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Chapter 9 [1] Patient Safety. Introduction Patient safety comprises the reporting, analysis and prevention of adverse healthcare events and medical error.

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Presentation on theme: "Chapter 9 [1] Patient Safety. Introduction Patient safety comprises the reporting, analysis and prevention of adverse healthcare events and medical error."— Presentation transcript:

1 Chapter 9 [1] Patient Safety

2 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 591 10/25/2015

3 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 10/25/2015 3 ETM 591

4 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 10/25/2015 4 ETM 591

5 Objectives From the Assessment of Safety Cultures Profiling Benchmarking Awareness Enhancement Measuring Change Accreditation 10/25/2015 5 ETM 591

6 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) 10/25/2015 6 ETM 591

7 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 10/25/2015 7 ETM 591

8 Common Safety Analysis Methods Technic of Operation Review (TOR) Fire Drill Seat Belt Checks Seeking Feedback 10/25/2015 8 ETM 591

9 Common Safety Analysis Methods Root Cause Analysis (RCA) Also known as: “The 5 Why’s” 10/25/2015 9 ETM 591

10 Common Safety Analysis Methods Root Cause Analysis (RCA) 10/25/2015 10 ETM 591

11 Common Safety Analysis Methods Hazard Operability Analysis (HAZOP) 10/25/2015 11 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!

12 Common Safety Analysis Methods Hazard Operability Analysis (HAZOP) 10/25/2015 12 ETM 591

13 Common Safety Analysis Methods Failure Modes and Effect Analysis (FMEA) Per System: 10/25/2015 13 ETM 591 Item(s) Function(s) Failure(s) Effect(s) of Failure Cause(s) of Failure Current Control(s) Recommended Action(s)

14 Common Safety Analysis Methods 10/25/2015 14 ETM 591

15 Common Safety Analysis Methods Fault Tree Analysis (FTA) 10/25/2015 15 ETM 591

16 Common Safety Analysis Methods Fault Tree Analysis (FTA) 10/25/2015 16 ETM 591

17 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 10/25/2015 17 ETM 591

18 Where to Get More Information http://jama.ama-assn.org/cgi/content/full/280/16/1444 http://jama.ama- assn.org/cgi/content/full/jama%3B287/15/1993 http://muse.jhu.edu/journals/journal_of_health_care_fo r_the_poor_and_underserved/v020/20.1.dingham.html 10/25/2015 18 ETM 591

19 Where to Get More Information Dr. Joan Burtner –burtner_j@mercer.edu Jason Coggins Jermaine Early Eric Hudnall Joshua Smith 10/25/2015 19 ETM 591

20 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, 2007. Also available online at www.jointcommission.org/patientsafety /nationallpatientsafetygoals/07_npsg_facts.htm [3] Patient Safety, Fact Sheets. World Health Professions Alliance, April 2002. www.whapa/factptsafety.htm. [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): 432-436. 10/25/2015 20 ETM 591

21 Questions? 10/25/2015 21 ETM 591

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