Chapter 9 [1] Patient Safety

Introduction Patient safety comprises the reporting, analysis and prevention of adverse healthcare events and medical error. Scary Facts: –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] 2 ETM /25/2015

Agenda 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 10/25/ ETM 591

Current Patient Safety Goals [2] Enhance the accuracy of patient identification Improve the safety of using medications Minimize patient slips, trips and falls Minimize surgical fire risks Minimize health care-related infections Enhance communication between caregivers 10/25/ ETM 591

Objectives From the Assessment of Safety Cultures Profiling Benchmarking Awareness Enhancement Measuring Change Accreditation 10/25/ ETM 591

How to Implement a Patient Safety Program (8-Step Process) Step 1: Perform safety climate survey Step 2: Educate staff members about safety education Step 3: Survey staff members in regard to safety concerns Step 4: Take an in-depth look Step 5: Plan and implement necessary improvements Step 6: Document the results Step 7: Share the stories Step 8: Repeat step 1 (safety climate survey) 10/25/ ETM 591

How to Develop Patient Safety Measures (6-Step Process) Step 1: Conduct a systematic literature review Step 2: Choose specific types of outcomes for evaluation Step 3: Choose pilot measures Step 4: Write design specifications for the measures Step 5: Assess data validity and reliability Step 6: Pilot test the measures 10/25/ ETM 591

Common Safety Analysis Methods Technic of Operation Review (TOR) Fire Drill Seat Belt Checks Seeking Feedback 10/25/ ETM 591

Common Safety Analysis Methods Root Cause Analysis (RCA) Also known as: “The 5 Why’s” 10/25/ ETM 591

Common Safety Analysis Methods Root Cause Analysis (RCA) 10/25/ ETM 591

Common Safety Analysis Methods Hazard Operability Analysis (HAZOP) 10/25/ ETM 591 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!

Common Safety Analysis Methods Hazard Operability Analysis (HAZOP) 10/25/ ETM 591

Common Safety Analysis Methods Failure Modes and Effect Analysis (FMEA) Per System: 10/25/ ETM 591 Item(s) Function(s) Failure(s) Effect(s) of Failure Cause(s) of Failure Current Control(s) Recommended Action(s)

Common Safety Analysis Methods 10/25/ ETM 591

Common Safety Analysis Methods Fault Tree Analysis (FTA) 10/25/ ETM 591

Common Safety Analysis Methods Fault Tree Analysis (FTA) 10/25/ ETM 591

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 10/25/ ETM 591

Where to Get More Information assn.org/cgi/content/full/jama%3B287/15/ r_the_poor_and_underserved/v020/20.1.dingham.html 10/25/ ETM 591

Where to Get More Information Dr. Joan Burtner Jason Coggins Jermaine Early Eric Hudnall Joshua Smith 10/25/ ETM 591

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, Also available online at /nationallpatientsafetygoals/07_npsg_facts.htm [3] Patient Safety, Fact Sheets. World Health Professions Alliance, April [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): /25/ ETM 591

Questions? 10/25/ ETM 591