Chapter 9 1 Patient Safety Introduction Patient safety

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Chapter 9 [1] Patient Safety

Chapter 9 [1] Patient Safety

Introduction Patient safety comprises the reporting, analysis and prevention of adverse healthcare events and

Introduction Patient safety comprises the reporting, analysis and prevention of adverse healthcare events and medical error. l Scary Facts: l – Patient-Safety related incidents cause harm in between 3% and 17% of hospital inpatients [4] – At least 50% of medical equipment in most developing countries is not in usable condition [3] ETM 591 2 2/28/2021

Agenda l In Chapter 9: – Current patient safety goals – Objectives from the

Agenda l In Chapter 9: – Current patient safety goals – Objectives from the assessment of safety cultures – How to implement a patient safety program – How to develop patient safety measures – Common safety analysis methods ETM 591 3 2/28/2021

Current Patient Safety Goals [2] l Enhance the accuracy of patient identification l Improve

Current Patient Safety Goals [2] l Enhance the accuracy of patient identification l Improve the safety of using medications l Minimize patient slips, trips and falls l Minimize surgical fire risks l Minimize health care-related infections l Enhance communication between caregivers ETM 591 4 2/28/2021

Objectives From the Assessment of Safety Cultures Profiling Accreditation Measuring Change ETM 591 Benchmarking

Objectives From the Assessment of Safety Cultures Profiling Accreditation Measuring Change ETM 591 Benchmarking Awareness Enhancement 5 2/28/2021

How to Implement a Patient Safety Program (8 -Step Process) l l l l

How to Implement a Patient Safety Program (8 -Step Process) l l l l Step 1: Step 2: Step 3: Step 4: Step 5: Step 6: Step 7: Step 8: ETM 591 Perform safety climate survey Educate staff members about safety education Survey staff members in regard to safety concerns Take an in-depth look Plan and implement necessary improvements Document the results Share the stories Repeat step 1 (safety climate survey) 6 2/28/2021

How to Develop Patient Safety Measures (6 -Step Process) l Step 1: Conduct a

How to Develop Patient Safety Measures (6 -Step Process) l Step 1: Conduct a systematic literature review l Step 2: Choose specific types of outcomes for evaluation l Step 3: Choose pilot measures l Step 4: Write design specifications for the measures l Step 5: Assess data validity and reliability l Step 6: Pilot test the measures ETM 591 7 2/28/2021

Common Safety Analysis Methods l Technic of Operation Review (TOR) Fire Drill Seat Belt

Common Safety Analysis Methods l Technic of Operation Review (TOR) Fire Drill Seat Belt Checks Seeking Feedback ETM 591 8 2/28/2021

Common Safety Analysis Methods Root Cause Analysis (RCA) l Also known as: “The 5

Common Safety Analysis Methods Root Cause Analysis (RCA) l Also known as: “The 5 Why’s” ETM 591 9 2/28/2021

Common Safety Analysis Methods l Root Cause Analysis (RCA) ETM 591 10 2/28/2021

Common Safety Analysis Methods l Root Cause Analysis (RCA) ETM 591 10 2/28/2021

Common Safety Analysis Methods l Hazard Operability Analysis (HAZOP) A HAZOP study is usually

Common Safety Analysis Methods l Hazard Operability Analysis (HAZOP) A HAZOP study is usually carried out by a team, Lead by an experienced member that is versed in both in the use of the HAZOP technique and the system under investigation. * Human Element is NOT the focus! ETM 591 11 2/28/2021

Common Safety Analysis Methods l Hazard Operability Analysis (HAZOP) ETM 591 12 2/28/2021

Common Safety Analysis Methods l Hazard Operability Analysis (HAZOP) ETM 591 12 2/28/2021

Common Safety Analysis Methods l Failure Modes and Effect Analysis (FMEA) Per System: •

Common Safety Analysis Methods l Failure Modes and Effect Analysis (FMEA) Per System: • Item(s) • Function(s) • Failure(s) • Effect(s) of Failure • Cause(s) of Failure • Current Control(s) • Recommended Action(s) ETM 591 13 2/28/2021

Common Safety Analysis Methods ETM 591 14 2/28/2021

Common Safety Analysis Methods ETM 591 14 2/28/2021

Common Safety Analysis Methods Fault Tree Analysis (FTA) l ETM 591 15 2/28/2021

Common Safety Analysis Methods Fault Tree Analysis (FTA) l ETM 591 15 2/28/2021

Common Safety Analysis Methods l Fault Tree Analysis (FTA) ETM 591 16 2/28/2021

Common Safety Analysis Methods l Fault Tree Analysis (FTA) ETM 591 16 2/28/2021

Summary – Current patient safety goals – Objectives from the assessment of safety cultures

Summary – Current patient safety goals – Objectives from the assessment of safety cultures – How to implement a patient safety program – How to develop patient safety measures – Common safety analysis methods ETM 591 17 2/28/2021

Where to Get More Information l http: //jama. ama-assn. org/cgi/content/full/280/16/1444 l http: //jama. amaassn.

Where to Get More Information l http: //jama. ama-assn. org/cgi/content/full/280/16/1444 l http: //jama. amaassn. org/cgi/content/full/jama%3 B 287/15/1993 l http: //muse. jhu. edu/journals/journal_of_health_care_fo r_the_poor_and_underserved/v 020/20. 1. dingham. html ETM 591 18 2/28/2021

Where to Get More Information l Dr. Joan Burtner – burtner_j@mercer. edu l l

Where to Get More Information l Dr. Joan Burtner – [email protected] edu l l ETM 591 Jason Coggins Jermaine Early Eric Hudnall Joshua Smith 19 2/28/2021

References [1] Dhillon, B. S. , (2008). Patient Safety. Reliability Technology, Human Error and

References [1] Dhillon, B. S. , (2008). Patient Safety. Reliability Technology, Human Error and Quality in Health Care (pp 129 – 139). Boca Raton, FL: CRC Press [2] National Patient Safety Goals. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO), 1 Renaissance Blvd. , Oakbrook Terrace, Illinois, 2007. Also available online at www. jointcommission. org/patientsafety /nationallpatientsafetygoals/07_npsg_facts. htm [3] Patient Safety, Fact Sheets. World Health Professions Alliance, April 2002. www. whapa/factptsafety. htm. [4] Sary, A. F. , Sheldon, T. A. , Cracknell, A. , Turnbull, A. Sensitivity of Routine System for Reporting Patient Safety Incidents in an NHS Hospital: Retrospective Patient Case Note Review. British Medical Journal 327 (2006): 432 -436. ETM 591 20 2/28/2021

Questions? ETM 591 21 2/28/2021

Questions? ETM 591 21 2/28/2021