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Transcript of Patient Safety
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Patient Safety
Dr.Abhimanyu Bishnu
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Patient safety is a healthcare discipline that emphasizes the reporting, analysis, and prevention of medical error that often lead to adverse healthcare events.
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Systems for therapeutic action designed to preempt/rescue from failure
Workers: teams trained to preempt / rescue from / manage failureR
ec
ipie
nts
of
ca
reMethods: CQI on info, hardware, plant, policy
Methods: CQI on: competence communication, teamwork
Preparation on: illness understanding, accessing care systems, advocacy
A patient safety model of health care Emmanuel et al 2008
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Knowledge & Expertise
Patients
•experience of illness• social circumstances•attitude to risk• values• preferences
Clinicians
• diagnosis disease • etiology• prognosis•treatment options• outcome
probabilities
Coulter A Picker Institute 2001
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Important:
• understand the multiple factors involved in failures• avoid blaming• practise evidence-based care• maintain continuity of care for patients• be aware of the importance of self-care• act ethically everyday
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Human factors
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Human factors definition
• the study of all the factors that make it easier to do the work in the right way
• apply wherever humans work
• also sometimes known as ergonomics
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Human factors• acknowledges:
○ the universal nature of human fallibility○ the inevitability of error
• assumes that errors will occur
• designs things in the workplace to try to minimize the likelihood of error or its consequences
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Human factors design principles
Senses- Vision - Hearing
Psychomotor- Hands
Input Devices- Buttons
Output- Display - Sound
INTERFACE
US Department of Veteran affairs
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Human factors
Importance of human factors has been recognized for a long time in:
• aviation
• nuclear power
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Importance in health care?• only recently been acknowledged as an essential part of patient safety
• a major contributor to adverse events in health care
• all health-care workers need to have a basic understanding of human factors principles
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Health care is increasingly complex
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We cope quite well with complexity
• Health-care workers are quite good at compensating for some of the complex and unclear design of some aspects of the workplace
○ equipment
○ physical layouts
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Because the human brain is ….
• very powerful
• very flexible
• good at finding shortcuts (fast)
• good at filtering information
• good at making sense of things
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Sometimes though our brain is “too clever” …
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Are the lines crooked or straight?Optillusions.com
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Look at the chartSay the colour of the word, not the word itself
Why is it hard? Optillusions.com
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The fact that we can misperceive situations despite the best of
intentions is one of the main reasons that our decisions and actions can
be flawed such that …
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Human beings make “silly” mistakes
Regardless of their experience, intelligence, motivation or vigilance, people make mistakes
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Traps in health care?
look-alike and sound-alike pharmaceuticals equipment design, e.g. infusion pumps hand-offs and shift of level of care lack of verification during procedures/ medication
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Avoidable confusion is everywhere…
US Department of Veteran affairs
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Look-alike, sound alike drugs
√
×
Name Confusion- 25% of all medication errors
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The context of health careWhen errors occur in the workplace the consequences can be a problem for the patient
○ a situation that is relatively unique to health care
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Errors
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One definition of “human error” is “human nature”
Error is the inevitable downside of having a brain!
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What is an error?
• the failure of a planned action to achieve its intended outcome
• a deviation between what was actually done and what should have been done
Reason
• A definition that may be easier to remember is: ○ “Doing the wrong thing when meaning to do the right
thing.” Runciman
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Errors
Mistakes
Skill -based slips and lapses
Attentional slips of action
Lapses of memory
Rule -based mistakes
Know ledge -based mistakes
Reason
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Error and outcome
• error and outcome are not inextricably linked: – harm can befall a patient in the form of a complication of care
without an error having occurred
– many errors occur that have no consequence for the patient as they are recognized before harm occurs
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Situations associated with an increased risk of error
• unfamiliarity with the task*• inexperience*• shortage of time• inadequate checking• poor procedures
• poor human equipment interfaceVincent
* Especially if combined with lack of supervision
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Individual factors that predispose to error
• limited memory capacity• further reduced by:
○ fatigue○ stress○ hunger○ illness○ language or cultural factors○ hazardous attitudes
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Fatigue24 hours of sleep deprivation has performance effects
~ blood alcohol content of 0.1%
Dawson – Nature, 1997
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Stress and performance
The relationship between stress and performance
Stress level
Area of “optimum”
stress
Low stress Boredom
High stress Anxiety, panic
Perf
orm
ance
leve
l
Yerkes, R. M., & Dodson, J. D. (1908) The relation of strength of stimulus to rapidity of habit-formation.
Journal of Comparative Neurology and Psychology, 18, 459-482
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A performance-shaping factors “checklist”
• I Illness• M Medication
–prescription, alcohol & others • S Stress • A Alcohol• F Fatigue• E Emotion
Jensen, 1987
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Don’t forget ….
If you’re – H ungry– A ngry– L ateor – T ired …..
HALT
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Removing error traps
• a primary function of an incident reporting system is to identify recurring problem areas - known as “error traps” (Reason)
• identifying and removing these traps is one of the main functions of error management
Error traps
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Modified from Cook, 1997
Hindsight Bias
Before the Incident
After the Incident
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Apply human factors thinking to your work environment
1. Avoid reliance on memory2. Make things visible3. Review and simplify processes4. Standardize common processes and procedures5. Routinely use checklists6. Decrease the reliance on vigilance
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Human factors engineering is about designing the workplace and the equipment in it to accommodate for limitations of human performance
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Summary
• errors are inevitable
• there are situations that can increase the likelihood of error
○ recognize them for your patient’s sake - and yours!
• attention to human factors principles can lead to a reduction in error or its consequences
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Errors
• medical error is a complex issue, but error itself is an inevitable part of the human condition
• learning from error is more productive if it is considered at an organizational level
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Examples• order medications electronically
• hand off information
If all of these tasks become easier for the health-care provider, then patient safety can improve.
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Systems thinking
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A “system”
any collection of two or more interacting parts, or
“an interdependent group of items forming a unified whole”
NPSEF (p. 202)
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A “complex system”
many interacting parts
difficult if not impossible to predict the behaviour of the system based on a knowledge
of its component parts
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Health care is a complex system
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Complexity = increased chance of something going wrong!
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Two schools of thought regarding iatrogenic injury
o traditional or person approach* the “old” culture* “just try harder”
o systems approach* the “new look”
You may encounter a bit of both in your “journey”
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Person approachsee an errors as the product of carelessness
remedial measures directed primarily at theerror-maker
o namingo blamingo shamingo reassigning
Perspectives on error
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An individual failing?Not often the case
o people don’t intend to commit errors only a very small minority of cases are deliberate violations
o won’t solve the problem - it will make it worseo countermeasures create a false sense of security
“we’ve ‘fixed’ the problem” o clinicians will hide errorso may destroy many clinicians inadvertently
the second victim
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Systems approach
• Investigate• Analyze• Correct• Prevent
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Why investigate?
• the more we understand how and why these things occur, the more we can put checks in place to reduce recurrence
• strategies might include:
– education– new protocols– new systems
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Multiple factors usually involved
• patient factors• provider factors• task factors• technology and tool factors• team factors• environmental factors• organizational factors
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Reason’s “Swiss cheese” model of accident causation
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Example- Acute Respiratory Distress Syndrome (ARDS)
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Reason’s - Defences
VA NCPS
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Clinical risk management
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Why clinical risk is relevant to patient safety • clinical risk management specifically is concerned with improving the
quality and safety of health-care services by identifying the circumstances and opportunities that put patients at risk of harm and acting to prevent or control those risks
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4-step process to manage clinical risks
• identify the risk• assess the frequency and severity of the risk• reduce or eliminate the risk• cost the risk
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Incident Reporting
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Near miss: Process variation which did not affect the outcome but for which recurrence carries a significant chance of serious adverse outcome, eg.patient falls in bathroom but is immediately supported by the accompanying nurse.
Adverse event: Unanticipated, undesirable or potentially dangerous occurrence in a healthcare organization, eg. patient fall resulting in minor bruising; wrong medication resulting in a change of prescription.
Sentinel event: An unexpected event which involves death or serious physical and psychological injuries to a patient or employees, eg. patient fall resulting in internal head injury; patient suicide; infant
abduction;wrong surgery done etc.
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Confirmed transfusion reactionsSerious adverse drug events
Medication errorsDiscrepancies between properative and postoperative diagnosis
Adverse events associated with sedation and anaesthesiaInfectious disease outbreaks Equipment- related Incidents
Patient Falls in WardStaff falls in Ward
Needle Stick InjuryComplaints by Patients and / or Relatives
Cancellation of elective surgeryAssault or battery of patients by employees or other persons
Error in consent Adverse Outcome of Procedure
Incidents
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Incident monitoring
• involves collecting and analysing information about any events that could have harmed or did harm anyone in the organization
• a fundamental component of an organization’s ability to learn from error
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Incident form pathway
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Incident Reporting Form
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Causes of incidents
• Patient factors• Task and technology factors• Individual factors• Team factors• Work environment factors• Other factors
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Root Cause Analysis
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Engaging with patients and carers
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SEGUE framework ( Northwestern University)
o Set the stageo Elicit informationo Give informationo Understand the patient’s perspectiveo End the encounter
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Performance requirements• actively encourages patients and carers to share information• shows empathy, honesty and respect for patients and carers• communicates effectively• obtaining informed consent• shows respect for each patient’s differences, religious and cultural beliefs,
and individual needs• describes and understands the basic steps in an open disclosure process• apply patient engagement thinking in all clinical activities• demonstrates ability to recognize the place of patient and carer
engagement in good clinical management
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Gaining an informed consent
• the diagnosis • the degree of uncertainty in the diagnosis• risks involved in the treatment • the benefits of the treatment and the risks of not having the
treatment• information on recovery time• name, position, qualifications and experience of health
workers who are providing the care and treatment• availability and costs of the services required
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Harvard framework• preparing• initiating conversation• presenting the facts• actively listening• acknowledging what you have heard• responding to any questions• concluding the conversation• documentation
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SPIKESo Sharpen your listening skillso Pay attention to patient perceptionso Invite the patient to discuss detailso Know the factso Explore emotions and deliver empathyo Strategize next steps with patient or family
Robert Buckland
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Minimizing infection through improved infection control
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What is the urgency?
• We can no longer rely on antibiotics• increased rates of nosocomial infections• infected patients:
– stay longer in hospital– die– treated with more toxic and less effective drugs– prone to surgical site infections
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Campaigns to decrease infection rates
• WHO “Clean hands are safer hands” campaign• Centers for Disease Control and Prevention campaign to prevent
antimicrobial resistance in health-care settings• Institute for Healthcare Improvement “5 million lives” campaign
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Main causes of infection– person-person via hands of health-care providers patients
and visitors– personal equipment (e.g. stethoscopes, personal digital
assistants) and clothing– environmental contamination– airborne transmission– carriers on the hospital staff– rare common-source outbreaks
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Main types of infections
• urinary track infections usually associated with catheters • Surgical site infections• blood stream infections associated with the use of an
intravascular device• pneumonia associated with ventilators • other sites
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Burke J Infection control-a problem for patient safety New Eng Journal of Medicine
Main types of infections
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Prevention in hospitals
– make sure- visibly clean – increased cleaning during outbreaks– use hypochlorite and detergents
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Prevention through handwashing
– how to clean hands– rationale for choice of clean hand practice– technique for hand hygiene– protecting hands from decontaminates– promoting adherence to hand hygiene guidelines
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• gloves• aprons• face masks
Protective equipment
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• keep handling to a minimum • do not recap needles; bend or break after use• discard each needle into a sharps container at the point of use• do not overload a bin if it is full• do not leave a sharp bin in the reach of children
Safe disposal of sharps
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Act to minimize spread of infection
• before contact with each and every patient:– clean hands before touching a patient – clean hands before an aseptic task
• after contact with each and every patient: – clean hands after any risk of exposure to body
fluids– clean hands after actual patient contact– clean hands after contact with patient
surroundings
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“My 5 moments for hand hygiene- WHO”
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Medication Safety
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Medication
• Definition: A chemical substance intended for use in the diagnosis, cure, investigation, treatment or prevention of disease.
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Process in Medication
• 1. Prescription• 2. Transcription• 3. Dispensing• 4. Administration &
Documentation
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Medication Errors (MEs)• 1. Prescription• 2. Transcription• 3. Dispensing• 4. Administration & Documentation
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Wrong Drug (Look alike)
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Orders for Vancomycin
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Medication Errors
• Please bring these to the notice of the Quality & Clinical Pharmacy deptts. Extremely important. The responsible person fills in an Incident Report..
• Data will be collected and presented at the Quality Steering Committee.
• All such Measures are used as Quality Indicators for evaluating statistically significant improvement.
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Prescription• Drugs are ordered in Physician Order Sheet• Document correct date,time and signature.• Write in CAPITALS• Mention – i) Drug name , ii) Dose, iii) Route, iv) Frequency • DISCONTINUE medication with date, time and signature.• Dose changes to be done with date, time and signature.• For discontinued medications cross out drug and after the
last dose given
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Contd…• Use standard abbreviations.• Write the date of new medication.• Verbal orders to be used only in
emergency situations e.g. Code Blue.
• Always use leading zeros for decimal points. E.g.
.5 mg Digoxin ------- Incorrect Digoxin 0.5mg PO OD --------
Correct
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Contd…
• Orders should be legible, clear and with date, time and signature.
• All antibiotics to be charted in clinical chart.• In case of antibiotic prescribed, no. of days
should be mentioned. E.g. Inj. Cefrom 1gm iv BD ---- day 2 in clinical chart.
Can you read this???
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Transcription/ Indenting
Definition: Something written, especially copied from one medium to another as a type written version of dictation, as done in case of indenting a medicine ( copying drug order from drug chart to computer).
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Transcription/ Indenting• Always spell check and indent.• Verify correct name, UHID no. and bed no.• Mention allergies in remarks column.• Any doubt regarding medicine to be clarified with
the prescriber.
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Dispensing• Medications
dispatched from from pharmacy.
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Dispensing• No substitute or opened medication to be
received.• All medications to be received by T/L or
assigned nurse. • Check medications for their dose, expiry and
quantity after receiving.• All medications received should be kept
under lock in bedside of the patient.• Temperature of the fridge for medicine
storage to be maintained at 2-8 degree celsius.
• Narcotics are stored under lock.
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Administration
• Process of giving drug used in the diagnosis, treatment, or prevention of a disease or as a component of a medication.
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Administration• Always remember: Right patient Right drug Right dose Right route Right time
Right documentation• Self medication is not allowed.• All medications to be known and checked and signed by 2
nurses.• Prepare and label the medications.• In case of antibiotics, a sensitivity test need to be done
before administration.
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Contd…• Food drug reaction (FDR) and drug and drug reactions (DDR) should be known.
• All medication dosage, indication, side effects, precautions and route should be known.
• Some high-risk medications are Vancomycin Digoxin IV Phenytoin Chemotherapeutic drugs Theophylline Warfarin Heparin Narcotics IV Iron Morphine Fentanyl Inj Insulin• Some high alert medications are Concentrated electrolytes e.g. KCL, MgSO4,
10% dextrose.
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Contd…• Transdermal patches should be dated
and timed on the patch and document.• Remove old patches, clean the
remaining medication from the skin.• Administer all medicines one by one and
observe for 5 minute for any allergy.• Ensure that patient has taken oral
medicine completely.
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Contd…• Iron to be started only after test by the
doctor.• Base line investigations for high risk
medications e.g. PTT, ACT for heparin infusion.
• Monitoring of patients getting high risk medications.
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Documentation
• Process of transferring data or action into paper or computer record.
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Documentation
• Document the medication given with time, signature/name and emp ID no.
• Document the effect of medication if any.• Incident forms to be filled in case of any
medication errors.• If medication is not given on time, it is
considered as medication error.
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• Use standard timings for medication administration: OD 10AM,
• HS 10 PM, • TDS OR 8 hrly 6 AM, 2 PM, 10 PM, • BD OR 12 hrly 10am 10pm, OD warfarin 6PM/4PM, BD
diuretics 6AM- 4PM.• QID 6hrly 6AM- 12N - 6 PM – 12MN.• 4 hrly 0200- 0600 – 1000 – 1400 – 1800 – 2200 – 0200.
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• For making medication label, write: name of the medication, dilution, dosage, date, time, name and emp no. of the nurse making the medication.
• Record any known allergy.• All medication can be administered with ± 1 hr e.g. If medication is to be
given at 8.00am the nurse can give the medication between 7.00am to 9.00 am and document the exact time of administration like 8.25 am.
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Medication Reconciliation• Collect accurate list o f the all possible current
medications• Compare it with the list against
– Admission– Transfer– Discharge
• The prescribes shall document the reconciliation process on the medication reconciliation list document in the comments section.
• Reason for holding, discontinuing or changing dose / frequently
• Any other pertinent medication information.• Nurse shall enquire with the consultant regarding the
use of current medication and these medications if available with patients to be sent to pharmacy for verification.
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Home Medication & Self Administration
• No self medication of any kind is allowed in hospital.
.
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Adverse Drug Reaction (ADR)
• Definition: Any harm associated with the use of drug at normal dose.
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ADR levels
• Level 1 –ADE/ADR occurred but required no change in treatment with suspected drug
• Level 2 –Drug held, discontinued or changed but no antidote or additional
• treatment needed.• Level 3 –Drug held, discontinued or changed AND/OR antidote or
other treatment required. • Level 4 – ADE / ADR required patient transfer to an intensive care
setting• Level 5 – ADE / ADR caused permanent harm to the patient• Level 6 – ADE / ADR either directly or indirectly led to the patient’s
death
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ADRs• Document all ADRs on ADR
Form-send to Clinical Pharmacy.• Please report suspected or
confirmed ADRs on ADR Form. Incident Form to be filled for levels 4,5 and 6
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Read Back Policy• Read back, verify, document verbal orders• Applicable for; a) Code Blue Situation b) Critical Lab Values: The staff nurse has to read
the value back to confirm and duly sign her name and clock no. and write the name and emp no. of the person who has given the report.
c) Insulin orders: Eg: 29/04/08 6:00am – 40 units – Read back to Dr. -----------, signature, name of the staff and emp no.
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Remember• Never leave Medicines unattended.• Lock them in bedside cabinets.• Label all Open In Use Vials.
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Patient safety and invasive procedures
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The main causes of adverse events associated with invasive procedural and surgical care
• poor infection control methods • inadequate patient management • failure by health-care providers to communicate effectively before, during
and after operative procedures
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Requirements• follow a verification process to eliminate wrong patient, wrong side and
wrong procedure• practise operating room techniques that reduce risks and errors ( time-out,
briefings, debriefings, stating concerns)• participate in an educational process for reviewing surgical mortality and
morbidity
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Teamwork
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A team is….
a distinguishable set of two or more people who interact dynamically, interdependently and adaptively towards a common and valued goal/objective/mission, who have been each assigned specific roles or functions to perform, and who have a limited lifespan of membership.
Eduardo Salas
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What types of teams do you find in health care?
Many different teams are found in health care:
o multiprofessional/drawn from a single professiono co-located/distributedo transitory or long standing
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How do teams improve patient care?
o teams represent a pragmatic way to improve patient care
o teams can improve care at the level of:o the organizationo the patient – outcomes and safetyo the team as a wholeo the individual team member
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What makes for a successful team?
Effective teams possess the following features:o a common purposeo measurable goalso effective leadership and conflict resolutiono good communicationo good cohesion and mutual respecto situation monitoringo self-monitoringo flexibility
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Requirements…Practical tips to improve teamwork include:o always introducing yourself to the teamo reading back/closing the communication loopo stating the obvious to avoid assumptionso asking questions, checking and clarifyingo delegating tasks to people not to the airo clarifyng your roleo using objective (not subjective) language
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Requirements…
o learning and using people’s nameso being assertive when requiredo if something doesn’t make sense, finding out the other person’s
perspectiveo doing a team briefing before undertaking a team activity and a
debriefing afterwardso when conflict occurs, concentrating on “what” is right for the
patient, not “who” is right
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Communication
A number of techniques have been developed to promote communication in health care including:
o SBAR (Situation, Background, Assessment, Recommendation)o call-outo check-backo handover/handoff
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In conclusion…………….
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Quality & PatientSafety
QUALITY AND PATIENT SAFETY
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Thank you!!!
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www.powerofteamworkmovie.com