PATIENT SAFETY INITIATIVE OVERVIEW

DR LEE OI WAH

MD(UKM), CMIA

Patient Safety Definition• Healthcare

organizations including hospitals were founded to give care to those who need it and to keep patients safe.

• It is generally agreed upon that the definition of patient safety is…

What is Patient Safety?

The absence of the potential for patient harm

Involves all Employees/Contract workers, All job descriptions

Involves all Departments Time frame: 24/7

A model of patient safety

1. Those who work in health care.

2. Those who receive health care or have a stake in its availability.

3. The infrastructure of systems for therapeutic interventions (health-care delivery processes).

4. The methods for feedback and continuous improvement.

Systems for therapeutic action designed to preempt/rescue from failure

Workers: teams trained to preempt / rescue from / manage failureR

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Methods: 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

Avoidable confusion is everywhere…

Health care is increasingly complex

Gaba

Traps in health care?

• look-alike and sound-alike pharmaceuticals

• equipment design○ e.g. infusion pumps

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

What is being done to make healthcare organizations safe for patients?

• Joint Commission on Accreditation for Healthcare Organizations (JCAHO) first established patient safety goals in 2002.

• Each year those goals are re-evaluated and revisions are published.

• When healthcare organizations are accredited, they are given report cards and graded on their compliance with meeting the goals.

National Safety Goals

• Improve the accuracy of patient identification.

• Improve the effectiveness of communication among caregivers.

• Improve the safety of using medications.

National Safety Goals

• Reduce the risk of healthcare associated infections.

• Accurately and completely reconcile medications across the continuum of care.

• Reduce the risk of patient harm resulting from falls.

PATIENT SAFETY INITIATIVEOF HOSPITAL CHANGKAT

MELINTANG

Click icon to add picture Clean care is safer care Communication policy Patient identification Medication safety Notification of critical lab results Safe blood transfusion Patient fall Incident reporting and management

WHO SHOULD KNOW?

Click icon to add picture Medical Officers Paramedics Pharmacists PPKs Allied health

professionals HSS

EVERYBODY WORKING IN OUR HOSPITAL

WHY???

Click icon to add picture Reduce medical error Improve patient safety Requirement for

Accreditation Protect from litigation Patient’s right

What else is being done to promote patient safety?

• Committees to investigate all aspects of patient safety.

• Employee training on proper lifting and transfer techniques which benefit both employees and patients.

What else is being done to promote patient safety?

• Policies for safe disposal of contaminated articles and sharps– Syringes– Needles– Blades

What else is being done to promote patient safety?• Frequent Fire and Disaster drills• Inspection and maintenance of all

equipment…– Hospital beds– Patient Lifting equipment– Gas containers– Infusion pumps– Monitoring equipment

What can employees do to promote patient safety?

• Report any potentially dangerous patient situation to your supervisor.

• Know about and participate in performance improvement processes in your department or unit.

• Take your annual mandatory training seriously; it will help you to identify safety issues.

What can employees do to promote patient safety?

• Don’t take “shortcuts”.• Use check lists.• Ask co-workers to complete double

checks.

Conclusion

Be an advocate for our patients.

Patient safetyis