Patient safety and risk management

workshop by

Hatim A BanjarRisk manager and patient safety officer

Al – Amal Hospital Jeddah

introduction Everyday a large number of patients are

treated and cared for without incident by health care practitioners worldwide.

Like other high risk industries safety incidents occur during the course of medical care, placing patients at risk for injury or harm.

Over the past ten years, patient safety has been increasingly recognized as an issue of global importance, but much work remains to be done.

Definition

What is patient safety? Patient safety is the absence of

preventable harm to a patient during the process of health care. The discipline of patient safety is the coordinated efforts to prevent harm, caused by the process of health care itself, from occurring to patients.

Medication and medical Errors

Leading cause of harm in hospitals in developed countries

About one patient in 10 is harmed About a third are preventable

One medication error per patient per day Most don’t result in harm

Causation of harms

Individuals made Errors that are done due the human factor in the

process ( mix up , wrong calculations , not following the 5

rights in medication administration ) system made holes in the system that allows errors to slip

through ( no clear and detailed policy and procedures, no

double checking system, no warning signs) Environmental made the dangers that come from the seating of the

hospital and the material and equipments used inside it ( no exit doors , warn out cables and cords )

Human Factors Principles

1. Avoid reliance on memory2. Simplify3. Standardize4. Use constraints and forcing

functions5. Use protocols & checklists

wisely6. Improve information access7. Reduce handoffs8. Increase feedback

How is patient safety cared for in hospitals?

Protecting the patient from case prognoses. This is done by making the right diagnoses and

formulating the correct treatment plan and making the needed intervention as quick as possible

Protecting the patient from medical errors. This is done by setting a clear and unified departmental

manual of policies and procedures that comply with international standards and patient safety guidelines for medical practices and make sure that every one fallow's it.

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Protecting the patient from the physical surrounding:

That is done by making sure that the patient is placed in a save place and free from any harmful mater that might cause harm to the patient.

The patients consciousness level must be

monitored to prevent any possible danger of falling down for patients during sleep precautions like sidereal, decreasing bed height must be taken.2/11/2009 8Hatim Banjar

How is patient safety cared for in hospitals?

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 fall GOAL (7) Improve the Safety of Using

Infusion Pump

These should be every where

Blood sample tubes: - RED tube for serology (6cc)- -GREEN tube for chemistry (5cc) - VIOLET tube for hematology (2cc) If doctor order- ( hormone or

depakin ) investigation use RED tube.

(pt,ptt) investigation use BLUE tube.

يستخدم معدي مرض بحاله االشتباه حال فيالعينة ارسال خالل بذلك الخاص الكيس

Interactive

Give an example of human performance limitation ?

Give an example of a human factors problem?

Communication problem? Latent error in your setting?

Mental health patient safety Although many of the patient safety risk factors

that exist in medical settings also apply to mental health settings

there are unique patient safety issues in mental health that are

different to those in medical care. Seclusion and restraint use, self-harming

behavior and suicide , absconding, and reduced capacity for self-advocacy are particularly prominent to mental health patients.

Both the patient population and the environment make patient safety in mental health unique.

How is patient safety cared for in mental health?

Protecting the patient from harming himself : That is done by monitoring patients with tendency to

comet suicide or to cause harm to themselves and placing them under clues observation, exploring their thought content and try to distract them away from such ideas and try to occupy their time with different activities and give them a since of hope in life and place them in a safe environment in the wards away from any external stimulators for such ideas and away from any harmful object that he might use to cause harm to him self .

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That is done by monitoring aggressive and provoking behaviors so

physical contact ( fights) don't happen among patients, delusions and wrong beliefs are also monitored to prevent patients from causing harm to each other due to the delusions or beliefs and in case of any physical contact among patients nurses must interfere as quickly as possible using the right manner of intervention

patients of deferent age groups and genders must be separated to prevent sexual assault ( male – female ) ( adult – teenagers - children ) .

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Protecting the patient from being harmed by others:

That is done by following the correct and safe steps to administer restrains :never use restrains with out a medical order.never use retrains as a punishment method or for personal revenge.always tell the patient the reason from restraining him.make sure that restrains do not block the blood circulation .chick on patient and take vital signs every 15min.make sure room temperature is appropriate .always restrain the patient in a supine position.make sure that the patient's physical needs are met.do not apply restrains to cases of resent ophthalmic surgery, spinal surgery, harts conditions, chest and respiratory problems.the restrain room physical surrounding must be appropriate and equipped with a monitoring camera.patient should be on monitors through all the restraining time .

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Patient safety during restrain episodes

Patient safety during seclusion episodes

That is done by following the correct safety measures:never use seclusion with out a medical order.never use seclusion as punishment or for personal revenge.always tell the patient the reason of putting him in seclusion.chick on patient every 15 min.make sure that the room is harm free.make sure that the room physical surrounding is appropriate and equipped with a monitoring camera. make sure that the patient physical needs are met.seclusion should not be done to cases in risk of self harm, autism, cardiac and respiratory disorders and phobic patients.

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Nurses safety during P.T encounter

Never face an aggressive P.T on your own. Always be calm and use an appropriate

voice tone. Never turn your back to the patient. Always keep eye contact. Always keep an arm space between the

nurse and the patient during confrontation.

When trying to physically control the patient approach him from the back and sides.

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Interactive

A patient that had been admitted to an addiction treatment facility was recognized by one of the employees and that employee told his sister about the patient identity.

Is there a safety risk? What kind of risk ? How dose it affect the patient?

Clinical risk management In easy words clinical risk

management is identifying the risk factors and sources of harm that might cause a threat to patient safety in a health service seating and working on reducing and eliminating them

Safety cycle

Basic Methods of risk management

Observation Self-reports Physical evidence (document review)

Observation ϰο ήϤϟΔϣϼγϖϳήϓ

:ϒϳήόΘϟ

ι ΎΨϟϰο ήϤϟΔϣϼγΞϣΎϧήΑάϴϔϨΘΑϰϨόϳΕΎμ μ ΨΘϟ ΩΪόΘϣϞϣΎϜΘϣϞϤϋϖϳήϓϮϫϢψϨϣϭϖγΎϨΘϣϞϤϋέϮψϨϣϝϼΧϦϣϚϟΫϭΓΪΠΑϞϣϷ ϰϔθΘδϤΑ

:ϖϳήϔϟϦϣϑ ΪϬϟ

έΎτ ΧϷϦϣΔϴϟΎΧΔΒγΎϨϣΔϴΟϼϋΔΌϴΑήϴϓϮΗϭϰο ήϤϟ ΔϣϼγϰϠϋι ήΤϟ

:ϖϳήϔϟΔϴόΟήϣ

:ϖϳήϔϟϡΎϬϣ

˺- ϰϔθΘδϤϟΎΑΔϳϮϴΤϟϡΎδϗϷϭΔΤϨΟϷϰϠϋΔϴϣϮϳΔϳΪϘϔΗΔϟϮΟϞϤϋ ˻- ΎϬϴϟϮΌδϣύϼΑϭϡΎδϗϷϭΔΤϨΟϷϞΧΩήτ ΨϟϦϣΎϜϣΪϳΪΤΗ ˼- Ύϣϭήτ ΨϟϦϣΎϜϣϪϴϓ ο ϮϳϰϔθΘδϤϟΎΑϰο ήϤϟ ΔϣϼγϝϮΌδϤϟϲϋϮΒγ ήϳήϘΗϊ ϓέ

ΕέϮτ ΗϦϣΎϬϴϠϋ ήσ ˽- ˯Ύτ ΧϷϲϓϼΗϰϠϋϞϤόϟ ϭϰο ήϤϟΔϣϼδΑΔλ ΎΨϟν έΎόϟΙ ΪΤϟήϳέΎϘΗΔόΟήϣ

ϡΎδϗϷϭΔΤϨΟϷϞΧΩ ˾- ϰο ήϤϟΔϣϼδϟΔϴϤϟΎόϟϑ ΪϫϷϖϴΒτ ΗϦϣΪϛΘϟ ˿- ϰο ήϤϟΔϣϼδϟΔϴϟϭΪϟήϴϳΎόϤϟϖϴΒτ ΗϰϠϋϰϔθΘδϤϟΎΑϦϴϠϣΎόϟ ΐ ϳέΪΗ b- ϰϔθΘδϤϟϞΧΩΔϣϼδϟΔϓΎϘΛήθϧϲϓΔϛέΎθϤϟ e- ϰϔθΘδϤϟΎΑ˯ϱέϮτ ϟΕϻΎΣΕΎΪϨϟΔΑΎΠΘγϻ j- ϰο ήϤϟΔϣϼδΑΔλ ΎΨϟ˯ΩϻϦϴδΤΗΞϣήΑϲϓΔϛέΎθϤϟ

ΔϣϼδϟϭϦϣϷΔϨΠϟ

ήσΎΨϤϟΓέΩϝϮΌδϣ

ϰο ήϤϟΔϣϼγϖϳήϓ

: الفريق اعضاء-) المخاطر ) ادارة مسئول الجودة ادارةوالسلالمة - األمن ادارة-) جناح ) + كل عن ممثل التمريضية الجودة مسئول التمريض ادارةالمختبر - قسمالعدوى - مكافحة قسمالتغذية - قسمالصيدلية - قسمالمساندة - الخدمات

العمل : اسلوب ) ( تم- ما و للجوالت األسبوعية التقارير فيه تناقش شهر كل بداية شهري اجتماع عقد

السالمة و األمن لجنة على لعرضه منها المتعذر تحديد و عمل من عليهاازالتها- وكيفية الخطر مصادر حجم تقليل طرق دراسة

قبل- من المخاطر ادارة لمسئول فوري ابالغ يتم عالي خطر مصدر وجود حالة فيفورا األمر عالج على العمل ويتم الفريق عضو

Patient safety rounds reports

Department:

wen tue mon sun sat Risk source

Patient safety officer: signature:

OVR flowchart

Yes Yes

No No

No

Yes

Incompatibility accurse

Discovering incompatibility

Patient safety

related

Needs immediate

action

Take quick corrective action

Fell out OVR form Fell out patient safety OVR form

Inform department head Inform department head

Comment of incompatible department head

Comment of department patient safety officer

Comment of department head

Send recommendations of corrective actions needed to

responsible department

TQM do RCA

Send OVR to TQM

Recommendation implementation Follow

up

Sentinel or recreant

Self – reporting

What to be measured

Error The failure of a planned action to be

completed as intended or use of a wrong inappropriate, or incorrect plan to achieve an aim.

Adverse event An injury that was caused by medical

management or complication instead of the underlying disease and that resulted in prolonged hospitalization or disability at the time of discharge from medical care, or both

Near miss An event that almost happened or an

event that did happen but no one knows about. If the person involved in the near miss does not come forward, no one may ever know it occurred.

The optimum goal Safety culture

A culture that exhibits the following five high-level attributes that health care professionals strive to operationalize through the implementation of strong safety management systems. (1) A culture where all workers (including front-line staff, physicians,

and administrators) accept responsibility or the safety of themselves, their coworkers, patients, and visitors.

(2) [A culture that] prioritizes safety above financial and operational goals.

(3) [A culture that] encourages and rewards the identification, communication, and resolution of safety issues.

(4) [A culture that] provides for organizational learning from accidents. (5) [A culture that] provides appropriate resources, structure, and

accountability to maintain effective safety systems.

Please always remember