NATIONAL PATIENT SAFETY DAYJune 25, 2011

THEME:

“ Working Together Towards Patient Safety”

Slogan:

“Kaligtasan ng Pasyente, Una Lagi”

What is Patient Safety?

Patient Safety is the avoidance, prevention and amelioration of adverse outcomes/ injuries stemming from the process of health care

Date: July 30, 2008

Administrative Order No. 2008-0023

National policy on Patient Safety

Goal: To ensure that the patient safety is institutionalized as a fundamental principle of the health care delivery system in improving health outcomes.

The Veterans Regional Hospital Administrative Manual Patient Safety

Plan

I. PURPOSE OBJECTIVE:To provide a planned, ongoing, comprehensive, coordinated and integrated Hospital-wide mechanism to objectively and systematically monitor and evaluate the safety of patient care, promptly identify and resolve problems, plan education to improve patient safety and to reduce medical errors throughout the organization.

The essential elements of the program include:

• The integrated Patient Safety Committee, supported by the COH, have the authority to recommend changes and take necessary actions in order to make improvements to patient care services provided.

•Responsibility for Patient Safety activities are shared by the Medical Staff Departments, Patient Care Services, the Clinical Support Services and all other hospital departments.

•Department Chiefs of all hospital departments are responsible for the ongoing education, monitoring, and evaluation in preventing, detecting and correcting medical errors within their departments.

•The information collected addresses the requirements of DOH and PHIC for a Patient Safety Program.

•Appropriate actions are taken to resolve identified problems and/or identified opportunities to improve patient care and non-clinical services rendered.

•The information derived from each department’s monitoring, evaluation and improvement activities is shared with other departments as deemed necessary by the Department Chief and is integrated with information obtained from other hospital-wide patient safety activities as appropriate.

•The Patient Safety program is reviewed annually to assure the program’s objectives are attained and that improvement to patient care and service delivery is made.

II. DEFINITIONS OF TERMSThe following definitions are uniformly used in the hospital’s Incident Report, Sentinel Event and other relevant environment of care and medication use policies.

•Sentinel Event Unexpected incident involving death or serious physical or psychological injury, or the risk thereof.

The fundamental objective of sentinel event reporting is corrective in nature and the identification of appropriate actions to prevent recurrence.

http://en.wikipedia.org/wiki/File:Sentinelgraph.png

•Near Miss or “close call” An event or situation that could have resulted in an accident, injury, or illness, but did not, either by chance or timely intervention.

It is a serious error or mishap that has the potential to cause as adverse event but fails to do so because of chance or because it is intercepted.

•Latent Failure An error precipitated as a consequence of management and organizational processes that poses the greatest danger to complex systems.

Latent failures cannot be foreseen but, if detected, they can be corrected before they contribute to mishaps.

•No Blame Culture

A non-punitive encouraging voluntary reporting of adverse events.

•Risk

Is any exposure to a harmful event. It is directly related to hazard and vulnerability and, inversely, to capacity.

•Adverse Drug Reaction

Any undesirable or unexpected medication related event that requires discontinuing a medication or modifying the dose, requires or prolongs hospitalization, results in disability, requires supportive treatment, is life threatening or results in death, results in congenital anomalies, or occurs following vaccination.

•Medication Error

Any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in control of the health care professional, patient or consumer.

Such events may be related to

1.professional practice2.health care products3.procedures and systems, including prescribing; order communication; product labeling; packaging, and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use.

•Unexpected Event

Any situation that is not consistent with the routine operation of the affiliate or routine care and safety of a patient. All events identified should be reported following the Patient Incident Report Policy utilizing the patient incident report.

Policy on Patient Safety

Safety standard policies:•Access to care and continuity of care (ACC) Policies: Admission Networking Transport Discharge Others

Policy on Patient Safety

Safety standard policies:

•Patient and family rights

Policies: Information Patient care Autopsy Confidentiality Security Others

Policy on Patient Safety

Safety standard policies:

•Assessment of care

Policies: Referral Credentialing and hiring Others

Policy on Patient Safety

Safety standard policies:• Care of patients

Policies: Clinical pathways. Dse related groups, clinical practice Medication preparation, storage Periodic clinical monitoring and evaluation Special care/Intensive care Others

Policy on Patient Safety

Safety standard policies:

•Anesthesia and surgical care

Policies: pre-anesthetic evaluation Surgical site preparation Post –anesthetic care Credentialing Others

Policy on Patient Safety

Safety standard policies:•Medication Management and use

Policies: Procurement Storage/dispensing Preparation Medication errors/near misses Adverse drug reaction Others

Policy on Patient Safety

Safety standard policies:•Medication Management and use

Policies: Procurement Storage/dispensing Preparation Medication errors/near misses Adverse drug reaction Others

Policy on Patient Safety

Safety standard policies:

•Patient and family education

Policies: Training and education Participative care Others

Policy on Patient Safety

Safety standard policies:

•Quality improvement and patient safety

Policies: Sentinel event reporting and handling or processing Others

Policy on Patient Safety

Safety standard policies:•Prevention and control of infection

Policies: Hand washing Disinfection Handling of infectious waste, sharps, specimens Personal protective equipment (PPE) Rational use of antibiotics (3rd gen and above) Others

Policy on Patient Safety

Safety standard policies:•Governance, Leadership and direction

Policies: Organizational mission Monitoring and evaluation Periodic review of policies and procedures Handling of complain Patient survey Accountability Others

Policy on Patient Safety

Safety standard policies:•Facility Management and safetyPolicies: Safe Environment Equipment maintenance Building and environment maintenance Patient transport maintenance Other facility maintenance such as electricity, generator, water, gas management Waste segregation and disposal Others

Policy on Patient Safety

Safety standard policies:•Staff qualification and educationPolicies: Hiring Training needs analysis Continuing professional training Others

Role:

To take the lead role in planning, implementing, managing,, and evaluating safety initiatives and programs

Committee on Patient Safety

7 STEPS TO PATIENT SAFETY

1. Build a safety culture2. Lead and support your staff3. Integrate your risk

management activity4. Promote reporting5. Involve and communicate with

patients and the public6. Learn and share safety

lessons7. Implement solutions to prevent

harm

Committee on Patient Safety

MEDICAL TEAM

1. Safe Surgery Team2. Medication Safety Team3. Blood Transfusion Safety Team4. Fall Prevention Team5. Adverse Event Team6. Infection Control Team

ENVIRONMENTAL SAFETY TEAM