nearly 50% of them being preventable (3). Each year, 134 million adverse events occur in hospitals in low- and middle-income countries (LMICs), due to unsafe care, resulting in 2.6 million deaths (4). Another study has estimated that around two-thirds of all adverse events resulting from unsafe care, and the years lost to disability and death (known as disability adjusted life years, or DALYs) occur in LMICs (5). Globally, as many as 4 in 10 patients are harmed in primary and outpatient health care. Up to 80% of harm is preventable. The most detrimental errors are related to diagnosis, prescription and the use of medicines (6). In OECD countries, 15% of total hospital activity and expenditure is a direct result of adverse events (2). Investments in reducing patient harm can lead to significant financial savings, and more importantly better patient outcomes (2). An example of prevention is engaging patients, if done well, it can reduce the burden of harm by up to 15% (6).

4. Definition   “ The reduction and mitigation of unsafe acts within the health-care system, as well as through the use of best practices shown to lead to optimal patient outcomes.” • Essentially, patient safety is about constantly working to avoid, manage and treat unsafe acts within the health care system.

5. What is patient safety

6. Definition Patient safety practice is a type of process or structure whose application reduces the probability of adverse events resulting from exposure to healthcare system. Mistake-proofing is the use of process or design features to prevent errors or the negative impact of errors.

7. Concept of patient safety

8. PATIENT SAFETY Evolving Issues Taxonomy – how we categorize and group different patient safety events. Nomenclature – using a common and universally accepted language Patient Safety

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

10. Patient Safety: Challenges and Concerns Difficulty recognizing errors Lack of information systems to identify errors Relationship of trust with providers Shortages of clinical professionals Concern about liability Limited capacity on how to use quality improvement tools such as PDSA Culture of patient safety is lacking

11. 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

12. Not Who caused the accident but What caused the accident ? “ We cannot change the human condition, but we can change the conditions under which human works.” (Reason 2000) Adoption of this paradigm by leaders is the beginning for culture change

13. Trigger s DEFENSES

14. Swiss chees theory

15. Example of swiss model

16. Patient Safety Active Failures highly visible errors with immediate consequences Latent Failures may be hidden for years and generally rooted in organizational culture takes the right set of circumstances for the error to become visible or known

17. The Anatomy of Errors in Healthcare Blunt End of the System Organizational Factors - culture, policies, procedures, regulations Environmental Factors - equipment, staffing, resources, constraints Sharp end of the System Human Factors - clinical competency, communication skills, problem solving skills

18. Culture of Safety Indicate the extent to which you agree with following statements. Scoring : strongly disagree, neutral, agree, strongly agree. A . Senior management provides a climate that promotes patient safety B . If people find out that I made a mistake, I will be disciplined. C . My supervisor/manager says a good word when he/she sees a job done according to established patient safety procedures D . Discussion around major events focuses mainly on systems-related issues, rather than focusing on the individual(s) most responsible for the event.

19. Important issues facing healthcare organizations. Establishing culture of patient safety and just culture. Identifying organizational champions. Deploying patient safety strategies. Adoption of safety-related technologies.

20. Just culture Balancing safety and accountability. The single greatest impediment to error prevention in the medical industry “that we punish people for the medical mistakes ”.  

21. 3 basics features of just culture 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.

22. Behaviors Human error – inadvertent action: doing other than what should have been done. 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.

23. Red rules cannot be broken few in number easy to remember associated only with processes that can cause serious harm to employees, customers, or the product line. must be followed exactly as specified except in rare or urgent situations. Every worker, regardless of rank or experience in the company, is expected to stop the work or production line if the red rule is violated.

24. Learning Organization A learning healthcare system “is designed to generate and apply the best evidence for the collaborative healthcare choices of each patient and provider; to drive the process of discovery as a natural outgrowth of patient care; and to ensure innovation, Quality, Safety, and value in healthcare ” ( IOM Roundtable on EBM)

25. Patient Safety Highly Reliable Organizations Risk auditing : monitoring of activities to identify both expected and unexpected risks Appropriate reward systems that encourage safety- related behavior System q uality standards Acknowledgment of risk to learn from error Flexible management model to promote teamwork and communication

26. Responsibilities of governing bodies of organization Zone safety Work around interruptions Deviation from policy Deviation from best practices Standard : policies and practices Procedure Standard of care SOP guidelines Routine practice of guidelines

27. Responsibilities of Governing body to enhance patient safety Getting data Establishing and monitoring system-level measures. Setting aims Change the environment, policies and cultures. Learning - Establish executive accountability.

28. More Definitions Never events : As defined by the National Quality Forum, these are preventable events considered so harmful that they should never occur. Also called serious reportable events (SREs ), they include most medication errors as well as instances of performing surgery on the wrong body part or the wrong patient. Complications of care : Healthcare-associated complications, including infections that patients develop while in the hospital, are thought to be largely preventable.

29. Patient Safety Communication and Teamwork Challenges Healthcare is traditionally hierarchical Personal communication styles of staff Lack of common language – led to development of SBAR Addressed with other patient safety initiatives Simulation training Rapid Response Teams (RRT) Walk rounds Patients participating on committees/RCAs

30. Patient Safety Miscommunication: Breakdowns in communication can result in the wrong treatment, a lack of treatment, or incorrect self-care by the patient. Miscommunication can be the result of faulty systems (poor methods of reporting critical test results, for example); lack of attention to the health literacy of patients; or a lack of cultural competency on the part of the healthcare team.

31. Disclosure Implement a formal (transparent) policy and process of disclosure of adverse events to patients/families, including support mechanisms for patients, family, and care/service providers

32. Reasons to Disclose Disclosure Right thing to do Patients expect it Professional responsibility Earn trust/possibly forgiveness of patient Supports patient safety initiatives Required by The Joint Commission for unanticipated outcomes

33. Personnel Barriers to Disclosure Fear of legal liability Fear of loss of credibility and reputation Fear of loss of licensure Fear of punishment by organization or loss of job Feelings of vulnerability Difficulty in accepting role in error

34. System Barriers to Disclosure We’ve always done it this way Hierarchical structure of medicine Profession demands perfection Struggle with accepting even most well trained and competent can make mistakes Conflict of Interest

35. patient safety :Michael Woods 4R’s Recognition Regret Responsibility Remedy

36. Patient Safety: Mistake Proofing Knowledge in the Head Knowledge in the Environment

37. Patient Safety - Technology to Improve Patient Safety CPOE Barcoding Robotics Electronic medical records

38. International Patient Safety Goals 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 the Risk of Health Care- Associated Infections Goal 6 Reduce the Risk of Patient Harm Resulting from Falls

39. The burden of harm Every year, millions of patients suffer injuries or die because of unsafe and poor-quality health care. Many medical practices and risks associated with health care are emerging as major challenges for patient safety and contribute significantly to the burden of harm due to unsafe care. Below are some of the patient safety situations causing most concern. Medication errors  are a leading cause of injury and avoidable harm in health care systems: globally, the cost associated with medication errors has been estimated at US$ 42 billion annually  (10). Health care-associated infections  occur in 7 and 10 out of every 100 hospitalized patients in high-income countries and low- and middle-income countries respectively  (11). Unsafe surgical care procedures  cause complications in up to 25% of patients. Almost 7 million surgical patients suffer significant complications annually, 1 million of whom die during or immediately following surgery  (12). Unsafe injections practices  in health care settings can transmit infections, including HIV and hepatitis B and C, and pose direct danger to patients and health care workers; they account for a burden of harm estimated at 9.2 million years of life lost to disability and death worldwide (known as Disability Adjusted Life Years (DALYs))  (5).

40. Continued Diagnostic errors  occur in about 5% of adults in outpatient care settings, more than half of which have the potential to cause severe harm. Most people will suffer a diagnostic error in their lifetime  (13). Unsafe transfusion practices  expose patients to the risk of adverse transfusion reactions and the transmission of infections  (14).  Data on adverse transfusion reactions from a group of 21 countries show an average incidence of 8.7 serious reactions per 100 000 distributed blood components  (15). Radiation errors  involve overexposure to radiation and cases of wrong-patient and wrong-site identification  (16).  A review of 30 years of published data on safety in radiotherapy estimates that the overall incidence of errors is around 15 per 10 000 treatment courses  (17). Sepsis  is frequently not diagnosed early enough to save a patient’s life. Because these infections are often resistant to antibiotics, they can rapidly lead to deteriorating clinical conditions, affecting an estimated 31 million people worldwide and causing over 5 million deaths per year  (18). Venous thromboembolism (blood clots)  is one of the most common and preventable causes of patient harm, contributing to one third of the complications attributed to hospitalization. Annually, there are an estimated 3.9 million cases in high-income countries and 6 million cases in low- and middle-income countries  (19) .

41. Goal 1: Identify Patients Correctly Rationale: Wrong-patient errors occur in virtually all aspects of diagnosis & treatment. The intent for this goal is two-fold: First , to reliably identify the individual as the person for whom the service or treatment is intended; Second , to match the service or treatment to that individual.  

42. Requirement Prior to the start of any invasive procedure, conduct a final verification process, (such as a “time out”) to confirm the correct patient, procedure and communication techniques. Problems associated with surgical safety in developed countries account for half of the avoidable adverse events that result in death or disability

43. Requirement Use at least two patient identifiers whenever collecting laboratory samples or administrating medications or blood products. Acceptable identifiers may be the individual’s name, an assigned identification number, telephone number, photograph or other person-specific identifier. (e.g. birth date)

44.  Goal 2: Improve Effective Communication Rationale: Ineffective communication is the most frequent cited category of root causes of sentinel events. Effective communication, which is timely, accurate, complete, unambiguous, and understood by the recipient, reduces error and results in improved patient/client/resident safety.

45. Requirement Simply repeating back the order or test result is not sufficient. Whenever possible, the receiver of the order or test result enter it into a computer, then read it back, and receive confirmation from the individual who gave the order or test result. Requirement “ Critical test results” are defined by the individual health care organization and will typically include “stat” test, “panic value” reports, and other diagnostic test results that require urgent response.

46.  Requirement o Requirement: Standardize a list of abbreviations, acronyms, symbols, and dose designations that are not be used throughout the organization .   Requirement Implement a standardized approach to “hand off” communications, including an opportunity to ask and respond to questions. Requirement Measure , assess, and if appropriate, take action to improve the timeliness of reporting, and the timeliness of receipt by the responsible licensed caregiver, of critical tests and critical results and values.

47. Communication in Patient Care Is not : - Yelling - Accusatory (angry) - Being respectful of authority Is : - Focused on patient - Nothing your perceptions - Persistently raising concerns, intended to move toward desired action

48. 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 .

49. SBAR description 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

50. S BAR 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

51. Example SBAR briefing 55 YO Man with HTN, admitted for GI Bleed – received 2 units, last hematocrite VS: BP 90/50, Pulse 120 Looking pale, sweaty Feels confused and weak, some problem with heavy chest

52. Example SBAR briefing Situation : 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.

53. Goal 3: Improve the Safety of High- Alert Medications Implementation Expectation Remove concentrated electrolytes (including, but not limited to, potassium chloride, potassium phosphate, Nacl~0.9%) from patient care units. Standardize & limit the number of drug concentrations available in the organization

54. Requirement Identify and, at a minimum, annually review a list of look-alike/sound-alike drugs used by the organization, and take action to prevent errors involving the interchange of these drugs. Label all medications, medication containers (for example, syringes, medicine cups, basins) or other solutions on and off the sterile field.

55. Goal 4: Ensure Correct-Site, Correct- Procedure, Correct-Patient Surgery   Rationale Wrong-site, wrong-patient, wrong-procedure surgery can be prevented if appropriate processes are in place. The intent is to establish and implement processes to always identify the correct site, correct person and correct procedure.

56. Goal 5: Reduce the Risk of Health Care-Associated Infections Rationale At any given time, 1.4 million people worldwide suffer from infections acquired in hospitals. The risk of health care-associated infection in some developing countries is as much as 20 times higher than in developed countries. Compliance with the CDC hand hygiene guidelines will reduce the transmission of infectious agents by staff to patients/clients/residents thereby decreasing the incidence of healthcare associated infections.

57. Goal 6: Reduce the Risk of Patient Harm Resulting from Falls Rationale Falls account for a significant portion of injuries in hospitalized patients, long-term care residents, and home care recipients. In the context of the population it serves, the services it provides, and its environment of care, the organization should assess, its patient risk for falls and take action to reduce the risk of falling and to reduce the risk of injury, if a fall occur.

58. Implementation Expectation As appropriate to the population served, the services provided, and the environment of care, a fall reduction program may include risk assessment and periodic re-assessment of individual patients or of the environment of care. 59.  Implementation Expectation The program should include risk reduction strategies involving patients/families in education and environment of care redesign. The program should also include development and implementation of transfer protocols (e.g., bed-to-chair), when relevant.

59. Question The most important procedure to prevent hospital acquired infection is : 1 . Using gloves 2 . Hand washing 3 . Wearing protective gowns 4 . All of the above 5 . None of the above

60. question For inpatient identification all of the following Can be used except for : 1 . Patient room number 2 . Patient medical ID 3 . Patient full name 4 . Patient national ID 5 . None of the above

61. Thank you so much for your patience for listening

62. Refernces References 1. Jha AK. Presentation at the “Patient Safety – A Grand Challenge for Healthcare Professionals and Policymakers Alike” a Roundtable at the Grand Challenges Meeting of the Bill & Melinda Gates Foundation, 18 October 2018 (https://globalhealth.harvard.edu/qualitypowerpoint, accessed 23 July 2019). 2. Slawomirski L, Auraaen A, Klazinga N. The economics of patient safety: strengthening a value-based approach to reducing patient harm at national level. Paris: OECD; 2017 (http://www.oecd.org/els/health-systems/The-economics-of-patient-safety-March-2017.pdf, accessed 26 July 2019). 3. de Vries EN, Ramrattan MA, Smorenburg SM, Gouma DJ, Boermeester MA. The incidence and nature of in-hospital adverse events: a systematic review. Qual Saf Health Care. 2008;17(3):216–23. http://doi.org/10.1136/qshc.2007.023622 https://www.ncbi.nlm.nih.gov/pubmed/18519629 4.National Academies of Sciences, Engineering, and Medicine. Crossing the global quality chasm: Improving health care worldwide. Washington (DC): The National Academies Press; 2018 (https://www.nap.edu/catalog/25152/crossing-the-global-quality-chasm-improving-health-care-worldwide, accessed 26 July 2019).