1. SHOPS is funded by the U.S. Agency for International Development. Abt Associates leads the project in collaboration with Banyan Global Jhpiego Marie Stopes International Monitor Group O’Hanlon Health Consulting Business for Health Business Skills for Private Medical Practices Module 12: Establish a Patient-Safety Culture

2. A Quick Start Welcome! While you are waiting for the class to begin, please take the Pre-Test and make sure your name is on it before you hand it to the facilitator. While you are waiting for the class to begin, please take the Pre-Test and make sure your name is on it before you hand it to the facilitator. Thank you!. 2Business Skills for Private Medical Practices

3. Agenda Welcome The Consequences of Silence A Patient-Safety Culture How to Create a Patient-Safety Culture How to Handle Patient-Safety Issues Summary and Evaluation Close 3Business Skills for Private Medical Practices

4. Learning Objectives During this session, you will: 1.define the adverse events that can affect patients, visitors, and/or staff; 2.review the consequences when adverse incidents that affect patients, visitors and/or staff are not reported; 3.define a “patient-safety culture;” 4Business Skills for Private Medical Practices

5. Learning Objectives 4.describe an Incident Reporting System; 5.explain how to set up an Incident Reporting System; 6.plan how to promote a patient-safety culture; 5Business Skills for Private Medical Practices

6. Always follow your national clinical guidelines and protocols Business Skills for Private Medical Practices6

7. Learning Objectives 7.propose how to manage patient-safety issues; 8.discuss the next step; and 9.state your key take-away from this session. 7Business Skills for Private Medical Practices

8. Introduction You will have 1 minute to introduce yourself: 1.Your name 2.Your position 3.Your business 4. How long you have been in business 8Business Skills for Private Medical Practices

9. The Consequences of Silence Business Skills for Private Medical Practices 9

10. Health Care Incidents Possible Adverse Event Why Staff Might Not Report It What Might Happen if This is Not Reported A patient, staff member or visitor falls 10Business Skills for Private Medical Practices

11. A Patient-Safety Culture Business Skills for Private Medical Practices 11

12. What is a Patient-Safety Culture If you have an answer to the questions below, please stand up: 1. What is a patient-safety culture? 2. If you ever worked in a healthcare institution where there was an effective patient-safety culture, what did it involve? 12Business Skills for Private Medical Practices

13. An Incident-Reporting System: Purpose A patient-safety culture emphasizes the safety of patients, staff and visitors. This is accomplished through a program that encourages reporting: an Incident Reporting System. 13Business Skills for Private Medical Practices

14. An Incident-Reporting System: Description A tool for identifying events (incidents) that indicate the need for closer risk management, safety, and/or quality review. The goal is to learn from the event to improve, not to find fault. 14Business Skills for Private Medical Practices

15. An Incident-Reporting System: Five Components 1.Incident Report Form 2.Incident reporting procedure 3.Follow-up investigation 4.Problem-solving patient safety conference with staff 5.Action taken to eliminate or minimize the recurrence of a similar incident 15Business Skills for Private Medical Practices

16. An Incident-Reporting System: What to Report and Investigate 1.All events that are “out-of-the-ordinary” 2.All events that are a breech of policies, procedures, or standards of practice 3.Any adverse incident that did or could have affected safety and well-being 4.Rare events with great clinical significance 5.Frequently occurring errors 16Business Skills for Private Medical Practices

17. What to Report: Sentinel Event Any unanticipated occurrence involving death or major permanent loss of function that is unrelated to the natural course of the patient’s illness. For example: Due to an incomplete patient record, a patient is given an antibiotic to which the patient was allergic, causing a serious reaction & emergency hospitalization. 17Business Skills for Private Medical Practices

18. What to Report: Near Miss Event An event where there is a process variation that did not affect the outcome for a patient, but if repeated could result in a serious adverse outcome for another patient in a similar circumstance. For example: A pharmacist realizes that a pediatric patient has been given a prescription that indicates an adult dose. 18Business Skills for Private Medical Practices

19. What to Report: Patient Treatment Error For example: A patient’s blood pressure is not monitored during pregnancy, resulting in unanticipated complications at delivery. For another example: A clinician orders a radiology study of a right breast for a mass detected in the left breast. 19Business Skills for Private Medical Practices

20. What to Report: Incident Involving Family or Visitors For example: A drunken husband is abusive to his wife and staff during a prenatal visit. For another example: A visitor slips and falls on a wet floor and breaks his hip. 20Business Skills for Private Medical Practices

21. What to Report: Incident Involving Staff For example: A nurse is punctured by a needle. Another example: Staff is observed failing to wash hands between patients. 21Business Skills for Private Medical Practices

22. What to Report: Administrative Incident For example: The laboratory results for Patient X are filed in Patient Y’s chart. Another example: The proper procedures for storage of pharmaceutical supplies are not followed. Medicines that require 30° C are in a storeroom with temperatures that go over 38° C. 22Business Skills for Private Medical Practices

23. Do Not File or Mention Incident Reports in the Patient Medical Record DO NOT FILE Incident Reports in the patient medical record or make any mention in the patient medical record that an incident report was generated. This is to protect you against any lawsuit resulting from a serious incident. 23Business Skills for Private Medical Practices

24. Conduct a Patient Safety Conference Staff responsible for the event and for managing these events need to: 1.evaluate the root causes of the problem 2.re-design relevant procedures and/or processes 3.implement the changes 4.review whether the changes resolved future problems 24Business Skills for Private Medical Practices

25. Incident Report Form  Date of incident  Location of incident  People involved in incident  Describe what happened  Describe immediate response to the event  What is unknown at this time? 25Business Skills for Private Medical Practices

26. Incident Report Form  What other systems/processes affected?  What was done to minimize the impact?  Staff person completing this form  Date 26Business Skills for Private Medical Practices

27. Recognizing Incidents  Sentinel Event  Near Miss Event  Patient Treatment Error  Incident Involving Family or Visitors  Incident Involving Staff  Administrative Incident 27Business Skills for Private Medical Practices

28. Recognizing Incidents Scenario #1: 28Business Skills for Private Medical Practices

29. Recognizing Incidents Scenario #1: Incident Involving Staff Scenario #2: 29Business Skills for Private Medical Practices

30. Recognizing Incidents Scenario #1: Incident Involving Staff Scenario #2: Patient Treatment Error Scenario #3: 30Business Skills for Private Medical Practices

31. Recognizing Incidents Scenario #1: Incident Involving Staff Scenario #2: Patient Treatment Error Scenario #3: Sentinel Event 31Business Skills for Private Medical Practices

32. Recognizing Incidents Scenario #4: 32Business Skills for Private Medical Practices

33. Recognizing Incidents Scenario #4: Incident Involving Family or Visitors Scenario #5: 33Business Skills for Private Medical Practices

34. Recognizing Incidents Scenario #4: Incident Involving Family or Visitors Scenario #5: Administrative Incident Scenario #6: 34Business Skills for Private Medical Practices

35. Recognizing Incidents Scenario #4: Incident Involving Family or Visitors Scenario #5: Administrative Incident Scenario #6: Near Miss Event 35Business Skills for Private Medical Practices

36. How to Create a Patient-Safety Culture Business Skills for Private Medical Practices 36

37. How to Establish a Patient-Safety Culture 1.How can you convince staff that it is important to report incidents? 2.How can you encourage staff to report incidents? 3.What do staff need so they are able to recognize that an adverse incident has or has almost occurred? 37Business Skills for Private Medical Practices

38. How to Establish a Patient-Safety Culture 4.Who should be responsible for reviewing and trending incident reports? 5.Who should be responsible for investigating incidents? 6.How should staff be involved in problem solving activities? 7.How should the results of policy and procedural changes be monitored? 38Business Skills for Private Medical Practices

39. Promoting a Patient-Safety Culture Create a poster on a flip chart that promotes a patient-safety culture through incident reporting, using both words and pictures. 39Business Skills for Private Medical Practices

40. How to Handle Patient-Safety Issues Business Skills for Private Medical Practices 40

41. Case: The Pediatric Critical Care Unit a.Identify the key issues involved; b.Classify the type(s) of incident(s) that occurred; c.Conduct a root cause analysis to determine the contributing factors; and d.Recommend corrective actions. Business Skills for Private Medical Practices41

42. Case: The Pediatric Critical Care Unit a.Identify the key issues involved: 1. Negligence 2. Non-adherence to protocol Business Skills for Private Medical Practices42

43. Case: The Pediatric Critical Care Unit b.Classify the type(s) of incident(s) that occurred: 1. Near Miss Event 2. Administrative Incidents Business Skills for Private Medical Practices43

44. Case: The Pediatric Critical Care Unit c.Conduct a root cause analysis: Business Skills for Private Medical Practices44

45. Case: The Pediatric Critical Care Unit d.Recommend corrective actions:  Remind doctors to: 1. read the patient file on transfer from one care area to another. 2.prescribe medication on the treatment sheet as well as document it in the patient file. Business Skills for Private Medical Practices45

46. Case: The Pediatric Critical Care Unit d.Recommend corrective actions:  Make sure all visiting consultants receive the same information about transfers and prescriptions. Business Skills for Private Medical Practices46

47. Case: The Pediatric Critical Care Unit d.Recommend corrective actions:  Make sure the PCAs understand the urgency and importance of giving priority to delivering treatment sheets to the pharmacy, collecting the medications and bringing them back to the PCCU. Business Skills for Private Medical Practices47

48. Case: The Pediatric Critical Care Unit d.Recommend corrective actions:  Alert all pharmacy staff to call the PCCU as soon as the medication has been dispensed, so it can be collected.  Create a tracking sheet to monitor the movements of the treatment sheet Business Skills for Private Medical Practices48

49. Summary and Evaluation Business Skills for Private Medical Practices 49

50. Evaluation Sheet 50Business Skills for Private Medical Practices

51. The Next Step 1.Discuss a patient-safety culture and Incident Reporting System with staff. 2.Implement an Incident Reporting System. 51Business Skills for Private Medical Practices

52. Let’s See How Much You’ve Learned Please take the Post-Test. We will compare it to your Pre-Test to see how much you’ve learned in this session. Thank you. Business Skills for Private Medical Practices52

53. My Key Take-Away 53Business Skills for Private Medical Practices