HISTORY OF PATIENT SAFETY AND ORIGINS Millennia ago, Hippocrates recognized the potential for injuries that arise from the well intentioned actions of healers. Greek healers in the 4th Century B.C., drafted and pledged to "prescribe regimens for the Hippocratic oath Good of my patients according to my ability and my judgment and never do harm to anyone”. This requires a new physician to swear upon a number of healing gods that he will uphold a number of professional ethical standards. Since then, the directive primum non nocere (“first do no harm”) has become a central tenet for contemporary medicine
HISTORY OF PATIENT SAFETY AND ORIGINS(Cont’) Therefore the frequency and magnitude of avoidable adverse patient events was not well known until the 1990s, when multiple countries reported staggering numbers of patients harmed and killed by medical errors. Recognizing the healthcare errors impact, the World Health Organisation(WHO) calls patient safety an endemic concern. Indeed, patient safety has emerged as a distinct healthcare discipline supported by an immature yet developing scientific framework.
HISTORY OF PATIENT SAFETY AND ORIGINS(Cont’) Over the past ten years, patient safety has been increasingly recognized by several countries as an issue of global importance. Patient Safety in Rwanda is a new discipline. Currently it is being implemented as a program only at King Faisal Hospital, where it has taken as concern since November 2011.Therefore much effort is still required to establish patient safety in all hospitals.
PATIENT SAFETY OBJECTIVES 1.Prevent health care errors 2.Protect patient from harm resulted from healthcare errors 3.To increase awareness among the health care providers on adverse health care. 4.To encourages disclosure and exchange of information in the event of errors, near misses, and adverse outcomes.
DEFINITION Patient safety is a subset of quality healthcare that emphasizes the reporting, analysis, and prevention of medical error that often leads to adverse healthcare.
FACTORS WHICH CAN LEAD TO HEALTHCARE ERROR Human factors Medical complexity System failures Inadequate communication
PATIENT SAFETY GOALS 1.Identify Patients Correctly 2.Improve Effective Communication 3. Improve the Safety of High-Alert Medications 4.Ensure Correct-Site, Correct-Procedure, Correct- Patient Surgery 5.Reduce the Risk of Patient Harm Resulting from Falls 6.Reduce the risk of healthcare-associated infections
IDENTIFY PATIENT CORRECTLY
INTRODUCTION Wrong-patient errors occur in virtually all stages of diagnosis and treatment. The intent for this goal is to reliably identify the individual as the person for whom the service or treatment is intended and to match the service or treatment to that individual when giving any treatment or doing any procedure.
Failure to correctly identify the pt lead: Medication error Transfusion error Testing error Wrong person procedure
PREVENTION MEASURES 1.Use at least 2 patient identifiers when administering medication,blood,or blood components and when providing treatments or procedures. 2.Label containers used for blood and other specimens in the presence of the patient. 3.Eliminate transfusion errors related to patient misidentification. 4.Develop policy and protocols on accurate patient identification.
IMPROVE EFFECTIVE COMMUNICATION
INTRODUCTION Effective communication essentially involves a heightened sense of situational awareness and great listening capability. Effective communication is an art, which can be taught as well as learned.
INTRODUCTION The intent of this goal is to improve effective communication through implementation of a process or procedure for taking verbal or telephone orders or for reporting critical test results that require a verification "read back” of the complete order or test result by the person receiving the information.
Factors contributing to miscommunications Patient handover between units and amongst care providers Communication not including all the essential information Poor misunderstand of information Lack of good communication Language barriers Patient care orders given verbally and over telephone Illegible orders
PREVENTION MEASURES 1.Develop written procedures for managing the critical results of tests and diagnostic procedures. 2.Implement the procedures for managing the critical results of tests and diagnostic procedures 3.Evaluate the timeliness of reporting the critical results of tests and diagnostic procedures. 4.Develop written procedure on verbal and telephonic orders
IMPROVE THE SAFETY OF HIGH ALERT MEDICATIONS
INTRODUCTION Medications are part of the patient treatment plan, appropriate management is critical to ensuring patient safety. Frequently cited medication safety issue is the intentional administration of concentrated electrolytes.
Easy access Inadequate prescription Wrong ordering Inadequate preparation Poor distribution Inadequate labeling Poor verification Misadministration Frequency of administration FACTORS INFLUENCING ERRORS
PREVENTIVE MEASURES Develop policy and/or procedure that prevents the location of concentrated electrolytes in patient care areas Ensure policies and procedure that address location, labeling and storage of concentrated electrolytes are implemented
ENSURE CORRECT-SITE, CORRECT-PROCEDURE, CORRECT –PATIENT SURGERY
INTRODUCTION Wrong-site, wrong-procedure, wrong-patient surgery is a disturbingly common occurrence in healthcare organization. these errors are the result of ineffective or inadequate communication between members of surgical team, lack of patient involvement in site marking, and lack of procedures for verifying the operative sits. The organization need to collaboratively develop a policy and/or procedure that is effective in eliminating this disturbing problem.
PROTOCOL Universal protocol for wrong site, procedure and surgery prevention is: Marking the surgical site A pre-operative verification process A time out that is held immediately before the start of a procedure
REDUCE THE RISK OF HEALTH CARE ASSOCIATED INFECTION
INTRODUCTION Patients continue to acquire infections while receiving care, treatment and services in a health care organization. Risks and patient populations, however, differ between hospitals. Consequently health care- associated infections are a patient safety issue affecting all health care organization.Therefore, prevention and control strategies must be tailored to the specific needs of each hospital based on its risk assessment.
PROTOCOL Promote effective hand hygiene Comply with the general accepted hand-hygiene guidelines
REDUCE THE RISK OF PATIENT HARM RESULTING FROM FALLS
INTRODUCTION Falls account for a significant portion of injuries in hospitalized patient. In the context of the population it serves, the services it provides, and its facilities, the organization should evaluate its patients 'risk for falls and take action to reduce the risk of falling and to reduce the risk of injury should a fall occur.
1.Demographic and history 2.Diagnosis or conditions 3.Medications 4.Environmental and other FALL RISK FACTORS
PROTOCOL Assess environmental factors and patient factors which could lead to patient falls Develop protocols to prevent risk patient harm from fall Implement protocols for preventing patient harm resulted from falls