3 HA

1
????? 3 ???? ??? HA
???????? ?????????? ??????????????????????????????
?????
2
????????????????????????????????????????????????
??????????????????????
3
HA ??????????????? HA ??????????????????????????
???HA ??????????????????????????HA
?????????????????????????????????????????????????
?
4
??????????????????????????????? external
evaluation ???????????????????
???????????????????????????? ????? 3 ???? ??? HA
5
??????? 3 ?????????????? ?????????????????????????
????????? HA ???????????????????
?????????????????? ?????????????????????? ????????
????????? HA ??????????
??????? 2 ???????????????????? ???????????????????
?????????????????????? ???????????????????????????
??????????????????????? ??????????????????????????
??? ????????????????? HA ?????????????????????
??????? 1 ?????????????????????????
?????????????? ????????????????? ????????????????
???????????? ???????????????????????/?????????????
?
6
???????????????? 3 ???? ??? HA
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COMPETENCY
Refer/Against Advice
Nurse Practice
OUTCOME
PATIENT CARE PROCESS
Adverse Event (Safety) M/M, NI, Med Err,
Incident
Concurrent Daily Round (C3THER)
Medical Record Review
Measurable Clinical Indicator (Effectiveness)
Evidence-based Practice (Appropriateness )
Complaint (Acceptability)
Utilization Review (Efficiency)
???????????????????????
12
???????????????????????????????????

• ????????????
• ????????????
• ???????????
• ???????????

13
?????????????????????????????????????

• ????????
• ?????????????
• round ??????????? C3THER
• ????????????
• grand round ????????????????
• ????????? gap analysis
• ??????????
• ??????????????????
• ??????????????????
• ????????????????????????

14
??????????????????????????
15
?????????????????????????????????????

• ???????? ??????????????????????????????????
• ??????? (???????????)
• ??????????????????????????????
• ?????????????????????????????
• ?????????????????????????????
• ??????????????????????????????? Gap Analysis

16
?????????
??????????????
???????????
?????????????
???????
17
User Friendly Empowerment

• ????????????????????????????????????????????????
• ??????????????????????????????
• ??????????????????????????????????????????????????
  ???????
• ????????????????????????????????????
• ?????????????? ????????????????????????????????
• ??????????????????????????????????????????????????
  ?????????

18
??????????????????????????????????????????????
check list ?????????????? ????????????????????????
??????????????????????????????????????
19
???????????????????????? 1 ??? HA
?????????????????????????
20
Sentinel Event Prevention
21

• Strategies For Reducing The Risk Of Wrong-Site
  Surgeries
• ???????????????????????????????????????????
• ???????????????????????
• ?????????????????????????????????????
• ????? checklist ?????????????????
  ????????????????????
• ?????????????????????????? informed consent
• ???????????????????????????????????????
• high-risk procedures

22

• The most frequent complications by type of
  procedure
• ??? NG tube ???????? trachea ???? bronchus
• Massive fluid overload ???????????? irrigation
  fluids
• ????????????????? Uro/Gyn
• ??????????????????????????????????????? acute
  respiratory failure
• ??? cardiac arrest ????????????
• ????????????????????????????????????? ????????
  ???
• ?????? Central venous catheter
  ????????????????????
• ????? biopsy ??????? tube ?????? imaging ?????
  ?????????
• liver laceration, peritonitis, respiratory arrest
• Burns ??? electrocautery ??????????????
  flammable prep solution

23

• High-Alert Medications and Patient Safety
• insulin opiates and narcotics KCl conc IV
  heparin NaCl gt 0.9
• Suggested Strategies for insulin
• ????????????????
• (??????????????????? ?????????????????)
• ??????? insulin ??? heparin ??????????
• ???????? "units" ??? "U"
• Build in an independent check system for
• infusion pump rates and concentration settings

24

• Risk reduction strategies for Neonatal Jaundice
• AAP Practice Guidelines
• ????????????????????????? 24 ??. ??? ??????
• ????????????????????????????????
• ????????????????????????????????????
  ????????????????
• ?????
• ???? bilirubin ??????????? ??? nomogram
  ????????????/??????
• ????????????????????? bilirubin ???????????????
• ?????????????????????????????????????????????????
  ????????
• ???????????????????????????? 24-48 ??.
  ??????????????????
• ??????????????? ??????????????????????,
  ?????????, ?????????
• ?????????????????????????
• ???????????????????????????? -bilirubin
  lights/blankets, bilirubin test

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Failure Mode Effect Analysis
Phase I
Define the Process
Process Flow
Planning / Identify Team Members

Identify the Requirements/Function

Specifications Tolerances

Phase II
Identify the Characteristic
Process Characteristics Worksheet

Identify the Failures
Special/Common Causes


Detect/Prevent Current Controls
Phase III
Measure the Potential Failure
Process FMEA
Identify Action Results

Severity, Occurrence, Detection

Recommended Actions

Phase IV
Control the Process
Process Control Plan
Identify Gages/Frequency/Sample

Identify Machines, Jigs

Gage Plans/Error Proofing

Phase V
Audit the Process
Process Overview
Identify High Risk Characteristics


Error Proof the Process
Continuous Improvement

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Mission/Purpose
Outcome
????????????/??
??????????????/??????????/PDCA
??????????????????/??????
????????, ???????
????????????/???????
????????????????????, ????????????,
?????????????????
30
- ???????????- ???????????- ???????????-
???????????- ??????????- ?????????????-
???????????????

• ?????????????????????????????

? ?????????????? ??????????????????????
?????????????- Accessibility- Acceptability
(Satisfaction)- Appropriateness- Competency-
Continuity- Effectiveness- Efficiency- Safety
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32
???????? ????????
?????????????
??????????
???????????
?????????????
????????????
???????
?????????????
?????????????
???????????
?????????????
???????????
??????????? ???????
??????????? ?????????
??????????? ???????
?????????????
?????????? ????????????
?????????????
??????????????
SWOT analysis
?????????????
?????????????
??????????????
????????????????????
33
????????????????????????
???????????????????
???????
??????? ????????????????
??????? ????????????????
??????? ??????????
???? ???? ?????????? ???????? ????????? ??????????
? ????????????
?? ??? ?????? ??????? ???????????
??????????? ????????????
??????????? ?????????
??????????? ???????
Outcome
Process
??????????? ????????? 5
??????????? ????????? 4
??????????? ????????? 3
??????????? ????????? 2
??????????? ????????? 1
34
?????????????????????????????????????????
?????????? ?????????????????????????????????????
?????