PATIENT SAFETY

Justin MFIZIPatient Safety officer

KFH

HISTORY OF PATIENT SAFETY AND ORIGINS

Millennia ago, Hippocrates recognized the potential for injuries that arise from the well intentioned actions of healers.

Greek healers in the 4th Century B.C., drafted and pledged to "prescribe regimens for the Hippocratic oath Good of my patients according to my ability and my judgment and never do harm to anyone”.

This requires a new physician to swear upon a number of healing godsthat he will uphold a number of professional ethical standards.

Since then, the directive primum non nocere (“first do no harm”) hasbecome a central tenet for contemporary medicine

HISTORY OF PATIENT SAFETY AND ORIGINS(Cont’)

Therefore the frequency and magnitude of avoidable adverse patientevents was not well known until the 1990s, when multiple countriesreported staggering numbers of patients harmed and killed by medicalerrors.

Recognizing the healthcare errors impact , the World HealthOrganisation(WHO) calls patient safety an endemic concern.Indeed, patient safety has emerged as a distinct healthcare disciplinesupported by an immature yet developing scientific framework.

HISTORY OF PATIENT SAFETY AND ORIGINS(Cont’)

• Over the past ten years, patient safety has been increasingly recognized by several countries as an issue of global importance.

• Patient Safety in Rwanda is a new discipline. Currently it is being implemented as a program only at King Faisal Hospital, where it has taken as concern since November 2011.Therefore much effort is still required to establish patient safety in all hospitals.

PATIENT SAFETY OBJECTIVES

1. Prevent health care errors

2. Protect patient from harm resulted from healthcare errors

3. To increase awareness among the health care providers on

adverse health care.

4. To encourages disclosure and exchange of information in the

event of errors, near misses, and adverse outcomes.

DEFINITION

Patient safety is a subset of quality healthcare that emphasizes the reporting, analysis, and prevention of medical error that often leads to adverse healthcare.

FACTORS WHICH CAN LEAD TO HEALTHCARE ERROR

• Human factors

• Medical complexity

• System failures

• Inadequate communication

PATIENT SAFETY GOALS

1. Identify Patients Correctly

2. Improve Effective Communication

3. Improve the Safety of High-Alert Medications

4. Ensure Correct-Site, Correct-Procedure, Correct-

Patient Surgery

5. Reduce the Risk of Patient Harm Resulting from Falls

6. Reduce the risk of healthcare-associated infections

IDENTIFY PATIENT CORRECTLY

INTRODUCTION

Wrong-patient errors occur in virtually all stages of

diagnosis and treatment. The intent for this goal is to

reliably identify the individual as the person for whom

the service or treatment is intended and to match the

service or treatment to that individual when giving any

treatment or doing any procedure.

Failure to correctly identify the pt lead:

• Medication error• Transfusion error• Testing error• Wrong person procedure

PREVENTION MEASURES

1. Use at least 2 patient identifiers when administering

medication,blood,or blood components and when

providing treatments or procedures.

2. Label containers used for blood and other specimens in the

presence of the patient.

3. Eliminate transfusion errors related to patient

misidentification.

4. Develop policy and protocols on accurate patient

identification.

IMPROVE EFFECTIVE COMMUNICATION

INTRODUCTION

Effective communication essentially involves a heightened

sense of situational awareness and great listening

capability.

Effective communication is an art, which can be taught as

well as learned.

INTRODUCTION

The intent of this goal is to improve effective

communication through implementation of a process or

procedure for taking verbal or telephone orders or for

reporting critical test results that require a verification

"read back” of the complete order or test result by the

person receiving the information .

Factors contributing to miscommunications

Patient hand over between units and amongst care providers

Communication not including all the essential information

Poor misunderstand of information

Lack of good communication

Language barriers

Patient care orders given verbally and over telephone

Illegible orders

PREVENTION MEASURES

1. Develop written procedures for managing the critical results

of tests and diagnostic procedures.

2. Implement the procedures for managing the critical results

of tests and diagnostic procedures

3. Evaluate the timeliness of reporting the critical results of

tests and diagnostic procedures.

4. Develop written procedure on verbal and telephonic orders

IMPROVE THE SAFETY OF HIGH ALERT MEDICATIONS

INTRODUCTION

Medications are part of the patient treatment plan, appropriate management is critical to ensuring patient safety. Frequently cited medication safety issue is the intentional administration of concentrated electrolytes.

• Easy access

• Inadequate prescription

• Wrong ordering

• Inadequate preparation

• Poor distribution

• Inadequate labeling

• Poor verification

• Misadministration

• Frequency of administration

FACTORS INFLUENCING ERRORS

PREVENTIVE MEASURES

• Develop policy and/or procedure that prevents the location of concentrated electrolytes in patient care areas

• Ensure policies and procedure that address location, labeling and storage of concentrated electrolytes are implemented

ENSURE CORRECT-SITE , CORRECT-PROCEDURE, CORRECT –PATIENT SURGERY

INTRODUCTION

Wrong-site , wrong-procedure , wrong-patient surgery is a

disturbingly common occurrence in healthcare organization.

these errors are the result of ineffective or inadequate

communication between members of surgical team, lack of

patient involvement in site marking, and lack of procedures

for verifying the operative sits. The organization need to

collaboratively develop a policy and/or procedure that is

effective in eliminating this disturbing problem.

PROTOCOL

Universal protocol for wrong site, procedure and

surgery prevention is:

• Marking the surgical site

• A pre-operative verification process

• A time out that is held immediately before the start

of a procedure

REDUCE THE RISK OF HEALTH CARE ASSOCIATEDINFECTION

INTRODUCTION

Patients continue to acquire infections while receiving care , treatment and services in a health care organization. Risks and patient populations, however, differ between hospitals. Consequently health care-associated infections are a patient safety issue affecting all health care organization .Therefore, prevention and control strategies must be tailored to the specific needs of each hospital based on its risk assessment.

PROTOCOL

• Promote effective hand hygiene

• Comply with the general accepted hand-hygiene

guidelines

REDUCE THE RISK OF PATIENT HARM RESULTING FROM FALLS

INTRODUCTION

Falls account for a significant portion of injuries in hospitalized patient. In the context of the population it serves, the services it provides, and its facilities, the organization should evaluate its patients 'risk for falls and take action to reduce the risk of falling and to reduce the risk of injury should a fall occur.

1. Demographic and history

2. Diagnosis or conditions

3. Medications

4. Environmental and other

FALL RISK FACTORS

PROTOCOL

• Assess environmental factors and patient factors

which could lead to patient falls

• Develop protocols to prevent risk patient harm from

fall

• Implement protocols for preventing patient harm

resulted from falls

Thank you