Patient Saftey

8/3/2019 Patient Saftey

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PATIENTSAFETY

STANDARDS

DrDrDrDr Y P BhatiaY P BhatiaY P BhatiaY P BhatiaManaging Director ASTRONManaging Director ASTRONManaging Director ASTRONManaging Director ASTRON

Founder Chairman INDIAN HEALTHCARE QUALITY FORUMFounder Chairman INDIAN HEALTHCARE QUALITY FORUMFounder Chairman INDIAN HEALTHCARE QUALITY FORUMFounder Chairman INDIAN HEALTHCARE QUALITY FORUM


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PATIENT SAFETYPATIENT SAFETYPATIENT SAFETYPATIENT SAFETY

Definition:Definition:Definition:Definition:

ActionsActionsActionsActions taken by individualstaken by individualstaken by individualstaken by individuals andandandand

organizations toorganizations toorganizations toorganizations to protect patientsprotect patientsprotect patientsprotect patients fromfromfromfrome n arme y e e ec se n arme y e e ec se n arme y e e ec se n arme y e e ec s oooo eaeaeaea

carecarecarecare services.services.services.services.

FREEDOM fromFREEDOM fromFREEDOM fromFREEDOM from UnintendedUnintendedUnintendedUnintended HealthHealthHealthHealthCare Errors / Injuries due to MedicalCare Errors / Injuries due to MedicalCare Errors / Injuries due to MedicalCare Errors / Injuries due to MedicalManagementManagementManagementManagement


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THE PARADOX:

First, do no HarmFirst, do no HarmFirst, do no HarmFirst, do no Harm

To Err is HumanTo Err is HumanTo Err is HumanTo Err is Human


4/21

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What ERRORS areWhat ERRORS areWhat ERRORS areWhat ERRORS are PatientsPatientsPatientsPatients exposed toexposed toexposed toexposed to ????

I. Products/ TechnologyI. Products/ TechnologyI. Products/ TechnologyI. Products/ Technology

DrugsDrugsDrugsDrugs:::: Reactions. FailuresReactions. FailuresReactions. FailuresReactions. Failures

Devices:Devices:Devices:Devices: Injections (Injections (Injections (Injections (75% of 2 Billions75% of 2 Billions75% of 2 Billions75% of 2 Billions UnsterilizedUnsterilizedUnsterilizedUnsterilized ))))

Machines ( Dialysis)Machines ( Dialysis)Machines ( Dialysis)Machines ( Dialysis)

5

II. ServicesII. ServicesII. ServicesII. Services:::: Health/medical practices:Health/medical practices:Health/medical practices:Health/medical practices:

Inpatient HAI,,Inpatient HAI,,Inpatient HAI,,Inpatient HAI,, Medication Error,Medication Error,Medication Error,Medication Error, wrong surgerywrong surgerywrong surgerywrong surgery

Inpatient &Inpatient &Inpatient &Inpatient & OutpatientOutpatientOutpatientOutpatient

nonnonnonnon---- personal services; Communication; Longer staypersonal services; Communication; Longer staypersonal services; Communication; Longer staypersonal services; Communication; Longer stay

III. EnvironmentIII. EnvironmentIII. EnvironmentIII. Environment of care:of care:of care:of care:

wastewastewastewaste managementmanagementmanagementmanagement


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RANGE OF HEALTH CARE ERRORS

Sentinel event = Serious incident

Minor incident

10%

H

arm

6

Near miss = Could have caused

harm but it did not this time

1 : 29 : 300


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PATIENT SAFETY AS A PUBLIC HEALTH RISK

A PROBLEM EVERYWHERE

The Relative RISKThe Relative RISKThe Relative RISKThe Relative RISK

Deaths Per 100 Million HoursDeaths Per 100 Million HoursDeaths Per 100 Million HoursDeaths Per 100 Million Hours

Being pregnantBeing pregnantBeing pregnantBeing pregnant 1111

7

Working at homeWorking at homeWorking at homeWorking at home 8888

Being in trafficBeing in trafficBeing in trafficBeing in traffic 50505050

Flying on a commercial airplane 100Flying on a commercial airplane 100Flying on a commercial airplane 100Flying on a commercial airplane 100

Being hospitalizedBeing hospitalizedBeing hospitalizedBeing hospitalized 2000200020002000


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PATIENT SAFETY:

THE ACCREDITORS TOOLS

StandardsStandardsStandardsStandards

DataDataDataData

GuidelinesGuidelinesGuidelinesGuidelines

Patient Safety GoalsPatient Safety GoalsPatient Safety GoalsPatient Safety Goals

EducationEducationEducationEducation


9/21

PATIENT SAFETY STANDARDS ANDJCILeaderships role in creating a culture of safetyLeaderships role in creating a culture of safetyLeaderships role in creating a culture of safetyLeaderships role in creating a culture of safety

Proactive system designProactive system designProactive system designProactive system design

ra n ng r entat onra n ng r entat onra n ng r entat onra n ng r entat on

CommunicationCommunicationCommunicationCommunication


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CRITICAL STEPS TO IMPROVEMENTS

IN PATIENT SAFETYIdentification of all adverse eventsIdentification of all adverse eventsIdentification of all adverse eventsIdentification of all adverse eventsAnalysis of each error to determine root causesAnalysis of each error to determine root causesAnalysis of each error to determine root causesAnalysis of each error to determine root causes

Compilation of data about error frequencies andCompilation of data about error frequencies andCompilation of data about error frequencies andCompilation of data about error frequencies andfrequencies of root causesfrequencies of root causesfrequencies of root causesfrequencies of root causes

Dissemination of derived information to permitDissemination of derived information to permitDissemination of derived information to permitDissemination of derived information to permitredesign of systems and processesredesign of systems and processesredesign of systems and processesredesign of systems and processes

Periodic assessment of effectiveness of riskPeriodic assessment of effectiveness of riskPeriodic assessment of effectiveness of riskPeriodic assessment of effectiveness of riskreduction effortsreduction effortsreduction effortsreduction efforts


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1.1.1.1. Potassium chloridePotassium chloridePotassium chloridePotassium chloride

2.2.2.2. Policy issuesPolicy issuesPolicy issuesPolicy issues3.3.3.3. Policy issuesPolicy issuesPolicy issuesPolicy issues4.4.4.4. Policy issuesPolicy issuesPolicy issuesPolicy issues5.5.5.5. Policy issuesPolicy issuesPolicy issuesPolicy issues6.6.6.6. Wrong site surgeryWrong site surgeryWrong site surgeryWrong site surgery7.7.7.7. SuicideSuicideSuicideSuicide8.8.8.8. Restraint deathsRestraint deathsRestraint deathsRestraint deaths9.9.9.9. Infant abductionsInfant abductionsInfant abductionsInfant abductions

21.21.21.21. Medical gas mixMedical gas mixMedical gas mixMedical gas mix----upsupsupsups

22.22.22.22. Needles & sharps injuriesNeedles & sharps injuriesNeedles & sharps injuriesNeedles & sharps injuries23.23.23.23. Dangerous abbreviationsDangerous abbreviationsDangerous abbreviationsDangerous abbreviations24.24.24.24. WrongWrongWrongWrong----site surgery #2site surgery #2site surgery #2site surgery #225.25.25.25. VentilatorVentilatorVentilatorVentilator----related eventsrelated eventsrelated eventsrelated events26.26.26.26. Delays in treatmentDelays in treatmentDelays in treatmentDelays in treatment27.27.27.27. Bed rail deaths & injuriesBed rail deaths & injuriesBed rail deaths & injuriesBed rail deaths & injuries28.28.28.28. NosocomialNosocomialNosocomialNosocomial infectionsinfectionsinfectionsinfections29.29.29.29. Surgical firesSurgical firesSurgical firesSurgical fires

SENTINEL EVENT ALERT

.... 11.11.11.11. High Alert MedicationsHigh Alert MedicationsHigh Alert MedicationsHigh Alert Medications12.12.12.12. Op/postOp/postOp/postOp/post----op complicationsop complicationsop complicationsop complications13.13.13.13. Impact ofImpact ofImpact ofImpact ofSE AlertSE AlertSE AlertSE Alert14.14.14.14. Fatal fallsFatal fallsFatal fallsFatal falls

15.15.15.15. Infusion pumpsInfusion pumpsInfusion pumpsInfusion pumps16.16.16.16. Proactive risk reductionProactive risk reductionProactive risk reductionProactive risk reduction17.17.17.17. Home fires (OHome fires (OHome fires (OHome fires (O2222 therapy)therapy)therapy)therapy)18.18.18.18. KernicterusKernicterusKernicterusKernicterus19.19.19.19. LookLookLookLook----alike/soundalike/soundalike/soundalike/sound----alike drugsalike drugsalike drugsalike drugs20.20.20.20. KreutzfeldtKreutzfeldtKreutzfeldtKreutzfeldt----Jakob diseaseJakob diseaseJakob diseaseJakob disease

....31.31.31.31. Anesthesia awarenessAnesthesia awarenessAnesthesia awarenessAnesthesia awareness32.32.32.32. KernicterusKernicterusKernicterusKernicterus #2#2#2#233.33.33.33. PCA by proxyPCA by proxyPCA by proxyPCA by proxy34.34.34.34. IntrathecalIntrathecalIntrathecalIntrathecal vincristinevincristinevincristinevincristine

35.35.35.35. Medication reconciliationMedication reconciliationMedication reconciliationMedication reconciliation36.36.36.36. Wrong route / wrong tubeWrong route / wrong tubeWrong route / wrong tubeWrong route / wrong tube37.37.37.37. Emergency power failureEmergency power failureEmergency power failureEmergency power failure38.38.38.38. MRIMRIMRIMRI----related injuriesrelated injuriesrelated injuriesrelated injuries39.39.39.39. Pediatric medication errorsPediatric medication errorsPediatric medication errorsPediatric medication errors40.40.40.40. Assaults & homicidesAssaults & homicidesAssaults & homicidesAssaults & homicides


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INTERNATIONAL PATIENT SAFETY

GOALS (JCI)

Modeled on the National Patient Safety Goals ofModeled on the National Patient Safety Goals ofModeled on the National Patient Safety Goals ofModeled on the National Patient Safety Goals of

The Joint CommissionThe Joint CommissionThe Joint CommissionThe Joint Commission

JCI sought and received input on the goals fromJCI sought and received input on the goals fromJCI sought and received input on the goals fromJCI sought and received input on the goals from,,,,

accreditation, consultants, and surveyorsaccreditation, consultants, and surveyorsaccreditation, consultants, and surveyorsaccreditation, consultants, and surveyors

Feedback represents 19 different countriesFeedback represents 19 different countriesFeedback represents 19 different countriesFeedback represents 19 different countries

Majority of respondents felt that the Goals areMajority of respondents felt that the Goals areMajority of respondents felt that the Goals areMajority of respondents felt that the Goals are

appropriate and achievableappropriate and achievableappropriate and achievableappropriate and achievable


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INTERNATIONAL PATIENT SAFETY GOALS

(2011) AS JCI TOOL

Identify Patients CorrectlyIdentify Patients CorrectlyIdentify Patients CorrectlyIdentify Patients Correctly

Improve Effective CommunicationImprove Effective CommunicationImprove Effective CommunicationImprove Effective Communication

Improve the Safety of HighImprove the Safety of HighImprove the Safety of HighImprove the Safety of High----Alert MedicationsAlert MedicationsAlert MedicationsAlert Medications

Ensure Correct Site, correct procedure, CorrectEnsure Correct Site, correct procedure, CorrectEnsure Correct Site, correct procedure, CorrectEnsure Correct Site, correct procedure, Correct

....

Reduce the risk of health careReduce the risk of health careReduce the risk of health careReduce the risk of health care----acquiredacquiredacquiredacquired

infectionsinfectionsinfectionsinfections

Reduce the risk of patient harm resulting fromReduce the risk of patient harm resulting fromReduce the risk of patient harm resulting fromReduce the risk of patient harm resulting fromfallsfallsfallsfalls


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PATIENT SAFETY STANDARDS AND NABH

NABH standards are related to patient safety:NABH standards are related to patient safety:NABH standards are related to patient safety:NABH standards are related to patient safety:

COPCOPCOPCOP COP7, COP 12 (d), , COP 12 (j), COP 13,COP7, COP 12 (d), , COP 12 (j), COP 13,COP7, COP 12 (d), , COP 12 (j), COP 13,COP7, COP 12 (d), , COP 12 (j), COP 13,

MOMMOMMOMMOM---- MOM 3 (e), MOM 4, MOM6, MOM 8MOM 3 (e), MOM 4, MOM6, MOM 8MOM 3 (e), MOM 4, MOM6, MOM 8MOM 3 (e), MOM 4, MOM6, MOM 8

HICHICHICHIC---- HIC 4HIC 4HIC 4HIC 4---- , ,, ,, ,, ,

ROMROMROMROM---- ROMROMROMROM---- 5555

FMSFMSFMSFMS---- FMS 2, FMS 5, FMS 6, FMS 7, FMS 8, FMS 9.FMS 2, FMS 5, FMS 6, FMS 7, FMS 8, FMS 9.FMS 2, FMS 5, FMS 6, FMS 7, FMS 8, FMS 9.FMS 2, FMS 5, FMS 6, FMS 7, FMS 8, FMS 9.


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PATIENT SAFETY STANDARDS OF NABH -

COP

COP 7: Policies and procedures guide the care of

vulnerable patients (elderly, children, physically and/or

mentally challenged)

COP 12 (d): Documented policies and procedures exist to

prevent adverse events like wrong site, wrong patient

COP 12 (j): The plan also includes monitoring of surgical

site infection rates

COP 13: Policies and procedures guide the care of

patients under restraints (physical and/or chemical)


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PATIENT SAFETY STANDARDS OF NABH

MOM AND HICMOM 3 (e): Sound alike and look alike medications arestored separately

MOM 4: Policies and procedures exist for prescription ofmedications

MOM6: There are defined procedures for medicationadministration.

MOM 8: Patients are monitored after medicationadministration.

HIC 4: The organization takes actions to prevent orreduce the risk of Hospital Associated Infections (HAI) inpatients and employees.


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PATIENT SAFETY STANDARDS OF NABH CQI

AND ROMCQI 2: The organization identifies key indicators tomonitor the clinical structures, processes and outcomeswhich are used as tools for continual improvement.

CQI 3:The organization identifies key indicators tomonitor the managerial structures, processes andoutcomes which are used as tools for continualimprovement.

CQI 6: Sentinel events are intensively analysed.

ROM 5: Leaders ensure that patient safety aspects andrisk management issues are an integral part of patientcare and hospital management


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PATIENT SAFETY STANDARDS OF NABH

FMSFMS 2: The organizations environment and facilities

operate to ensure safety of patients, their families, staff

and visitors.

FMS 5: The organization has plans for fire and non-fire

emergencies within the facilities. : e or an za on as a smo n m a on po cy.

FMS 7: The organization plans for handling community

emergencies, epidemics and other disasters.

FMS 8: The organization has a plan for management of

hazardous materials.

FMS 9: The organisation has systems in place to provide

a safe and secure environment.


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PATIENT SAFETY MEASUREMENTS IN

NABH

Patient fallPatient fallPatient fallPatient fall

Patient Bed soresPatient Bed soresPatient Bed soresPatient Bed sores

Adverse Drug reactionsAdverse Drug reactionsAdverse Drug reactionsAdverse Drug reactions

Medication errorsMedication errorsMedication errorsMedication errors

Adverse events analysisAdverse events analysisAdverse events analysisAdverse events analysis

Sentinel and near miss event analysisSentinel and near miss event analysisSentinel and near miss event analysisSentinel and near miss event analysis

Hospital acquired infection rates (RTI,UTI,IVDRI,SSI)Hospital acquired infection rates (RTI,UTI,IVDRI,SSI)Hospital acquired infection rates (RTI,UTI,IVDRI,SSI)Hospital acquired infection rates (RTI,UTI,IVDRI,SSI)

Variations observed in mock drillsVariations observed in mock drillsVariations observed in mock drillsVariations observed in mock drills

Security related incidences including theftsSecurity related incidences including theftsSecurity related incidences including theftsSecurity related incidences including thefts


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Our achievements of levels of Patient SafetyOur achievements of levels of Patient SafetyOur achievements of levels of Patient SafetyOur achievements of levels of Patient Safety

AreAreAreAre

Directly Proportional ToDirectly Proportional ToDirectly Proportional ToDirectly Proportional To

Level of Compliances achieved in meeting theLevel of Compliances achieved in meeting theLevel of Compliances achieved in meeting theLevel of Compliances achieved in meeting theStandardsStandardsStandardsStandards

LET US STRIVE TO ACHIEVE 100% COMPLIANCE TOLET US STRIVE TO ACHIEVE 100% COMPLIANCE TOLET US STRIVE TO ACHIEVE 100% COMPLIANCE TOLET US STRIVE TO ACHIEVE 100% COMPLIANCE TOPATIENT SAFETY STANDARDSPATIENT SAFETY STANDARDSPATIENT SAFETY STANDARDSPATIENT SAFETY STANDARDS

BECAUSEBECAUSEBECAUSEBECAUSE

WE ALL NEED THEMWE ALL NEED THEMWE ALL NEED THEMWE ALL NEED THEM


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THANK YOU FOR YOUR VALUABLE TIME

Hospital & Health Care Consultants

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