Patient Safety & Risk Management Staff Orientation
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Transcript of 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.
22 NOVEMBER 2014 / [email protected]
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.
22 NOVEMBER 2014 / [email protected]
RISK MANAGEMENT PROCESS
1. Risk Identification
2. Risk Assessment
3. Risk Treatments
4. Review and Follow-
Up
22 NOVEMBER 2014 / [email protected]
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)
22 NOVEMBER 2014 / [email protected]
RISK ASSESSMENT
Potential
severity of
damage, loss
and
recurrence.
22 NOVEMBER 2014 / [email protected]
RISK TREATMENTS
Risk Avoidance
Risk Reduction
Risk Retention
Risk Transfer
22 NOVEMBER 2014 / [email protected]
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
22 NOVEMBER 2014 / [email protected]
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
22 NOVEMBER 2014 / [email protected]
Occurrence Variance Reporting
System (OVRS)
Addressed and followed through with
appropriate individuals and entities.
SYSTEMS RATHER
THAN INDIVIDUALS
IS THE FOCUS OF THE
OVR.
22 NOVEMBER 2014 / [email protected]
What to REPORT?
MEDICATION ERRORS
Procedure/Practice
Variance
Security-related
Safety-related
Patient Variance
Miscellaneous
22 NOVEMBER 2014 / [email protected]
Sample of OVR Data
22 NOVEMBER 2014 / [email protected]
Patient-Related Incidents
UNKNOWN
Near Miss
Minor
Moderate
Major
Severe
22 NOVEMBER 2014 / [email protected]
Barriers in reporting incidents
What’s in it for
me?
Individuals
rather
than
systems/proces
ses
Punitive
No feedback
22 NOVEMBER 2014 / [email protected]
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
22 NOVEMBER 2014 / [email protected]
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.
22 NOVEMBER 2014 / [email protected]
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
22 NOVEMBER 2014 / [email protected]
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
22 NOVEMBER 2014 / [email protected]
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.
22 NOVEMBER 2014 / [email protected]
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
22 NOVEMBER 2014 / [email protected]
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
22 NOVEMBER 2014 / [email protected]
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
22 NOVEMBER 2014 / [email protected]
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.
22 NOVEMBER 2014 / [email protected]
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.
22 NOVEMBER 2014 / [email protected]
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.
22 NOVEMBER 2014 / [email protected]
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
22 NOVEMBER 2014 / [email protected]
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.
22 NOVEMBER 2014 / [email protected]
Ibn Al Gumahad, BSN-RN
Coordinator, Patient Safety
059 – 272 – 6391
894-5524 EXT 571
Quality Management-MDH
THANK YOU
VERY MUCH !