PREPARED BY :- DR.\ M. RAMZY ER RESIDENT-QUALITY COORDINATOR-MGH

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Patient Safety Definition

The working to avoid, manage and treat unsafe acts within the health-care system, through the use of best practices lead to optimal patient

outcomes.

The GOAL

Hospitals should provide an

environment that ensures safety of all

individuals

By promoting a proactive and non-

punitive Culture to facilitate reporting

of hazards, errors, near-misses,

concerns and otherwise unsafe

conditions within the Hospital.

What Should Be Reported?

Unanticipated death or permanent loss of

function

Healthcare acquired infection

Unanticipated patient outcome

Any adverse event involving patient care

&/or pt. environment.

Any near miss

Any safety concerns

FIRST DO NO HARM

NOW DO IT SAFE

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Patient Safety Terms

Adverse Event

Medical Error

Sentinel event

Near Miss

Retrospective Analysis

Prospective Analysis

Identifying risks and processes before they happen

Bad outcome from care

Major and enduring loss of function

An examination of past events

Deficient process of care

Could have resulted in loss, injury or illness, but did not

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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

تناغم

What is a culture of safety?

Components of a safety culture include:

Commitment to safety as the primary priority

Availability of the necessary resources

Incentives, and rewards for safety

Openness about errors and problems

Commitment to organizational learning

Unity, loyalty, and teamwork among staff

Non Punitive Environment (culture of safe reporting) leads to increase number of reported errors

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Just culture

3 basics:

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.

BEHAVIORS

Human error – inadvertent action: doing other than what

should have been done. غير مقصود-غفلة

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.

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قايتباىقلعة االســــــــــكندرية

The most common cause of medical errors is miscommunications

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MISCOMMUNICATION

Breakdowns in communication can result

in the wrong treatment, a lack of

treatment, or incorrect self-care by the

patient.

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Patient Safety Goals

IPSG.1 Identify Patients Correctly

IPSG.2 Improve Effective Communication

IPSG.3 Improve the Safety of High-Alert

Medications

IPSG.4 Ensure Correct-Site, Correct-Procedure,

Correct-Patient Surgery

IPSG.5 Reduce the Risk of Health Care–Associated

Infections

IPSG.6 Reduce the Risk of Patient Harm Resulting

from Falls

International Patient Safety GoalsIPSG

I

CAN

MEMOR

IZE

EVERY

THING

I

FANCY

Patient Safety Goals

Identify patient correctly by two identifiers before:

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Providing treatments

and proceduresAdministering

medications,

blood, or its products

Taking blood and

other specimens

uses Patient’s

NAME and

DATE of

BIRTH

Label specimen

containers in

presence of

patient

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IPSG.1 Identify Patients Correctly

IPSG.2 Improve Effective Communication

IPSG.3 Improve the Safety of High-Alert

Medications

IPSG.4 Ensure Correct-Site, Correct-Procedure,

Correct-Patient Surgery

IPSG.5 Reduce the Risk of Health Care–Associated

Infections

IPSG.6 Reduce the Risk of Patient Harm Resulting

from Falls

International Patient Safety GoalsIPSG

Improve effective communication through:

2Patient Safety Goals con..

The most common cause of medical errors is

miscommunications

Documentationa major form of

Communication.

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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.

SBAR

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

SBA

R

Example SBAR briefing

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.

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IPSG.1 Identify Patients Correctly

IPSG.2 Improve Effective Communication

IPSG.3 Improve the Safety of High-Alert Medications

IPSG.4 Ensure Correct-Site, Correct-Procedure,

Correct-Patient Surgery

IPSG.5 Reduce the Risk of Health Care–Associated

Infections

IPSG.6 Reduce the Risk of Patient Harm Resulting

from Falls

International Patient Safety GoalsIPSG

Patient Safety Goals

con..

Improve the safety of high alert medication

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Double check Why ?

Labeling?

To prevent medication errors

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Medication reconciliation: document meds

on admission

Medication brought in by family members

Herbals, supplements, OTC drugs

Develop a process for communicating

patient medications to all providers

Provide list of medications to patient upon

discharge from facility.

Standardizing drug concentrations

Reducing potential for error related to

look-alike and sound alike meds.

– Insulin – all types

– Chemotherapy

– Ambulatory medications

Label all medications and med

containers or other solutions on or off

the sterile field in operative and

procedural areas.

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IPSG.1 Identify Patients Correctly

IPSG.2 Improve Effective Communication

IPSG.3 Improve the Safety of High-Alert Medications

IPSG.4 Ensure Correct-Site, Correct-Procedure,

Correct-Patient Surgery

IPSG.5 Reduce the Risk of Health Care–Associated

Infections

IPSG.6 Reduce the Risk of Patient Harm Resulting

from Falls

International Patient Safety GoalsIPSG

Patient Safety Goals con..

ENSURE

• Marking the surgical site

• Preoperative verification:

• Correct site, patient, and procedure

• All relevant documents, images and studies are available and properly labeled

• Time out immediately before starting procedure

Ensure correct-site,

correct procedure, and correct-patient

surgery through:

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IPSG.1 Identify Patients Correctly

IPSG.2 Improve Effective Communication

IPSG.3 Improve the Safety of High-Alert

Medications

IPSG.4 Ensure Correct-Site, Correct-Procedure,

Correct-Patient Surgery

IPSG.5 Reduce the Risk of Health Care–Associated

Infections

IPSG.6 Reduce the Risk of Patient Harm Resulting

from Falls

International Patient Safety GoalsIPSG

Patient Safety Goals

con..

Reduce the risk of health care

associated infections by Hand

hygiene

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After exposure to body fluid

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IPSG.1 Identify Patients Correctly

IPSG.2 Improve Effective Communication

IPSG.3 Improve the Safety of High-Alert

Medications

IPSG.4 Ensure Correct-Site, Correct-Procedure,

Correct-Patient Surgery

IPSG.5 Reduce the Risk of Health Care–Associated

Infections

IPSG.6 Reduce the Risk of Patient Harm Resulting

from Falls

International Patient Safety GoalsIPSG

Patient Safety Goals con..

Reduce the risk of patient

harm resulting from falls by:

◦ Initial assessment for fall risk at the time of

admission

◦ Reassessment when change in patient condition,

medication , etc.

◦ Implement fall prevention measures

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Thank you

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