Patient Safety principles and details.pptx

Nursing

1. Dr. Alice Khachian PhD, MSN, BSN [email protected]

2. Everyone deserves safe and high-quality healthcare.

3. What is patient safety? …is a framework of organized activities that creates cultures, processes, procedures, behaviours, technologies and environments in health care that consistently and sustainably lower risks, reduce the occurrence of avoidable harm , make error less likely and reduce impact of harm when it does occur.

4. Patient safety is the reduction of risk of unnecessary harm associated with health care to an acceptable minimum. Patient harm is any unintended and unnecessary harm resulting from, or contributed by, health care. This includes the absence of indicated medical treatment. An adverse event is an incident during care that results in patient harm. Definitions

5. Until about 2-3 decades ago, it was assumed that adverse clinical outcomes resulted from unavoidable complications caused by the patient’s condition and comorbidities. This assumption started to be questioned in the 1980s & 1990s as healthcare started to be investigated in a more structured and scientific manner.

6. 6 How safe is our care?

7. SAFE HARM ≠ Does the absence of harm mean we are safe?

8. 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 Risk of Health Care-Associated Infections Goal 6 - Reduce the Risk of Patient Harm resulting from Falls 8

9. HPI Algorithm and Deviations from GAPS GAPS – Generally Accepted Performance Standard

10. How it Works

11. Safety event classification DEFINITIONS State Reportable Events (SRE): Can include SSEs, PSEs, Unsafe Conditions, and are required by the state of Utah to be reported. Patient Safety will triage these events. Serious Safety Events (SSE): Reaches the patient and results in moderate to severe harm or death as a result of a deviation from Generally Accepted Performance Standards (GAPS) Precursor Safety Events (PSE): Reaches the patient and results in minimal harm or no detectable harm as a result of deviations from GAPS Near Miss Safety Event (NM): Does not reach the patient and the error is caught either by detection or chance Not a safety event (NSE): No deviation in care. Care delivery went well according to generally accepted practice standards. Unsafe Conditions: No event occurred, but a situation exists that has the potential to cause harm. 13

12. Current and Future Goals Current Falls High risk medications Future Purposeful Provider Engagement Triangulation of data Improved reporting, follow-up and action planning 14

13. Underlying Contributing Factors Widening our view of harm 15 What happened Classification of how it happened Identify and address all forms of harm

14. Psychological safety and your future Psychological safety is about cultivating a work environment where people feel comfortable being and expressing themselves 16

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16. Fostering a psychologically safe environment leads to better learning opportunities, increased innovation, and improved patient safety.  18

17. Assurance & accountability Incident Management Policies, rules & guidelines Committees Patient Safety projects Score cards and audits Toolkits & Check list Responsibility of Managers and QI-Safety Departments Preventing Harm 19

18. Actively seeks contributions of patients and care partners Safety huddles and safety conversations Coaching A way of thinking, acting, responding Curiosity & Inquiry Proactively takes action Listening, observing and perceiving Everyone contributes to safety Creating Safety Policies, rules & guidelines Committees Patient safety projects Toolkits & checklists Assurance & accountability Incident management Score cards and audits Responsibility of managers and QI-safety departments Preventing Harm 20

19. Harm by the Healthcare System About 10% of patients admitted to hospital will be harmed. Half of these could have been prevented. 6% of these patients will have permanent disability and 8% will die. 14 th leading cause of global health burden comparable to diseases like TB and malaria. Slawomirski , L.A. et al., 2017 21

20. Causes of Harm Complex, dynamic and diverse. Stretch across all facets of healthcare delivery and system behaviour from planning to clinical activity. 22

21. Do no harm.... We have a moral and ethical duty to keep patients safe. Patient harm exerts a burden on people, their families, loved ones and the community. Maximizing safety is a fundamental responsibility of individual healthcare providers and the healthcare systems. 23

22. Economic effects of adverse events Need for additional treatment. More diagnostic testing. Readmission or prolonged hospital stay. Broader economic effects: Ongoing morbidity Reduced lifetime productivity Reduced trust in the healthcare system 24

23. Adverse Events and Harm Play out at the clinical interface. Root causes are structural, cultural and process oriented. Vast majority of patient harm, from the operating theatre to the community clinic, can be traced to failure in communication. (Francis, 2013) 25

24. Application of the rule 26

25. Patient safety: burden? 27

26. Adverse Events in Different C are Settings Level of Care Adverse Event General drivers of adverse events Primary care Adverse drug events/ medication errors; Diagnostic error/delayed diagnosis Lack of communication and information, lack of skills/knowledge, inadequate organizational culture, misaligned incentives. Long Term Care Adverse drug events, pressure injuries and falls Hospital Care Hospital infections, adverse drug events, pressure injury , wrong site surgery. 28

27. Reduction of Most Burdensome Adverse Events Clinical level interventions using a systems-perspective: Prophylaxis . Protocols to minimize central line catheter insertion. Pressure injuries. Urinary catheter associated infections. Procedural and surgical check lists. 29

28. In Hospital Falls 30

29. Surgical Site Infections 31

30. Deep Venous Thrombosis 32

31. Pressure Ulcers 33

32. The Global Patient Safety Action Plan (GPSAP) 2021-2030

33. Clinical Services organization Safe Primary Care Medication Safety Blood Safety Medical Device Safety Radiation Safety Staffing & Personnel Safety WASH Childbirth and immunization Mental Health Quality and Accreditation Infection prevention & Control Infectious Diseases Non- Communicable Diseases Centrality of Patient Safety

34. 36 GPSAP Strategic objective : Patient and family engagement Strategy 1 :   Co-development of policies and programmes with patients Strategy 4 :   Patient safety incident disclosure to victims Strategy2 : Learning from patient experience for safety improvement Strategy 3 :  Capacity building of patient advocates and patient safety champions Strategy 5 :   Information and education for patient and families

35. Improving Patient Safety Use of Evidence-Based Practice Guidelines

36. Improving Patient Safety in Healthcare Institutions Use of evidence-based practice guidelines. Retention of experienced nurses. Accreditation of services to continually improve quality of care. Control of Admitting Staff. Administrative Interventions. 38

37. Evidence Based Medicine--Definition Evidence based medicine (EBM) is defined as “ conscientious, explicit, and judicious use of current best evidence and knowledge of patient values by well-trained experienced healthcare professionals ( Institute of Medicine ). This means patients should receive care based on the best available scientific knowledge. Care should not vary illogically from clinician to clinician or from place to place. 39

38. Clinical Guidelines There are now clear guidelines and checklists to follow for the management of most conditions which are backed by evidence based results from controlled studies. Adhering to clinical guidelines derived from EBM fosters good practice and improves the quality of care and patient safety. A typical example of a guideline is the WHO Safety checklist used in operating theatres. 40

39. WHO Surgical Safety Checklist It is now universally recommended by accrediting bodies to use the safety checklist as there is overwhelming clinical evidence that it improves patient safety. Local adaptation of the checklist is encouraged to ensure effective integration into clinical practice in a hospital. 41

40. WHO Surgical Safety List ‘Sign In’ before induction of anaesthesia. ‘Time out’ before start of surgical intervention…skin incision. ‘Sign Out’ before any member of the team leaves theatre 42

41. WHO Surgical Safety ‘Sign In’ Has the patient confirmed identity, site, procedure and consent? Is the surgical site marked? Is the anaesthesia machine and medication check complete? Known allergies? Difficult airway/aspiration risk? Risk of >500mls of blood loss (7ml/kg in child)? 43

42. WHO Surgical Safety ‘Time Out’ Have all team members introduced themselves by name and role. Surgeon, anaesthetist & registered practitioner to confirm name of patient, procedure, site and position planned. What are the anticipated critical surgical, anaesthetic and nursing events? Has the SSI bundle been undertaken as well as VTE prophylaxis? Is essential imaging displayed if required? 44

43. WHO Surgical Safety ‘Sign Out’ Registered Practitioner verbally confirms: name of procedure is recorded Instrument, swab and sharp counts completed The specimen is labelled If any equipment issues have been noted that need to be addressed Surgeon, anaesthetist, Nurse to state key concerns during recovery and patient management. 45

44. Patient for patient Safety (PFPS)

45. Action points: WHO Regional Office 47

46. Action points: WHO Regional Office Support and provide technical assistance Member States to translate the action plan into actions: Advocate for patient safety revitalization. Determine baseline data/information. Develop national policy & strategies, strengthen coordination of patient safety programme at all levels, including resource mobilization. Train HCWs and patients advocates Facilitate measures for learning and experience sharing/dissemination. Put in place system to monitor patient safety implementation (e.g., annual regional webinar on patient safety) Support patient for patient safety associations 48

47. Action points: Member States Recognize patient safety as a strategic health priority in health sector policies and programmes, making it an essential component for strengthening health care systems in order to achieve UHC Plan to implement global action recommendations tailored to the country context: Establish a national patient safety programme Policy, strategy, institutional framework and action plan Advocate and commit to issues of patient safety in healthcare Identify and work with local private sector and patient groups and organizations. Plan for the celebration of World Patient Safety Day 17 September 2021, communication on announcement has been sent to all countries. Share plan plus TA for the celebration through the country WHO office 49

48. Way forward: partners & other stakeholders 50

49. Past Harm Has patient care been safe in the past? Reliability Are our clinical systems & processes reliable? Sensitivity to operations Is care safe today? Anticipation & Preparedness Will care be safe in the future? Integration & learning Are we responding and improving Safety measurement & Monitoring The Measurement and Monitoring of Safety Framework 51

50. READ “Rethinking Patient Safety” IDENTIFY a leading framework for Patient Safety to adopt (e.g. Measurement and Monitoring of Safety) TALK about patient Safety with our employees Patients/residents/clients and care partners REFLECT on what you hear, and SHARE what you learn about safety with others "Read, then think. Listen, then think. Watch, then think. Think – then speak.” – Jackie Kennedy Starting on a new path to Patient Safety 52

51. Start to place more emphasis  on the “practice of inquiry”  versus “reporting and accountability”.  4 Create an inviting space where it is safe for our staff and physicians to speak-up and ask questions. 3 Adopt a holistic safety framework such as the Measurement and Monitoring of Safety to help create a shared and consistent understanding of safety for our organization.    2 Shift our focus from past harm to  a more holistic view of safety. 1 Starting on a new path to Patient Safety 53

52. Promote the value that our patients and care partners have in creating safety. 8 Promote everyone’s role and contributions to safer care. 7 Recognize that safety can be created and start to take steps to promote safer care (not just prevent harm).   6 Empower our staff and physicians to take a proactive role in safety. 5 Starting on a new path to Patient Safety 54

53. What do you need to make you feel safe to raise concerns about safety? Who do you speak to when you have a safety concern or compliment? What has made you feel unsafe at work (or since we last talked)? Tell me about anything that alarmed or worried you during your delivery of care How safe is our care? How is the presence of safety different from the absence of harm? Is our care safe or are we just lucky? What does patient safety mean to you? Questions you can ask your colleagues 55

54. What has made you feel unsafe at work (or since we last talked)? What are your care preferences? (for example, ‘what matters to you?’) What makes you feel unsafe? What would make you feel safer? Tell me about anything that alarmed or worried you in the past 24 hours? What makes you feel safe? Who would you speak to if you didn’t feel safe? Questions you can ask your patients/residents/clients and care partners 56

55. Improving Patient Safety Role of the Nurse

56. The Nurse & Patient Safety Nurses intercept over 80% of all medication errors made by doctors, pharmacists, and others prior to the provision of those medications to patients. 58

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58. Retaining Nurses Experienced nurses are generally in demand and seek better terms of service in competing hospitals when the opportunity arises. A hospital that cannot retain its champions is doomed to have quality of care and patient safety issues. 60

59. Improving Patient Safety Accreditation of Services 61

60. Hospital Service Accreditation Accreditation helps organize and strengthen patient safety efforts by hospitals to manage and reduce risk. It strengthens community and patient confidence in the quality and safety of care, treatment and services provided in a hospital. It makes a strong statement to the patients about a hospital’s efforts to provide the highest quality services.  62

61. Accreditation Improves Adherence Accreditation has the power to compel hospitals to adhere to guidelines and regulations that ensure patient safety. There is a need to introduce healthcare targeted accrediting bodies in developing countries to improve standards of care. 63

62. Improving Patient safety Admitting Staff Control

63. Admitting Staff Control Strong criteria for the admission of clinical staff to use hospital facilities; with emphasis on the system used to determine whether the applicants have the required qualifications, experience and practice licenses. The scope of procedures a doctor should be allowed to perform is to be limited by experience, training and adherence to evidence-based guidelines. 65

64. Conditional Maintenance of Admission Rights Institutional annual review of the admitting staff performance and complications is practiced widely now. Withdrawal of admission rights could be enforced more vigorously for negligent or incompetent practice. 66

65. Improving Patient Safety Administrative Interventions 67

66. Management Interventions Hospital departments and management to address concerns about the standards of care in the clinical functions promptly as they arise . R egular Assessment for all healthcare professionals focusing on standards of care issues like process improvement . 68

67. The Shewhart Cycle and Process Improvement 69

68. Administrative Measures F inancial incentives and professional recognition assist in the efforts to retain experienced employees especially nurses . Simple measures like appropriate work loads, appreciation, emotional support, and sensitivity to staff needs leads to better process outcomes. 70

69. Donabedian’s Model applied to Patient Safety 71

70. Summary A health care institution can improve patient safety through the use of evidence-based medical practice and clinical guidelines. The nurse is the backbone of the service and her/his level of competence and motivation could determine the outcome of clinical processes that affect patient safety. Accreditation compels hospitals to adhere to guidelines and regulations which lead to improved patient safety. 72

71. Summary Hospitals can ensure delivery of quality healthcare and improve clinical outcomes by allowing privileges to only qualified admitting staff . Organisational leadership should actively foster quality improvement in the structures and processes of the institution. 73

72. Thank you for your attention 74