Patient Safety & Risk Management Staff Orientation

PATIENT SAFETY

AND

RISK MANAGEMENT

Ibn Al Gumahad, BSN-RN

Coordinator, Patient Safety

059 – 272 – 6391

894-5524 EXT 571

Quality Management-MDH

Safety Policy Statement

Patient comes first.

Most valuable resource:

STAFF

22 NOVEMBER 2014 / [email protected]

Dedicated to a safe and

healthful environment

for employees, patients

and others;

Preservation of company

assets and properties;

Safety Policy Statement

Committed to aggressive

management of clinical

and non-clinical (operational)

risk;

Control hazards, minimize

customer injuries, property

damage and/or loss;

Promoting safety is every

MDH employee’s

responsibility.


Risk is EVERYWHERE !

is not an exception!


RISK MANAGEMENT PROGRAM

To develop and implement an integrated

system of assisting MDH employees in ensuring

the quality of services by:

Identifying

Managing

Reducing hazards and risks of

undesirable or adverse events associated with

service delivery throughout the organization.


RISK MANAGEMENT PROCESS

1. Risk Identification

2. Risk Assessment

3. Risk Treatments

4. Review and Follow-

Up


RISK IDENTIFICATION

Know the hazards or potential

risks.

Risks when triggered, cause

problems.

Can be internal or external

(SOURCE ANALYSIS).

Events leading to a problem

are investigated (PROBLEM

ANALYSIS)


RISK ASSESSMENT

Potential

severity of

damage, loss

and

recurrence.


RISK TREATMENTS

Risk Avoidance

Risk Reduction

Risk Retention

Risk Transfer


Risk REVIEW & FOLLOW-UP

Incident Reporting System

Hazards Surveillance Rounds

Infection Control Surveillance

Hospital Safety Committee

Infection Prevention & Control

Committee

Medication Safety

Audits, focused studies


Occurrence Variance Reporting

System (OVRS)

VARIANCE – is anything that is

out of the STANDARDS

Incidents are reported thru

OVR

Processed by the Patient

Safety Coordinator

Entered in the data base

where trends and patterns are

identified


Occurrence Variance Reporting

System (OVRS)

Addressed and followed through with

appropriate individuals and entities.

SYSTEMS RATHER

THAN INDIVIDUALS

IS THE FOCUS OF THE

OVR.


What to REPORT?

MEDICATION ERRORS

Procedure/Practice

Variance

Security-related

Safety-related

Patient Variance

Miscellaneous


Sample of OVR Data


Patient-Related Incidents

UNKNOWN

Near Miss

Minor

Moderate

Major

Severe


Barriers in reporting incidents

What’s in it for

me?

Individuals

rather

than

systems/proces

ses

Punitive

No feedback


Proactive Safety Improvement

Gather and analyze

information about risk-

prone processes

Redesign high-risk

processes to reduce the

chance of patient harm

Document the process

Train people

Monitor continuing safety

of the process


Steps to Improve Safety

Basic Tenets of Human

Error

Everyone commits errors

Human error is generally the

result of circumstances that

are beyond the conscious

control of those committing

the errors.

Systems or processes that

depend on perfect human

performance are fatally

flawed.


Common Causes of Medical Errors

and Sentinel Events

Lack of staff orientation/training

Communication failure

Medication storage/access

problems

Important information not available

to caregivers

Staff competency/credentialing

problems

Inadequate supervision

Inadequate/improper labeling

Staff distraction


Need to Increase Focus

on the Human Factors

Human errors occur because of:

Inattention

Memory lapse

Failure to communicate

Poorly designed equipment

Exhaustion

Ignorance

Noisy working conditions

A number of other personal and

environmental factors


Where to Start ?

Consider safety improvement

recommendations made

during surveillance rounds

Share safety improvement

ideas

Focus attention on high-risk

processes

Incident reports and other

info are used to identify risk-

prone patient-care processes

Your help is needed – report

incidents and hazardous

situations.


REMEMBER:

People Are Set-Up to

Make Mistakes

Incompetent people are, at

most, 1% of the problem.

The other 99% are good

people trying to do a good

job who make very simple

mistakes and it's the

processes that set them

up to make these

mistakes.

Dr. Lucian Leape, Harvard School of Public Health


INTERNATIONAL PATIENT

SAFETY GOALS.

TO PROMOTE SPECIFIC

IMPROVEMENT IN PATIENT SAFETY

HIGHLIGHT PROBLEMATIC AREAS IN

HEALTHCARE

DESCRIBE EVIDENCE AND EXPERT-

BASED CONCENSUS SOLUTIONS TO

THESE PROMBLEMS.

JOINT COMMISSION INTERNATIONAL


IPSG 1. IMPROVE THE

ACCURACY OF

PATIENT

IDENTIFICATION.

Use at least TWO (2) PATIENT IDENTIFIERS:

1. Complete Name

2. Medical Record Number

A P P L I C A B I L I T Y O F P A T I E N T I D E N T I F I C A T I O N :1 . E m e r g e n c y R o o m2 . O p e r a t i n g R o o m3 . L a b o r a t o r y4 . R a d i o l o g y5 . B e f o r e a n y p r o c e d u r e6 . B e f o r e p r o v i d i n g a n y t r e a t m e n t7 . A t A L L P o i n t s o f C a r e


IPSG 2. IMPROVE THE

EFFECTIVENESS

OF COMMUNICATION

1.Verbal and telephone order or

test result is WRITTEN DOWN

by the receiver of the order.

2. READ BACK is done by the

receiver of the order or test result.

3. The order or test result is CONFIRMED by the

individual who gave the order or test result.


IPSG 3. IMPROVE THE SAFETY

OF HIGH ALERT

MEDICATIONS

Take caution on:

LOOK-ALIKE /

SOUND-ALIKE

MEDICATIONS

Restricting access

to CONCENTRATED

ELECTROLYTES in

patient care areas.


IPSG 4. ENSURE CORRECT SITE,

CORRECT PROCEDURE,

CORRECT-PATIENT

SURGERY

1. MARKING THE SURGICAL SITE

for all cases involving

laterality, multiple structures or

levels.

2. PRE-OPERATIVE

VERFICATION PROCESS

3. TIME OUT is

held immediately

before the star t

of the procedure.


IPSG 5. REDUCE THE RISK OF

HEALTH-CARE

ASSOCIATED

INFECTIONS

• Surgical Site Infection Prevention

• Hand Hygiene Program

• Ventilator-Associated Pneumonia

Prevention

• C A U T I Prevention

• Central Line Infection Prevention


IPSG 6. REDUCE THE RISK OF

PATIENT HARM

RESULTING FROM

FALLS

• Fall Risk Assessment Upon

Admission

• Fall Risk Re-assessment

After Invasive Procedure

• Implementation of Patient

Fall Management for those

assessed to be at risked.


Ibn Al Gumahad, BSN-RN

Coordinator, Patient Safety

059 – 272 – 6391

894-5524 EXT 571

Quality Management-MDH

THANK YOU

VERY MUCH !

Patient Safety & Risk Management Staff Orientation

Health & Medicine

Transcript of Patient Safety & Risk Management Staff Orientation