Chapter 9 1 Patient Safety Introduction Patient safety
- Slides: 21
Chapter 9 [1] Patient Safety
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 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 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 Awareness Enhancement 5 2/28/2021
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 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 Checks Seeking Feedback ETM 591 8 2/28/2021
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 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 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 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
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. 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 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 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
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