1. An Imperative for Performance Improvement
PATIENT SAFETY
An Imperative for Performance Improvement
Neil G. Jaymalin, RN, MBAH, CQA
February 26, 2010

2. Definition
Patient Safety is a new healthcare discipline that emphasizes the reporting, analysis, and prevention of medical error that often lead to adverse healthcare events.

3. Wrong Site / Patient Surgery Patient Identification
Fall Prevention
Pressure Ulcers
Hand Hygiene
Surgical Fire
Wrong Site / Patient Surgery
Patient Identification
Proactive Risk Assessment
Medication Safety
Patient Involvement
Staff Communication

4. Medication Safety
Accounted for 9.9% of the sentinel events reviewed by JCI
Policy cascade and promotion
High Alert Meds
PCA
SALAD
Labels
Reconciliation (Drug Profile)

5. Standards
Joint Commission – covers from prescription to administration including monitoring of medication effect to patient

6. Approach to Safety Leadership driven culture of safety
Improve reporting of errors by establishing a non – blame environment
Evaluate where technology can help reduce the risk of medication error

7. Establish a fool proof method of controlling high alert medications
Patient Involvement
Establish a controlled formulary

8. Medication Error
JAN
FEB
MAR
APR
MAY
JUN
JUL
AUG
SEP
OCT
NOV
DEC
IPD Medication Error
0.19
0.22
0.12
0.16
0.14
0.20
0.06
0.00
Reported medication error / total dispensed medication * 1000
Benchmark = 3.1 %

9. Practice Recommendation
Reporting
Safety Walkrounds
FMEA

10. Reporting
The primary purpose of patient safety reporting systems is to learn from experience.
It is important to note that reporting in itself does not improve safety. It is the response to reports that leads to change.
(WHO Guidelines for Adverse Event Reporting and Learning Systems, 2005)

11. Characteristics of Successful Reporting Systems (7)
Non-punitive
Reporters are free from fear of retaliation against themselves or punishment of others as a result of reporting.
Confidential
The identities of the patient, reporter, and institution are never revealed.

12. 3. Independent 4. Expert analysis
The reporting system is independent of any authority with power to punish the reporter or the organization.
4. Expert analysis
Reports are evaluated by experts who understand the clinical circumstances and are trained to recognize underlying systems causes.

13. 5. Timely Reports 6. Systems-oriented
are analyzed promptly and recommendations are rapidly disseminated to those who need to know, especially when serious hazards are identified.
6. Systems-oriented
Recommendations focus on changes in systems, processes, or products, rather than being targeted at individual performance.

14. 7. Responsive
The agency that receives reports is capable of disseminating recommendations. Participating organizations commit to implementing recommendations whenever possible.

15. Safety WalkRounds
A “Safety WalkRound” is a process whereby a group of senior leaders visit areas of a health-care organization and ask front-line staff about specific events, contributing factors, near misses, potential problems, and possible solutions.

16. Can often result in prompt changes that improve care and safety.
It also can lead to culture change, as the concerns of front-line staff are addressed.
front-line staff are engaged in continuous observation of hazards and solutions for discussion with senior leadership.

17. Leadership walkrounds are a low-cost way to identify hazards of concern to front-line staff and make needed changes.
Require no additional staff, equipment, or infrastructure.

18. Failure Modes and Effects Analysis
Failure modes and effects analysis (FMEA) is a widely used tool for proactively identifying process vulnerabilities.
It begins by systematically identifying each step in the process and then searches out “failure modes”, that is, noticing what could go wrong.

19. The next step is to evaluate how the failure mode could occur, and what are the “effects” of this failure.
If a failure mode could result in catastrophic effects, the process must be corrected or buffered.
The FMEA is a proactive tool, used to evaluate a new process, or an existing process for proposed design changes.

20. Medication Admin Process Flow

21. - End-