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Patient Safety

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Patient Safety Prevention of Medical Errors – PowerPoint PPT presentation

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Title: Patient Safety


1
Patient Safety
  • Prevention of Medical Errors

2
Why are we here?
  • Concern over incidence of Medical Errors
  • IOM Report (1999)
  • To Err is Human, Building a Safer Healthcare
    System
  • Statistics
  • 44,000 98,000 Hospital deaths due to medical
    error each year

3
Why are we here?
  • To commit to paying greater attention to the
    problem
  • We make a difference one at a time
  • To evaluate current approaches
  • To build better systems to reduce the incidence
    of error

4
Why are we here?
  • 2001 FL Legislative response
  • FS 456.013
  • Mandates 2 hour course for ALL health care
    providers as part of licensure and renewal
    process
  • Course shall include the study of
  • root-cause analysis
  • error reduction
  • error prevention
  • patient safety

5
Why are we here?
  • FL BON Requirement
  • 64B9-5.011
  • Continuing Education on Prevention of Medical
    Errors

6
FL BON Requirement
  • Subject Areas
  • Factors that impact the occurrence of medical
    errors
  • Recognizing error-prone situations
  • Processes to improve patient outcomes
  • Responsibilities for reporting
  • Safety needs of special populations
  • Public education

7
Definitions
  • Error (IOM report)
  • The failure of a planned action to be completed
    as intended or the use of a wrong plan to achieve
    an aim
  • Error of Execution
  • Error of Planning

8
Definitions
  • Adverse Events
  • Injury caused by medical management rather than
    underlying disease condition
  • Unpreventable
  • Preventable

9
Definitions
  • Medical Error
  • Preventable adverse events with our current state
    of medical knowledge
  • Not defined as intentional act of wrongdoing
  • Not all rise to level of medical malpractice or
    negligence

10
Reporting Requirements
  • Florida Law requires all licensed facilities to
  • Have Internal Risk Management and incident
    reporting system
  • Report Serious Adverse Events to
  • AHCA Agency for Health Care Administration

11
Joint Commission
  • National organization
  • Mission to improve the quality of care in
    healthcare institutions
  • Provides Accredited status to healthcare
    facilities

12
Joint Commission
  • Defines Sentinel Event
  • An unexpected occurrence involving death of
    serious physical or psychological injury or risk
    thereof

13
Joint Commission
  • Sentinel events subject to review by Joint
    Commission
  • an event resulting in unanticipated death or
    major permanent loss of function not related to
    the underlying condition or if the event is one
    of the following

14
  • Suicide in setting with 24 hour care or within 72
    hours of discharge
  • Unanticipated death of a full-term infant
  • Abduction of any patient
  • Discharge of infant to wrong family
  • Rape
  • Hemolytic Transfusion Reaction involving blood
    group incompatibilities

15
Joint Commission
  • Requires
  • Process in place to recognize sentinel events
  • Credible root cause analysis
  • Focus on systems not individuals
  • Risk reduction strategies
  • Internal corrective action plan
  • Measure effectiveness of process
  • System improvements to reduce risk

16
Root Cause Analysis
  • Goal-directed, systematic process
  • uncovers basic factors that contribute to medical
    error
  • Focuses primarily on systems and processes and
    not individuals
  • Product of root cause analysis is an action plan
    to reduce risk of similar future events

17
Root Cause Analysis
  • Gather facts
  • Assemble team
  • Determine sequence of events
  • Identify causal factors
  • Select root causes
  • Take corrective action and follow-up plan

18
Joint Commission
  • Sentinel Event Statistics
  • Type
  • Setting
  • Outcome
  • Root Causes
  • And more
  • Sentinel Event Alerts
  • Periodic publication
  • Sharing information
  • To share information
  • To prevent medical errors/adverse events
  • Website http//www.jointcommission.org/

19
Sentinel Events by Type Dec. 31, 2006
  • 1. Wrong Site Surgery (13.1)
  • 2. Patient Suicide (12.8)
  • 3. Op/Post-op Complication(12.1)
  • 4. Medication Error (9.5)
  • 5. Delay in Treatment (7.4)
  • 6. Patient Fall (5.5)
  • 7. Patient death/injury in restraints
    (3.8)

20
Sentinel Events by Setting Dec. 31, 2006
  • 1. General Hospital (67.9)
  • 2. Psychiatric Hospital (10.8)
  • 3. Psych unit in general hosp. (4.9)
  • 4. Behavioral health facility (4.6)
  • 5. Emergency Dept. (3.9)
  • 6. Long Term Care Facility (3.0)
  • 7. Ambulatory Care (2.7)

21
Root Causes of ALL Sentinel Events 1995-2005
  • 1. Communication
  • 2. Orientation / Training
  • 3. Patient Assessment
  • 4. Staffing
  • 5/6. Availability of Info
  • Competency / Credentialing
  • 7. Procedural compliance
  • 8. Environmental Safety / Security

22
Root Causes of ALL Sentinel Events - 2006
  • 1. Communication
  • 2. Patient Assessment
  • 3. Leadership
  • 4. Procedural Compliance
  • 5. Environ. Safety / Security
  • 6. Competency / Credentialing
  • 7. Orientation / Training
  • 8. Availability of Info

23
Root Causes Wrong Site Surgery 1995-2004
  • 1. Communication
  • 2. Orientation / Training
  • 3. Procedural compliance
  • 4. Availability of Info
  • 5. Patient Assessment
  • 6. Leadership
  • 7. Competency / Credentialing
  • 8. Organizational Culture

24
Root Causes Wrong Site Surgery 2005
  • 1. Communication
  • 2. Procedural compliance
  • 3. Leadership
  • 4. Competency / Credentialing
  • 5. Availability of Info
  • 6. Organizational Culture
  • 7. Orientation / Training
  • 8. Patient Assessment Care Planning

25
Root Causes Wrong Site Surgery 2006
  • 1. Procedural compliance
  • 2. Communication
  • 3. Leadership
  • 4. Availability of Info
  • 5. Competency / Credentialing
  • 6. Orientation / Training
  • 7. Patient Assessment Organizational Culture
  • 8. Environmental Safety / Security

26
Root Causes Suicide 1995-2004
  • 1. Environmental Safety / Security
  • 2. Patient Assessment
  • 3. Orientation / Training
  • 4. Communication
  • 5. Availability of Information
  • 6. Continuum of Care
  • 7. Competency / Credentialing
  • 8. Staffing levels

27
Root Causes Suicide 2005
  • 1. Patient Assessment
  • 2. Environmental Safety / Security
  • 3. Communication
  • 4. Orientation / Training
  • 5. Competency / Credentialing
  • 6. Availability of Information
  • 7. Leadership
  • 8. Procedural Compliance Continuum of Care

28
Root Causes Op/Post-op Complications 1995-2004
  • 1. Orientation / Training
  • 2. Communication
  • 3. Procedural compliance
  • 4. Patient Assessment
  • 5. Staffing
  • 6. Competency / Credentialing Availability of
    Info
  • 7. Care Planning
  • 8. Leadership

29
Root Causes Op/Post-op Complications 2005
  • 1. Communication
  • 2. Patient Assessment
  • 3. Procedural compliance
  • 4. Care Planning
  • 5. Availability of Info
  • 6. Organizational Culture
  • 7. Competency / Credentialing
  • 8. Leadership

30
Root Causes Medication Error 1995-2004
  • 1. Communication
  • 2. Orientation / Training
  • 3. Competency / Credentialing
  • 4. Staffing
  • 5. Procedural Compliance
  • 6. Availability of Info
  • 7. Patient Assessment
  • 8. Environmental Safety Security Leadership

31
Root Causes Medication Error 2005
  • 1. Communication
  • 2. Procedural Compliance
  • 3. Competency / Credentialing
  • 4. Leadership Patient Assessment Orientation
    / Training
  • 5. Environ. Safety/Security
  • 6. Organizational Culture Staffing

32
Root Causes Delay in Tx. 1995-2004
  • 1. Communication
  • 2. Patient Assessment
  • 3. Continuum of Care
  • 4. Orientation / Training
  • 5. Availability of Info
  • 6. Competency / Credentialing
  • 7. Staffing
  • 8. Care Planning

33
Root Causes Delay in Tx. 2005
  • 1. Communication
  • 2. Patient Assessment
  • 3. Procedural Compliance
  • 4. Continuum of Care / Availability of Info
  • 5. Care Planning / Leadership
  • 6. Competency / Credentialing

34
Root Causes Patient Falls 1995-2004
  • 1. Orientation/Training
  • 2. Communication
  • 3. Patient Assessment
  • 4. Environmental Safety / Security
  • 5. Care planning
  • 6. Leadership Staffing
  • 7. Competency / Credentialing
  • 8. Availability of Info

35
Root Causes Patient Falls 2005
  • 1. Patient Assessment
  • 2. Communication
  • 3. Environmental Safety / Security
  • 5. Leadership
  • 6. Procedural Compliance
  • 7. Orientation / Training Care Planning
  • 8. Availability of Info Competency /
    Credentialing

36
Root Causes Restraint Injury/Death 1995-2004
  • 1. Orientation / Training
  • 2. Patient Assessment
  • 3. Communication
  • 4. Care Planning
  • 5. Staffing
  • 6. Competency / Credentialing
  • Availability of Info.
  • 7. Environmental Safety / Security
  • 8. Procedural Compliance
  • 9. Continuum of Care

37
Root Causes Restraint Injury/Death 2005
  • 1. Communication Patient Assessment
  • 2. Environmental Safety / Security
  • 3. Orientation / Training Competency /
    Credentialing
  • Availability of Info.
  • 4. Procedural Compliance Care Planning
  • 5. Leadership

38
Now What?
  • Learn from Knowledge of
  • Sentinel Event Statistics
  • Root Causes
  • Make Prevention a Priority
  • Make changes
  • Improve patient safety
  • Follow Joint Commission recommendations
  • Sentinel Event ALERT

39
Wrong Site Surgery Prevention
  • Clearly mark the operative site and involve the
    patient in the process
  • Require oral verification of the correct site in
    the OR by each member of the surgical team
  • Develop verification checklist that includes all
    documents

40
Wrong Site Surgery Prevention
  • Surgical teams consider taking a time out to
    verify patient, site, procedure using active
    communication
  • Ensure ongoing monitoring that verification
    process is followed

41
Inpatient Suicide Prevention
  • Identify/Remove/Replace non-breakaway hardware
  • Weight test all breakaway hardware
  • Revise procedures for contraband detection and
    include family and friends in process

42
Inpatient Suicide Prevention
  • Standardize suicide risk assessment/reassessment
    procedures
  • Enhance staff orientation and education
  • Ensure consistency in implementation of
    observation procedures

43
Inpatient Suicide Prevention
  • Redesign, retrofit, or introduce security
    measures
  • Revise information transfer procedures
  • Implement education for family and friends
    regarding suicide risk factors

44
Op/Post-Op Complications Prevention
  • Improve staff orientation and training
  • Educating and counseling physicians
  • Revising credentialing and privileging procedures
  • Clearly defining expected channels of
    communication

45
Op/Post-Op Complications Prevention
  • Standardizing procedures across settings of care
  • Revising the competency evaluation process.
  • Monitoring consistency of compliance with
    procedures

46
Op/Post-Op Complications Prevention
  • Implementing a teleradiology program
  • Correct placement of catheters and tubes should
    be verified with a test or x-ray

47
Medication Errors Prevention
  • Recognize High Alert Meds
  • Insulin
  • Opiates and Narcotics
  • Injectable Potassium Chloride
  • Intravenous Anticoagulants
  • Sodium Chloride Solutions above 0.9

48
Medication Errors Prevention
  • Follow the 5 (6) Rights of Medication
    Administration
  • Use 2 identifiers
  • Limit and institute Read Back policy of all
    verbal orders
  • Standardize Abbreviations

49
Medication Errors Prevention
  • Joint Commission abbreviations on the DO NO USE
    list
  • U for Unit write unit
  • IU for International Unit write international
    unit
  • QD, QOD Write daily or every other day

50
Medication Errors Prevention
  • Joint Commission abbreviations on the DO NO USE
    list
  • Trailing zero (X.0 mg.) write (X mg.)
  • Lack of leading zero (.X mg) - write (0.X mg)
  • MS, MSO4, MgSO4 - write morphine sulfate,
    magnesium sulfate

51
Medication Errors Prevention
  • Expand the DO NOT USE list
  • ug for microgram write mcg.
  • H.S. write out half strength or at bedtime
  • T.I.W. write 3 times weekly
  • S.C. of S.Q. write Sub-Q or subQ
  • D/C write discharge or discontinue
  • cc. write ml.

52
Medication Errors Prevention
  • Remove Potassium Chloride/Phosphate from floor
    stock
  • Standardize and limit drug concentrations
  • Move drug preparation off units and use
    commercially available premixed IV solutions

53
Medication Errors Prevention
  • Do not store heparin and insulin next to each
    other
  • System plan for sound alike and look alike meds
  • Educate staff about hydromorphone and morphine
  • Implement PCA protocols that involve
    double-checks of drug, pump setting and dosage

54
Medication Errors Prevention
  • Use only IV pumps with set-based free flow
    protection
  • Limit the variety of pumps available in the
    organization
  • Provide or ask for both brand and generic names
    of drugs for medication orders

55
Medication Errors Prevention
  • Provide the generic and brand name on all
    medication labels
  • Provide the patient with written information
    about their drugs which includes the brand and
    generic names

56
Medication Errors Prevention
  • Patient controlled analgesia by proxy
  • Develop criteria for selecting appropriate
    patients to receive PCA
  • Carefully monitor patients
  • Teach staff, patients and family members about
    dangers of pressing button for patient

57
Medication Errors Prevention
  • Using medication reconciliation to prevent errors
  • Process for obtaining and documenting complete
    list of current medications on admission/transfer/
    discharge
  • Create a process for reconciling medications at
    all interfaces of care

58
Delay in Treatment Prevention
  • Implement processes and procedures designed to
    improve the timeliness, completeness and accuracy
    of staff-to-staff communication
  • Implement face to face interdisciplinary
    change-of-shift debriefings
  • Reduce verbal orders and require read-back
    policy

59
Patient Falls Prevention
  • Standardize Assessment of Risk for Falls
  • Ongoing reassessment regarding risk
  • Orient staff to formal fall prevention protocols

60
Restraint Injury/Death Prevention
  • Redouble efforts to reduce use of physical
    restraints
  • Enhance staff education regarding alternatives to
    physical restraints
  • Develop structured procedures for consistent
    application of restraints

61
Restraint Injury/Death Prevention
  • Continuously observe patients in restraints
  • If patient is restrained in supine position,
    ensure head is free to rotate and HOB is
    elevated.
  • Do not restrain a patient in bed with unprotected
    split side rails

62
Creating a Culture of Safety
  • Understand human factors and system flaws
  • Make safety everyones responsibility
  • Report errors or near misses to decrease future
    error
  • Actively seek improvement to process

63
Creating a Culture of Safety
  • Know and understand the six major categories of
    negligence
  • Failure to follow standard of care
  • Failure to use equipment in proper, responsible
    manner
  • Failure to communicate, including inadequate
    transfer of information

64
Creating a Culture of Safety
  • Know and understand the six major categories of
    negligence
  • Failure to document properly
  • Failure to accurately assess and monitor
  • Failure to act as an advocate for the patient

65
Patient Responsibilities
  • Be an active member of the healthcare team
  • Make sure doctors know about all medicines you
    are taking
  • Make sure doctors know about your allergies or
    adverse reactions
  • When the doctor writes a prescription be sure you
    can read it

66
Patient Responsibilities
  • Ask for information about your medicine that you
    can understand
  • When pick up medicine from pharmacy, ask if this
    is the medicine your doctor prescribed
  • If you have any questions about the directions,
    ask!

67
Patient Responsibilities
  • Choose a hospital at which many patients have had
    the surgery or procedure you need
  • Ask care providers if they have washed their
    hands
  • Prior to surgery, make sure that you, your doctor
    and your surgeon all agree on what is to be done

68
Patient Responsibilities
  • Speak up if you have questions
  • Ask a family member or friend to be there with
    you to be your advocate
  • Learn about your condition and treatments by
    asking your doctor and using other reliable
    resources

69
2007 National Patient Safety Goals
  • Improve the accuracy of patient identification
  • Improve the effectiveness of communication among
    caregivers
  • Improve the safety of using medications
  • Reduce the risk of health care-associated
    infections.

70
2007 National Patient Safety Goals
  • Accurately and completely reconcile medications
    across the continuum of care
  • Reduce the risk of patient harm resulting from
    falls
  • Reduce the risk of influenza and pneumococcal
    disease in institutionalized older adults
  • Reduce the risk of surgical fires

71
2007 National Patient Safety Goals
  • Implementation of applicable NPSG and associated
    requirements by components and practitioner sites
  • Encourage patients active involvement in their
    own care as a patient safety strategy
  • Prevent health care-associated pressure ulcers
  • The organization identifies safety risk inherent
    in its patient population.
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