Chapter 9 [1] Patient Safety. Introduction Patient safety comprises the reporting, analysis and...

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Chapter 9 Chapter 9 [1] [1] Patient Safety

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Transcript of Chapter 9 [1] Patient Safety. Introduction Patient safety comprises the reporting, analysis and...

Page 1: Chapter 9 [1] Patient Safety. Introduction Patient safety comprises the reporting, analysis and prevention of adverse healthcare events and medical error.

Chapter 9Chapter 9[1][1]

Patient Safety

Page 2: Chapter 9 [1] Patient Safety. Introduction Patient safety comprises the reporting, analysis and prevention of adverse healthcare events and medical error.

Introduction Introduction Patient safety comprises the reporting,

analysis and prevention of adverse healthcare events and medical error.

Scary Facts:

– Patient-Safety related incidents cause harm in between 3% and 17% of hospital inpatients [4]

– At least 50% of medical equipment in most developing countries is not in usable condition [3]

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Page 3: Chapter 9 [1] Patient Safety. Introduction Patient safety comprises the reporting, analysis and prevention of adverse healthcare events and medical error.

AgendaAgenda

In Chapter 9:

– Current patient safety goals – Objectives from the assessment of safety

cultures– How to implement a patient safety program– How to develop patient safety measures– Common safety analysis methods

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Page 4: Chapter 9 [1] Patient Safety. Introduction Patient safety comprises the reporting, analysis and prevention of adverse healthcare events and medical error.

Current Patient Safety GoalsCurrent Patient Safety Goals [2][2]

Enhance the accuracy of patient identification

Improve the safety of using medications

Minimize patient slips, trips and falls

Minimize surgical fire risks

Minimize health care-related infections

Enhance communication between caregivers

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Page 5: Chapter 9 [1] Patient Safety. Introduction Patient safety comprises the reporting, analysis and prevention of adverse healthcare events and medical error.

Objectives From the Assessment Objectives From the Assessment of Safety Culturesof Safety Cultures

Profiling

Benchmarking

AwarenessEnhancement

MeasuringChange

Accreditation

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Page 6: Chapter 9 [1] Patient Safety. Introduction Patient safety comprises the reporting, analysis and prevention of adverse healthcare events and medical error.

How to Implement a Patient Safety How to Implement a Patient Safety Program (8-Step Process)Program (8-Step Process)

Step 1: Perform safety climate survey Step 2: Educate staff members about safety education Step 3: Survey staff members in regard to safety concerns Step 4: Take an in-depth look Step 5: Plan and implement necessary improvements Step 6: Document the results Step 7: Share the stories Step 8: Repeat step 1 (safety climate survey)

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Page 7: Chapter 9 [1] Patient Safety. Introduction Patient safety comprises the reporting, analysis and prevention of adverse healthcare events and medical error.

How to Develop Patient Safety How to Develop Patient Safety Measures (6-Step Process)Measures (6-Step Process)

Step 1: Conduct a systematic literature review

Step 2: Choose specific types of outcomes for evaluation

Step 3: Choose pilot measures

Step 4: Write design specifications for the measures

Step 5: Assess data validity and reliability

Step 6: Pilot test the measures

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Page 8: Chapter 9 [1] Patient Safety. Introduction Patient safety comprises the reporting, analysis and prevention of adverse healthcare events and medical error.

Common Safety Analysis MethodsCommon Safety Analysis Methods

Technic of Operation Review (TOR)

Fire Drill Seat Belt Checks

Seeking Feedback

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Page 9: Chapter 9 [1] Patient Safety. Introduction Patient safety comprises the reporting, analysis and prevention of adverse healthcare events and medical error.

Common Safety Analysis MethodsCommon Safety Analysis Methods

Root Cause Analysis (RCA)

Also known as:“The 5 Why’s”

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Page 10: Chapter 9 [1] Patient Safety. Introduction Patient safety comprises the reporting, analysis and prevention of adverse healthcare events and medical error.

Common Safety Analysis MethodsCommon Safety Analysis Methods

Root Cause Analysis (RCA)

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Page 11: Chapter 9 [1] Patient Safety. Introduction Patient safety comprises the reporting, analysis and prevention of adverse healthcare events and medical error.

Common Safety Analysis MethodsCommon Safety Analysis Methods

Hazard Operability Analysis (HAZOP)

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A HAZOP study is usually carried out by a team, Lead by an experienced member that is versed in both in the use of the HAZOP technique and the system under investigation.

* Human Element is NOT the focus!

Page 12: Chapter 9 [1] Patient Safety. Introduction Patient safety comprises the reporting, analysis and prevention of adverse healthcare events and medical error.

Common Safety Analysis MethodsCommon Safety Analysis Methods

Hazard Operability Analysis (HAZOP)

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Page 13: Chapter 9 [1] Patient Safety. Introduction Patient safety comprises the reporting, analysis and prevention of adverse healthcare events and medical error.

Common Safety Analysis MethodsCommon Safety Analysis Methods

Failure Modes and Effect Analysis (FMEA) Per System:

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•Item(s) •Function(s) •Failure(s) •Effect(s) of Failure •Cause(s) of Failure •Current Control(s) •Recommended Action(s)

Page 14: Chapter 9 [1] Patient Safety. Introduction Patient safety comprises the reporting, analysis and prevention of adverse healthcare events and medical error.

Common Safety Analysis MethodsCommon Safety Analysis Methods

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Page 15: Chapter 9 [1] Patient Safety. Introduction Patient safety comprises the reporting, analysis and prevention of adverse healthcare events and medical error.

Common Safety Analysis MethodsCommon Safety Analysis Methods

Fault Tree Analysis (FTA)

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Page 16: Chapter 9 [1] Patient Safety. Introduction Patient safety comprises the reporting, analysis and prevention of adverse healthcare events and medical error.

Common Safety Analysis MethodsCommon Safety Analysis Methods

Fault Tree Analysis (FTA)

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Page 17: Chapter 9 [1] Patient Safety. Introduction Patient safety comprises the reporting, analysis and prevention of adverse healthcare events and medical error.

SummarySummary

– Current patient safety goals

– Objectives from the assessment of safety cultures

– How to implement a patient safety program

– How to develop patient safety measures

– Common safety analysis methods

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Page 18: Chapter 9 [1] Patient Safety. Introduction Patient safety comprises the reporting, analysis and prevention of adverse healthcare events and medical error.

Where to Get More InformationWhere to Get More Information

http://jama.ama-assn.org/cgi/content/full/280/16/1444  http://jama.ama-assn.org/cgi/content/full/jama

%3B287/15/1993  http://muse.jhu.edu/journals/

journal_of_health_care_for_the_poor_and_underserved/v020/20.1.dingham.html

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Page 19: Chapter 9 [1] Patient Safety. Introduction Patient safety comprises the reporting, analysis and prevention of adverse healthcare events and medical error.

Where to Get More InformationWhere to Get More Information

Dr. Joan Burtner – [email protected]

Jason Coggins Jermaine Early Eric Hudnall Joshua Smith

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Page 20: Chapter 9 [1] Patient Safety. Introduction Patient safety comprises the reporting, analysis and prevention of adverse healthcare events and medical error.

ReferencesReferences

[1] Dhillon, B.S., (2008). Patient Safety. Reliability Technology, Human Error and Quality in Health Care (pp 129 – 139). Boca Raton, FL: CRC Press

[2] National Patient Safety Goals. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO), 1 Renaissance Blvd., Oakbrook Terrace, Illinois, 2007. Also available online at www.jointcommission.org/patientsafety/nationallpatientsafetygoals/07_npsg_facts.htm

[3] Patient Safety, Fact Sheets. World Health Professions Alliance, April 2002. www.whapa/factptsafety.htm.

[4] Sary, A.F., Sheldon, T.A., Cracknell, A., Turnbull, A. Sensitivity of Routine System for Reporting Patient Safety Incidents in an NHS Hospital: Retrospective Patient Case Note Review. British Medical Journal 327 (2006): 432-436.

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Page 21: Chapter 9 [1] Patient Safety. Introduction Patient safety comprises the reporting, analysis and prevention of adverse healthcare events and medical error.

Questions?Questions?

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Patient Safety:

Patient Safety: