Orientation lecture to Patient safety aspects
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Transcript of Orientation lecture to Patient safety aspects
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Introduction to Patient Safety
Dr. Shailendra.V.L.Patient Safety Department
Al Bukeriya general hospital
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Outline
• Introduction to the concept of Patient Safety• Occurrence Variance Report (OVR)– Adverse Events– Near Miss– Sentinel Events
• International Patient Safety Goals
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SECTION-I
INTRODUCTION TO THE CONCEPTOF
PATIENT SAFETY
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Patients and Medical Errors
• Healthcare errors impact 1 in every 10 patients around the world (WHO)
• Institute of Medicine, USA found in a study:-– Medical errors injure 1 in 25 hospital patients– Kills about 44,000 to 98,000 every year– Medical errors costs USA billions of dollars each
year
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Risk Comparison• Less than one death per 100,000 encounters– Commercial airlines– Nuclear power generation– Off shore oil rigs
• One death in 1,000 – 100,000 encounters:– Motor vehicle driving– Chemical manufacturing
• More than one death per 1,000 encounters– Bungee jumping– Mountain climbing– Health care
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Why Errors?“To err is human”
• Not always willful negligence but systemic flaws• Inadequate communication• Wide-spread process variation• Patient ignorance
Every error has a root causeEvery cause has a solution
Errors can be prevented with every one’s participation in the system
Here comes the role of the patient safety department
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Patient Safety
• Patient safety is a new healthcare discipline that emphasizes on – Reporting– analysis, and– prevention ofmedical errors that may leads to adverse patient
outcomes
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Patient Safety• Goals of Patient Safety– Detection of safety issues– Preventive & corrective actions– Processes to reduce risks
• Broad Strategies– Self reporting (OVR)– Safety oriented Leadership Walk Rounds– Communication / education– MOH – Patient safety standards monitoring– Promoting patient safety culture
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SECTION-II
OCCURRENCE VARIANCE REPORT (OVR)
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Sources of Errors
1. Individual made: Errors due to human factor in the process e.g. wrong calculations of dosage
2. System made: Holes in the system that allow to slip through e.g. no clear, detailed policy, no double checking systems
3. Environment made: Hazards that come from the environment of the hospital e.g. emotions, dangerous medicines, radiation hazards
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How to Make it Safer
• Acceptance, not denial• Identifying the causes of the medical errors
and patient harm• Finding solutions• Improving systems
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Identifying the Causes
• Significant patient harm• Patient complaints• Colleagues reporting• Management trying to detect• Self Reporting i.e. OVR
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Occurrence Variance Report (OVR)
• Self Reporting – corner stone of improvement– Voluntary reporting of process variation by all
health care workers– Non punitive – no punishments– To improve the quality of services– To prevent recurrence of same errors – To target system, not individuals
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Types of Events
1. Adverse Event: Any variation in the processes leading to unsafe situations in everyday working life
2. Near Miss: An event or situation that could have resulted in patient harm but did not, either by chance or timely intervention
3. Sentinel Event: Unexpected incident involving death or serious physical or psychological injury or the risk thereof
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Example
• An inpatient received 2 (two) unit of the incorrect type of blood at the time. The patient’s blood was drawn for a type/cross match, the sample was mislabeled with another patient's name. The transfusion was given to the patient whose name appeared on the type/cross match lab report, not the patient whose blood was in the lab specimen vial.
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Examples of Reportable Events
• Eclampsia in booked patient• APGAR score less than 7 at 5 minutes• Unplanned blood transfusion• Wrong implant or prosthesis• Injury or unplanned repair or removal of an organ• Complications post ERCP• Complications post angiogram • Retinopathy of prematurity (ROP) needing laser
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SECTION-III
INTERNATIONAL PATIENT SAFETY GOALS
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International Patient Safety GoalsGoal 1: Identify patients correctlyGoal 2: Improve effective communicationGoal 3: Improve the safety of high-alert
medicationsGoal 4: Ensure correct-site, correct-procedure,
correct-patient surgeryGoal 5: Reduce the risk of health care–associated
infectionsGoal 6: Reduce the risk of patient harm resulting
from falls
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Goal 1
• Identify Patients Correctly– Wrong-patient errors occur in virtually all aspects
of diagnosis and treatment – At least two patient identifiers• File number• Name
– Before• Administering medications, blood, or blood products • Taking blood and other specimens for clinical testing
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Goal 2
• Improve Effective Communication– Verbal and telephone order or test result is• written down by the receiver• then read back by the receiver, and• confirmed by the giver
– Reporting back of critical test results and panic values
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Goal 3
• Improve the Safety of High-alert Medications– Medicines with high risk of patient harm
– Policies to address the location, labeling, and storage of concentrated electrolytes
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Goal 4
• Ensure Correct-site, Correct-procedure, Correct-patient Surgery– Mark surgical site identification and involve the
patient in the marking process
– Use time-out procedure before starting a surgical procedure
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Goal 5
• Reduce the Risk of Health care–associated Infections– Implement an effective hand hygiene program
– Catheter associated infections
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Goal 6
• Reduce the Risk of Patient Harm Resulting from Falls– Policies to reduce the risk of patient harm
resulting from falls – Implement initial assessment of patients for fall
risk and reassessment when indicated – Implement measures to reduce fall risk for those
assessed to be at risk
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Conclusion
• Identification and prevention of patient harm
• Self reporting the events
• Adherence to the Six International Patient Safety Goals
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THANK YOU