Prepared by:

Faten Yahia.

Ahlam Aboalmaaty.

Under supervision:

Dr. Neama

� 1-Objective.

� 2-Introduction.

� 3-Definition of patient safety.�

� 4-Psychological safety.�

� 5-Safety culture.�

� 6-Patient safety committee.�

� 7-Patient safety plan.�

� 8-Leadership related standards on patient safety.�

� 9-Patient safety in Intensive Care Unit�

� -ICU Team Collaboration

� - Barriers to Team Collaboration

� -Causes of un safe ICU�

� -Error in ICU�

� 10-Patient safety goals�

� 11-Root cause analysis

� 12-Reference�

Outlines

�

�

Define patient safety.

Understand Psychological safety.

Define culture of safety.

Identify patient safety committee

Explain patient safety plan

Understand leadership related standards on

patient safety

Discuss patient safety in ICU.

List international patient safety goals.

Identify Root Cause Analysis.

Objectives

Medical errors have become a leading causes of death, killing more people

each year than AIDS or Airplane crashes.

These medical errors can be classified into five categories:

1- Poor communication.

2- Poor decision making.

3- Poor patient monitoring.

4- Poor patient identification.

5- Poor patient tracking.

Definition of patient Safety

Freedom from accidental injury, ensuring the establishment of operational

systems and processes that minimize the likelihood of errors so they won’t

occur.

�

Psychological safety :

Psychological safety is a belief that one will not be punished or humiliated

for speaking up with ideas, questions, concerns, or mistakes.

A shared sense of psychological safety is a critical input to an effective

learning system.

Introduction

:afety cultureS

An atmosphere of mutual trust in which all staff Members can talk freely

about safety problems and how to solve it ---without fear of blame or

punishment.

:culture safety Creating a

1- Support teamwork and respect others.

2- Educate staff.

3- Engage physicians.

4-Share lessons learned.

5- Encourage use of communicating.

6- Assign 1 (one) or 2 (two) clinical staff members.

7-Take a proactive approach to error.

8-Study and learn from near misses.

9- Search for information about how to do things safely.

10-Provide team training to a culture of safety.

11- Encourage patient and family involvement in the care process.

12- Share information about safety with others.

Care ?What Gets in the Way of Optimal

1- Not knowing the plan.

2- Communication issues.

3- Surprises.

4- Missing information.

5- Lack of resources.

6- Failure to plan, recognize and rescue others.

Patient safety committee �

�A patient safety committee is a multidisciplinary team that takes a proactive

approach to patient safety; It provides coordination and oversight to

advance an organizations safety program and implement safety-related

policies and procedures.

tient safety committee do?What is a pa

� The patient safety committee coordinates the following:

1- Risk management.

2- Environmental safety.

3- Infection control.

4- Quality improvement.

Patient safety plan:

1- Should standardize the definitions and categorize medical errors.

2- Establish or enhance an error, near miss reporting mechanism.

3-Identify data collection plan, reporting structure, as well as performing

scheduling.

on patient safety :Leadership related standards The leadership is to build an environment that recognizes the importance of

safety.

Leadership focus :

1- Create & maintain a culture of safety.

2- Encourage decision making.

3- Implement patient safety program throughout the organization.

4- Ensure that the processes are designed well, using available information

from internal or external sources about potential risks to patient and successful

practices.

:tensive Care UnitPatient safety in In Patient safety in the ICU and collaboration among ICU care

providers are interconnected.

Poor collaboration leads to increased errors and increased risk of bad

outcomes for ICU patients.

ICU team

Barriers to Team Collaboration

Poor communication

Poor decision making.

Shared knowledge and skills of care providers influence the care given,

decision making, problem solving, conflict management, and

coordination.

causes of an unsafe ICU: Problems with the organization and structure of the unit .

Problems with the process of care used.

Poor communication between physician and nurse.

Error in intensive care:

Medication errors.

Inappropriate disconnection of lines, catheters and drains.

Equipment failure.

Loss, obstruction or leakage of artificial airway.

Inappropriate turning-off of alarms.

The presence of organ failure.

Higher intensity in level of care and time of exposure all related.

Doctors

Nurses

Respiratory

therapists

Clinical

pharmac

y

Other Social worker

Dietitians

Take Action to Reduce Risk :

Reactive:

Investigate significant patient incidents (sentinel events).

Proactive: Monitor patient safety and redesign high-risk processes to prevent a

sentinel event from occurring.

Example of sentinel event: An inpatient received 2 (two) unit of the incorrect type of blood at the time.

The patient’s blood was drawn for a type/cross match; the sample was

mislabeled with another patient's name. The transfusion was given to the

patient whose name appeared on the type/cross match lab report, not the

patient whose blood was in the lab specimen vial.

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 falls.

�

Use at least two patient identifiers when

providing Care, treatment, and services.

when administering medications, blood, or blood

components;

when collecting blood samples and other specimens for

clinical testing;

When providing treatments or procedures. The patient's room number or

physical location is not used as an identifier.

Label containers used for blood and other specimens in the presence of the

patient.

Eliminate transfusion errors related to patient misidentification.

Before initiating a blood or blood component transfusion:

- Match the blood or blood component to the order.

- Match the patient to the blood or blood component.

- Use a two-person verification process or a one-person verification process

accompanied by automated identification technology, such

As bar coding.

Misidentification lead to: Wrong medication.

Wrong procedure.

Wrong operation.

Late giving medication.

Cancelled operation

Goal 1

Identify patients correctly

Report critical results of tests and diagnostic procedures on a timely

basis.

Verbal order should be in emergency situation only and should be

written as soon as possible.

Before a procedure, label medicines that are not labeled. For

example, medicines in syringes, cups and basins. Do this in the area

where medicines and supplies are set up.

Reduce the patient harm associated with the use of anticoagulant

therapy.

Maintain and communicate accurate patient medication information.

High alert medication

Insulin.

Narcotic drugs.

Coagulant drugs.

Potassium chloride.

Sodium chloride >0.9%

Remove concentrated electrolytes(including, but not limited to,

potassium chloride, potassium phosphate, Nacl >0.9%) from

patient care units

Standardize and limit the number of drug concentrations available

in the organization

Goal 2

Improve the effectiveness of communication

among caregivers.

Goal 3

Improve the safety of using medications.

Official “Do Not Use” List

Use Instead Potential Problem Do Not Use

Write "unit"

“0” (zero), the number “4”

(four) or “cc”

U, u (unit)

Write

"International Unit"

IV (intravenous) or the

number 10 (ten)

IU (International

Unit)

Write "daily"

�

Write "every

other day"

Mistaken for each other

Period after the Q mistaken

for "I" and the "O"

mistaken for "I

Q.D., QD, qd

(daily)

Q.O.D.,QOD,q.o.d,

qod (every other

day)

Write

"morphine

sulfate" Write

"magnesium

sulfate"

Can mean morphine

sulfate or magnesium

sulfate Confused for one

another

MS

MSO4 and

MgSO4

Wrong-site, wrong-procedure surgery can be prevented if appropriate

processes are in place:

-Effective communication.

- Mark the procedure site by physician.

-Preoperative checklist.

-Documentation.

- Time-out is performed before the procedure.

Goal 4

patient and -site, wrong-eliminate wrong

procedure surgery.-wrong

Hand hygiene.

Prevent health care–associated infections due to multidrug-

resistant organisms in critical access hospitals. This requirement applies to, but is not limited to,

epidemiologically important organisms such as methicillin

resistant staphylococcus aureus (MRSA), clostridium difficile

(CDI), vancomycin-resistant enterococci (VRE), and

multidrug-resistant gram-negative bacteria.

Prevent central line–associated bloodstream infections.

Central venous catheters and peripherally inserted central

catheter (PICC) lines.

Goal 5 Reduce the risk of health care-associated

infections

Preventing surgical site

infections.

Prevent indwelling catheter-associated urinary tract infections

(CAUTI).

Risk assessment

Periodic reassessment of individual patients

Assessment of environment of care.

Assessment Yes No Comments

Assess for injury including range of movement, pain,

bruises, lacerations, etc.

Assess vital signs and mental /neurological status

Assess degree of injury: SCORE LOCATION

0 = none

1 = minor injury ( bruises, abrasions, minor)

( Laceration which require no suturing )

2 = major injury ( fractures, head trauma,

( laceration requiring sutures

3 = death: a sentinel event which

Requires immediate review and reporting

Goal 6 Reduce the risk of patient harm resulting from

falls.

ž ž ž ž ž ž Assess and periodically reassess each resident’s risk for developing a

pressure ulcer and take action to address any identified risks.

ž

Identify patients at risk for suicide.

Identify risks associated with home oxygen therapy, such as

home fires.

Root Cause Analysis :

Reviewing the process:

What happen?

How did it happen?

Why did it happen?

What can we do differently?

Goal 7 Prevent health care-associated pressure ulcers

(decubitus ulcers).

Goal 8 The organization identifies safety risks inherent

in its patient population.

References

-Rothschild JM, Landrigan CP, Cronin JW, et al. The Critical Care Safety

Study: the incidence and nature of adverse events and serious medical

errors in intensive care.

Critical Care Med. 2005;33(8):1694-1700.

-Alberts WM. The importance of health-care teams [president’s report].

2006;1:11.

-The Joint Commission. Accreditation Program: Hospital—National

Patient Safety

Goals. http://www.jointcommission.org.

-Thomas EJ, Sexton JB, Helmreich RL. Discrepant attitudes about

teamwork among critical care nurses and physicians. Crit Care Med.

2003;31(3):956-959.

-American Association of Critical-Care Nurses. AACN standards for

establishing and sustaining health work environments: a journey

to excellence. Aliso Viejo, CA: AACN; 2005.

http://www.aacn.org/aacn/pubpolcy.nsf

/Files/HWEStandards/$file/HWEStandards .pdf. Accessed January 30,

2009.