1. Action Plan Development

2. Action plan for PSFH improvement
Elements of the action plan
Define the problem, or the standard
Define steps and procedures ,activities
or action
Define the responsible person
Define the time needed to solve the problem
Develop a monitoring strategy

3. How to develop Patient Safety Action Plan?
How to comply to standard?
Who will develop it?
When will it be developed?
How will you monitor?

4. Action Plan Draft Measures Responsible person Actions Time frame
End time
Monitoring
Strategy
Measures
A. Leadership and Governance
A Hospital has designated a senior staff member with responsibility, accountability and authority for patient safety.
PSO
Develop PSO terms of reference
20.09\2009
A The leadership conducts regular Patient Safety Executive Walk to promote patient safety culture, learn about risks in the system, and act on patient safety improvement opportunities.
Dr.Atef El Nimri
establish a team to plan the schedule of rounds and action taken
17.09\2009
A The hospital conducts regular monthly morbidity and mortality meetings.
Hospital Director(Dr.Braizate)
Establish a committee with TOR including the schedule for meetings
01.10\2009
A The hospital ensures availability of essential equipment.
Hospital Director(Dr.Braizate),nursing manager
Review the list to ensure that emergency cart are available in all departments
30.10\2009

5. What are the patients identifiers
What are the patients identifiers? How does hospital verify its patients? How are high risk groups e.g. new born babies, patients in coma, senile patients identified?
HOW?WHO?WHEN?HOW TO MONITOR?

6. How does the hospital maintain clear channels of communication for urgent critical results?
How? Who? When?

7. How does the hospital monitor and implement guidelines, on safe blood and blood products?
WHO?WHEN?HOW?

8. How does the hospital ensure availability of life saving medications at all times?

9. How to ensure proper segregation of hospital’s waste?
WHO?WHEN?HOW?

10. How does the hospital conform to guidelines on management of sharps waste?
Who? When? How?

11. Thank you for your attention
Injy Khorshid,MBBCh,MPA,FAIHQ,CHS