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Patient Safety 2018
What is Patient Safety? “The reduction and mitigation of unsafe acts within the health-care system, as well as through the use of best practices shown to lead to optimal patient outcomes”
Patient Safety Culture - “The way we do things around here” Just Culture: • Shared commitment to provide the safest care possible. (Vision) • Shared commitment to learn from adverse events • Shared commitment to continue to improve *Staff need to feel safe to report and learn from incidents
Common Patient Safety Issues • • • Medications errors Patient falls Recognition/knowledge of patient condition Communication breakdown Test result reporting Procedure error Not respecting/acknowledging Patients rights Documentation Poor workplace safety conditions Equipment/product use Confidentiality
Common Patient Safety Issues Medication errors and patient falls are two of the most frequent patient safety issues in health care.
Medication Errors There are many different types of medication errors • Patient receives wrong medication, wrong dose, doesn’t receive medication etc. • Many medication errors do not reach the patient • Caught by nurse before administration • Good catches but don’t want to solely rely on vigilance of staff to catch error before it reaches patient.
Patient Falls • Key priority at SMGH is to reduce patient falls. • Patients are most vulnerable to falls when disoriented or confused, frail elderly. • Patients who are confused or suffer dementia are far less likely to understand or comply with requests from staff to call for assistance before getting out of bed. • Many falls occur when patient exits the bed to go to the bathroom.
Communication Breakdowns • Communication breakdowns are a key contributor to many adverse events, examples include: • Changes in patient condition not communicated or noted when staff shift changes • Failure to note to properly review orders may result in missed orders or medications • A report failing to be sent or sent to the wrong physician.
What is an Adverse Event? An unexpected incident or circumstance which has caused (or has the capacity to cause) harm or death to an individual; loss or damage to property; or risk to the normal/usual operations of the hospital.
Reason’s Theory of Adverse Events Each slice of cheese is a defensive layer in the process/system. The holes are opportunities for the process/system to fail. When all the holes align for each step of the process the hazard defeats the defenses and causes and incident.
Systems Approaches to Patient Safety: • Are based on engineering principles • Recognize that there need to be multiple, independent barriers to prevent harm to patients. • Allow that even the most conscientious and professional will occasionally make errors • Improving patient safety cannot involve solely concentrating on the individuals who make errors • Design and change systems so that they are robust enough to withstand human error. • e. g. OR hose connectors that are designed so that the wrong host cannot be connected into the wrong outlet.
Hierarchy of Patient Safety
Patient Safety at SMGH • Foster a culture of quality & safety • Partner with patients and families in quality & safety • Adverse events analysis • Risk Management program • Process Improvement • Leadership Safety walks/weekly quality, risk & safety huddles • Daily unit quality, risk & safety huddles Patient safety strategies Infection Control strategies Policy review and education Continual Education opportunities • Leverage Technology • Safe product/equipment strategies • •
An Example of System Failure Do No Harm: Jess’ Story
Adverse Events • Range from in severity from near miss to patient death. • Can never be eliminated – goal is to reduce both the number and severity of adverse events. • Need to learn from adverse events • What type of incidents happen, when do they happen, where do they happen, why do they happen? • Target most severe incidents and most frequent incidents.
Recognize, Respond to and Disclose Adverse Events Incident Reporting • RL 6 (Electronic Incident Reporting) • Complaints, Staff injury, Patient events • Near miss reporting as well as harm Disclosure • SMGH Policy related to disclosure • Documentation guidelines • Patients appreciate transparent, honest, empathetic communication
Incident Analysis Framework What happens when I submit an incident report? 1. Manager investigates and follows up 2. Analysis of event - Contributing factors - Root cause analysis - Trending 3. Data reviewed at Quality and Operations Committees 4. Quality of Care Rounds (harm or risk) 5. Organizational spread of recommendations
Safe Practices There a variety of strategies put in place to increase patient safety: • • • Medication reconciliation Technologies (smart pumps, monitors) Policies Procedures and guideline Standard order sets Hand Hygiene
Your Role in Patient Safety View errors as opportunities for improvement Be aware of risks Seek assistance when unsure Speak up in unsafe situations Familiarize yourself with applicable policies Report adverse events Participate in patient care reviews and process improvements • Encourage patients/families to be involved in their health care • Get involved in patient safety initiatives • •
Safe Hospital for Staff and Patients St. Mary’s was recognized in 2017 by the Ministry of Labour as a Safe Hospital Workplace for staff and recognized as one of the safest acute care hospitals in Canada for patient mortality rates.
Joint Heath & Safety Committee (JHSC) Perform workplace inspections Meet monthly Members made up of (union, worker, management) Bulletin Board (members, minutes, reports, Health & Safety Policy Statement, Green Book) • Location of Safety Bulleting Board? • •
Your Workplace Safety Coordinators are: Robin Ridsdale ext. 4667 Tracey Dowhaniuk ext. 2680