1. Patient Safety 2018

2. 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”

3. Patient Safety Culture
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
St. Mary’s tries to foster a patient safety culture – one in which staff are encouraged to highlight safety issues and participate in problem solving to eliminate or decrease safety issues. The focus is on improving systems rather than solely focusing on the individuals errors lead to adverse events. Only by learning from errors and incidents does the Hospital have a chance of meeting it’s vision and commitment to provide the safest care possible.

4. 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
There are many different patient safety issues that arise on a daily basis at the Hospital. Those listed in this slide are either types of incidents or factors that can contribute or cause incidents.

5. Common Patient Safety Issues
Medication errors and patient falls are two of the most frequent patient safety issues in health care.
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6. 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.
Medication errors are amongst the most common in Hospitals. While many are caught by nurses prior to administration of the medication to the patient, many other wrong medication, wrong dosage, wrong route medication errors do get to the patient. Mediation errors can range from relatively little to no harm to the potential for serious harm.

7. 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.
Reducing the number of patient falls is a key corporate objective at St. Mary’s General Hospital. Patient falls are one of the most common incidents causing serious injury or death among patients in healthcare.

8. 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.
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9. 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.
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10. Reason’s Theory of Adverse Events
James Reason developed a theory of why adverse events occur, which is based on failures of systems rather than on individual failure or error. Patient care, such as medication administration, is seen as a process in which successive barriers to error are put in place. However, each barrier has its weaknesses or holes which is why a graphical representation above represents a number of slices of Swiss Cheese. An error or failure (e.g. wrong drug) reaches the patient when the weakness or holes align.
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.

11. 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.
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12. Hierarchy of Patient Safety
Methods for increasing patient safety range from those focused on individuals to those focused on systems. Notice that the most effective are focused on improving systems. Engineering the system to make it safer is more effective than trying to engineer the person to make them less human (i.e. less fallible)
Note: need citation for this graphic and previous one.

13. Patient Safety at SMGH Foster a culture of quality & safety
Patient safety strategies
Infection Control strategies
Partner with patients and families in quality & safety
Policy review and education
Continual Education opportunities
Adverse events analysis
Risk Management program
Leverage Technology
Process Improvement
Safe product/equipment strategies
Leadership Safety walks/weekly quality, risk & safety huddles
Daily unit quality, risk & safety huddles
There are many different parts to the patient safety program at St. Mary’s

14. An Example of System Failure
Do No Harm: Jess’ Story
This video provides an example of how errors and not listening to the patient/family can result in a terrible outcome for the patient.

15. 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.
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16. Recognize, Respond to and Disclose Adverse Events
Incident Reporting
RL6 (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
In order to learn form adverse events the Hospital needs to know about them. RL 6 is the reporting system that provides data on adverse events. It is a self-reporting system that is entirely dependent on staff entering details of staff injuries, patient events. The system also contains data on compliments and complaints.
Legislation requires disclosure to patient’s and/or families or substitute decision makers about harm that occurs to patients during their stay at the Hospital. St. Mary’s Hospital has a disclosure to ensure that the Hospital complies with it’s legal obligations with respect to disclosure of patient harm. As important however is the ethical obligation to be open, honest and empathetic in communicating with patients – something that is truly appreciated by patients and families.

17. 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
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18. Safe Practices
There are 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
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19. 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
Read slide and then say “remember, the only bad question is the question that should have been asked that wasn’t. Don’t be afraid to ask questions or raise concerns when in doubt because by speaking up you may well prevent an adverse event to a patient.”.

20. Just a bit about Workplace Safety

21. 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.
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The Ministry of Labour continues to applaud the work we have done to keep our Staff and our patients safe; we like to call this “people safety”.

22. Safety Logo
LEAD THE WAY, CHOOSE SAFETY TODAY is St. Mary’s Safety Logo. It was the chosen slogan out of over 100 entries for our safety logo contest. You will see this logo on any staff safety materials and communication around the hospital.

23. 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?
St. Mary’s has a Joint Health and Safety Committee that:
Performs monthly workplace inspections throughout the hospital
Meets on a monthly basis
The members are made up of union, worker and management representatives
The Health & Safety Bulletin Board is located in the basement, just off the cafeteria past the vending machines. It holds documents such as members names, meeting minutes, different reports, Health & Safety Policy Statement and the Occupational Health & Safety Act (Green Book)

24. Your Workplace Safety Coordinators are:
Robin Ridsdale ext Tracey Dowhaniuk ext. 2680
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