1. Development Policies and Procedures Manual
Examples of table of contents: Example 1: demonstrates a organization numbering system Example 2: demonstrates a service-specific numbering system

2. Patient Safety Dr. Hussein Saad Assistant Professor and Consultant
Family &Community Medicine
College of Medicine
King Saud University

3. Quality of Care
■ The degree to which patient care services increase the probability of desired patient outcomes and reduces the probability of undesired outcomes.

4. Accreditation
Focus on
Quality

5. What is the importance and benefits of Accreditation?
Improve the quality of patient care and outcome.
Improve the Patient Safety, Save Environment.
Competition for excellence.
Enhance the confidence of public.
Shows accountability.

6. What is Quality Improvement?
■ An organization philosophy that seeks to meet clients’ needs and exceed their expectations by using a structured process that selectively identifies and improves all aspects of service.

7. How will be benefit?
Communication
Positive
Change
Sharing
Ideas

8. Elements of Quality Safety Client Competence Continuity Acceptability
Accessibility
Effectiveness
Appropriateness
Efficiency

9. Policies and Procedures
■ Policies are guidelines or instructions on what
“needs to be done”
■ Guides for organizational strategies objectives
■ Policies are statements about pre-determined
courses of action

10. Patient Safety
The Reduction of unsafe acts within the health care system.
Patient safety is to Avoid, Manage and Treat unsafe acts within health care system.

11. Goal Areas:
Communication
Medication Use
Worklife
Infection Prevention and Control
Patient
Safety
Areas

12. Improve effectiveness among care providers
Goal:
Improve effectiveness among care providers
Safe administration of Drugs
Communication
Medication Use

13. Infection Prevention and Control
Goal:
Safe Physical Environment
Reduce Risk of Organization-Acquired Infection
Worklife
Infection Prevention and Control

14. Steps to Insure Patient Safety
Develop and Support the principles of patient safety.
Identify key individuals to be involved- key stakeholders.
Identify activities/action steps to develop and implement your patient safety program.
Make ongoing improvements to patient safety.

15. ROP Required Organization Practice
The practice that is expected to enhance Patient Safety and Minimize Risk.
ROP

16. ROP Required Organization Practice
An essential practice that organizations must have in place to enhance Patient / Client Safety and Minimize Risk.
ROP

18. Patient Safety Area Communication:
Client Verification: Implement a client verification protocol for all services and procedures.

19. Patient Safety
Communication

20. Patient Safety Area Communication
Medication Reconciliation: Reconcile the client’s medications upon admission to the organization (including the emergency department or patient units)
Control of Concentrated Electrolytes: Remove concentrated electrolytes from client service areas

21. Patient Safety Area Communication
Medication Reconciliation: Reconcile the client’s medications to prevent Adverse Drug Reactions.

22. Patient Safety Area Communication
Safe Surgical Practices: Develop a process and written protocol for preventing wrong- site, wrong –procedure and wrong-person strategy.

23. Patient Safety Area Worklife
Training on Patient Safety: Deliver training and education on patient safety at least annually to senior leaders, staff, service providers and volunteers.
e.g. Good system of Fire Drill.

24. Rescue persons in immediate danger Activate the alarm call
Patient Safety Area
Actions in case of Fire (RACE)
Rescue persons in immediate danger
Activate the alarm call
Contain the fire
Extinguish if safe and possible or
Evacuate the place

25. Patient Safety Area Hand Hygiene
Provide easy access and resources for staff to comply with recommended hand hygiene guidelines.

26. Patient Safety Area
Hand Hygiene: provide easy access and resources for staff to comply with recommended hand hygiene guidelines.

27. Patient Safety Area Infection Control
Injection Safety: develop safe injection protocols and practices in order to prevent harm to clients, health care workers and community.
Antibiotic Prophylaxis during surgery: Administer prophylactic antibiotics to prevent surgical site infections.

28. The Accreditation Canada Qmentum Program ROPs Safety Culture
Create a culture of safety within the organization
1. Adverse Events Reporting
Communication
Improve the effectiveness of communication among service providers and with the recipients of care.
2. Client Verification
3. Dangerous Abbreviations
4. Medication Reconciliation
5. Information Transfer
Infection Control
Reduce the risk of health care-associated infections
6. Hand Hygiene
7. Safe Injection Practice
Worklife/Workforce
Create a worklife and physical environment that supports the safe delivery of care
8. Education and Training
9. Falls Prevention Strategy

29. Some reasons Why Errors Occur
System Factors
Complexity of health care processes.
Complexity of health care work environments.
Lack of consistent administration practices.
Deferred maintenance.
Clumsy technology.
Human factors
Limited knowledge.
Poor application of knowledge.
Fatigue
Sub-optimal teamwork.
Attention distraction.
Inadequate training.
Reliance on memory.
Poor handwriting.

30. “Exercise” Patient Safety terms
Identify risks and processes before they happen. Bad outcome from care. Major and enduring loss of function. An examination of past events. Deficient process of care. Could have resulted in loss, injury or illness but did not.
1. Adverse Event 2. Medical Error 3. Sentinel Event 4. Near miss 5. Retrospective analysis 6. Prospective Analysis

31. Quality Improvement Plan

32. The PDCA P
PLAN D DO C
CHECK A
ACT

33. O V R
Occurrence
Variance
Report

34. OVR
What is OVR?
It is a process for reporting errors, deviations and improper actions.
When there is deviation from standards of care and safety.
Sentinel Events: death of the patient or loss of organ or function,
Near Miss: incident about to happen , but by chance it didn’t occur
Major incidents : revisable damage or risk for permanent loss

35. Reporting and Critical Test Notification:
The Lab will call the assigned person to notify certain critical tests
The nurse/Physician receiving the result must inform the attending physician /team leader immediately.
Patient call for action

36. Patient fall: what are you going to do?
Put the patient back on bed/chair
Check his vital signs and quick assessment
Inform the physician
Write an OVR

37. Patient suffering pain : What do you do:
Do Pain assessment
Use pain scale and document the grade
Inform the physician
Follow instruction and monitor pain intensity

38. CONCLUSION The Reduction of unsafe acts within the health care system.
Good system of Communication
Quality Improvement Plan
Occurrence Variance Report “OVR”

39. THANK YOU