PATIENT SAFETY

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• PATIENT SAFETY
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5

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  ???????.
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  ????? ??? ????? ? ???? ???!
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  ?????? ??? ???? ?

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• FIRST
• DO
• NO HARM

7
?????? ? ??????? ?????

• ???? ????? ????? ?????? IOM ??? ??????? 44
  ??98???? ????? ?? ??? ?????? ??????
• ???? ???????? ??? ?? 195???? ????? ???
• ???? ?????? 6 ????? ?? ????????!
• 5?? 6??? ??? ??? ?? ??????
• ????? ????? 10-12 ????? ?????
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  ??? ?? ????? ????? ?????? ?? ?????!
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  ???? ?? ????

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Professor James Reasons Swiss Cheese Model of
Error
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Layers of defenses
10
??? ?????
Fatalities Accidents Incidents Close Calls
??? ??? ??
????? ???? ?? ???
??? ????? ?????
????? ???? ?? ???? ????
?????? ?? ???? ?? ???? ????
?????? ??? ???? ?? ?????? ????? ????? ?????
??????? ???
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Blunt and Sharp End Model
?????
Sharp End
?????? ? ???????? ...
??????
???????? ? ???
The Messy Blunt End
????????? ????? (????)
????? ??????
?????? - ??????
????????? ???????
??????? ? ????????????
????? ?????
???????
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Elements

1. Medical treatment problem
2. Surgical treatment problem
3. Perinatal problem
4. Equipment problem
5. Medication error
6. Fall
7. Diagnostic/testing problem
8. Admission/transfer problem
9. Environment hazard
10. Behavior problem
11. Procedure problem
12. IV/transfusion problem
13. Injury other than fall

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NHS Seven Steps to Patient Safety

• ??? ???
• ????
• ????? ?????

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1

• Step 1 Build a safety culture
• ????? ????? ? ????????
• ????? ??? ? ??????? ???? ??????? ?? ????? ?????
  ????? ????

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2

• Step 2 Lead and support your staff
• ??????? ??? ?? ????? ? ????? ????
• ???? ???? ? ???? ?? ?????? ??? ?? ????? ?????
  ????? ? ????? ????

16
3

• Step 3 Integrate your risk management activity
• ?????? ?????? ??? ?? ?? ?? ? ??????? ????
• ???? ?????? ?????? ??????? ? ?????????? ?????
  ???? ? ????? ?? ??????? ? ??????? ??????.

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4

• Step 4 Promote reporting
• ????? ??? ?? ????? ???? ?????? ????
• ?? ??????? ??? ??? ??????? ?? ????? ?? ?? ??????
  ?? ????? ????? ?? ?? ??? ???? ? ??? ????? ????.

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5

• Step 5 Involve and communicate with patients and
  the public
• ???? ? ????? ?? ?? ????? ????????? ?? ???? ??????
  ?????? ????
• ??????? ?? ???? ??????? ?????? ???? ?? ???????
  ????? ? ?? ??? ???? ??? ????.

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6

• Step 6 Learn and share safety lessons
• ?????? ????? ?? ???????? ? ?? ?????? ?? ??? ????
• ??????? ?? ?? ????? ???? ?? ??? ????? ???? ?? ???
  ?????? ?? ??? ? ????? ????? ?? ?? ????

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7

• Step 7 Implement solutions to prevent harm
• ??? ???????? ?? ???? ??????? ?? ???? ???? ??????
  ????
• ??????? ?? ?? ?????? ??? ?? ????? ?? ???????
  ???????? ?? ????? ??????? ? ???? ?????.

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Safety Culture

1. Learning Culture
2. Flexible Culture
3. Reporting Culture
4. Just Culture
5. Informed Culture

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To Err Is Human

• ????? ???? ???????

23
???? ????? ???
???? ??? ?? ??????
????? ? ?????
???? ???? ????? ?? ??? ???? ? ???? ??? ????
????? ???? ?? ??? ??? ??? ??? ???? ??
???? ???? ?? ??? ???
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Research for Patient Safety
1 Measuring harm
5 Translating Evidence
2 Understanding causes
4 Evaluating impact
3 Identifying solutions
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WHO Patient Safety Challenges

• Health Care Acquired Infections
• ????????? ????? ????????? ?????? ??? ? ???????
  ???? (Hand Hygiene) (Safe Injection) ???? WHO
  ????? ??? ???.
• Unsafe Surgery
• ?? ???? ????? ????? ???? ???? WHO ????? ??? ???
  (Safe Surgery Checklist)

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(No Transcript)
27
??? ?? ???? ?? ????? 10 ???? ???? ????? ?????
????? ?? ??????

1. ????? ????? ??? ???? ???? ??? ????? ????
2. ????? ?????? (??????? ??????)
3. ???? ???? ?????? ????? ? ?????? ??????
4. ????? ????? ??? ?? ??? ????
5. ????? ???????? ?? ?????? ??????
6. ??????? ?? ????? ??? ??? ?????
7. ?????? ?? ??????? ???? ????? ????? ? ????? ?? ???
   ???
8. ????? ???? ??? ????? ???? ????? ??? ????? ??
   ?????????
9. ??????? ?????? ???? ??? ????? ???
10. ??????? ???? ?????? ???? ???? ??? ? ?????? ?????
    ????

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??????? ????? ????? Patient Safety Indicators

• ???? ??? ????? ?????? ????????? ????? ?? ?? ???
  ?????? ?? ??? ?????? ????? ?????? ???? ??????? ?
  ????? ? ????? (Outcome) ?? ???? ?? ????.
• ?? ???? ??? ?????? ?? ???? ?????? ?????? ????? ?
  ????? ????? ?? ??? ????? ?? ??? ?????? ?? ??????
  ???? ???.

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AHRQ ???? ??? ????? ?????

• 1-????? ??????
• 2-??? ?? ??????? ?????? (DRG) ?? ?????? ??? ?????
• 3-??? ????
• 4- ???? ?? ???? ?????
• 5-??? ????? ??? ????? ?? ??? ????? ?? ????? ???
  ?????
• 6-??????????? ?? ??? ?? ??????? ???? ??????
• 7-????? ??????? ?? ???? ?????? ??????
• 8-?????? ??? ??? ?? ??? ?????
• 9-?????? ?? ??????? ??? ?? ??? ?????
• 10-???????? ?????????? ? ???????? ??? ?? ???
  ?????

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AHRQ ???? ??? ????? ?????

• 11-??????? ????? ??? ?? ???
• 12- ?????? ???? ?? ??????? ???? ?????
• 13- ????? ??? ??? ?? ??? ?????
• 14- ??? ??? ??? ??? ?? ??? ????? ?? ??????? ?????
  ???? ? ????
• 15- ????? ? ????? ???? ??????
• 16- ????? ???? ?? ?????? ???
• 17- ???? ??? ????- ???? ?? ?????
• 18- ?????? ?????? ????? ?? ?????
• 19-?????? ?????? ????? ???? ?????
• 20-?????? ?????? - ??????

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(No Transcript)
32
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• ???? ??????? ?? ????? ???????? ?????? (96 ???
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  ???? ????? ??? ?? ?? ??? ???? ???? ?????? ? ?????
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  ?????? ????.
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• ?????? ?? ?? ??????? ? ??????? ??? ?? ???? ??????
  ?? ?????? ??? ???? ? ?? ????? ????? ??????
  ????????? ????.

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?? ???? ??????

• ????? ????? ????? ???-???????
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  ???? ????? ? ????? ????? ???? ?????? ????? ?? ???
  ????? ??? ??? ? ????? ?????? ??? ????? ????
  ??????? ???? ?????.
• (Root Cause Analysis)

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  (250 ???? ??????/?????? ??????)
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  ????? ????? ?? ??? ???)
• ???? ????? ??????????
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• ?????? ??? ????? ????? ???? ? ?????? ???
• ???? ???? ????? ????? ?? ????????? ??????
• ?????? ???????????? ??????? ????? ?????(PSFHI)

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?????? ???????????? ??????? ????? ?????Patient
Safety friendly Hospital Initiative

• ????? ???????????? ?????? ? EMRO? ???? ???? ????
  ?? ?????? ? ????? ????? ????? ??? ??? ??
  ?????????? ??????????????????? ???? ??? ?? ????
  ????????? ???? ????? ????? ????? ???.
• ????? ???? 7 ????????? ?? 7 ???? ???? ? EMRO
  ????? ????? ??? ?????? ?????.(????????????????????
  ????? ????????????)
• ?????? ?? ??????? ?? ??? ???? ?? WHO?
  10????????? ????????? ?????? ??? ?????? ????? ??
  ?? ???? ????? ????? ???? ?? ???? ? ??????? ????
  ???? ? ??????? ??? ?????? ? ????? ?????? ?????
  ???.
• ??? ??? ????? ??? ????? ? ????? ????? ??????? ??
  ???? ????.

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PSFHI Manual

• ?? ??? ?????? ?????? ????? ???????? ???? ???????
  ?????? ??????????? ?? ???????????? ?????
  ????????? ?????? ?? ???????????? ??????? ?????
  ????? ????? ?????? ???.
• Standards
• ??? ??????????? ?? ??? ????? ? ?????? ?? 3 ???
  ?????
• ???????????? ????? ?? ????? (Critical Criteria)
• ???????????? ????? (Core Criteria)
• ???????????? ????? ??(Developmental Criteria)

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Domains

• ??????????? ?? 5 ???? ?? ???? ???? ?? ?????
• ????? ? ?????? (Leadership and Management)
• ?????? ????? ? ?????
  (Patient Public Involvement)
• ????? ?????? ???? ????? ?? ?????
  (Safe Evidence Based Clinical Practice)
• ???? ????(Safe Environment)
• ??????? ????? (Lifelong Training)
• ?? ?????? ???????????? ????? ?? ??? 5 ???? ?? 3
  ??? ???????????? ?????? ?????? ???.

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Standards Standards Standards Sub domains Domains
Developmental Core Critical Sub domains Domains
7 20 9 6 A. Leadership and Management
10 16 2 7 B. Patient and Public Involvement
8 29 7 6 C. Safe Evidence based Clinical Practices
0 19 2 2 D. Safe Environment
5 6 0 3 E. Lifelong Learning
30 90 20 24 Total
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Scoring
Hospital Level Critical Standards Core Standards Developmental Standards
Level 1 100 Any Any
Level 2 100 60-89 Any
Level 3 100 90 Any
Level 4 100 90 80
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  ????? ????? (?????? ????? ???? ? ?????? ???)
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41

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