Chapter 9Chapter 9[1][1]

Patient Safety

Introduction 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]

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AgendaAgenda

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

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Current Patient Safety GoalsCurrent Patient Safety Goals [2][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

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Objectives From the Assessment Objectives From the Assessment of Safety Culturesof Safety Cultures

Profiling

Benchmarking

AwarenessEnhancement

MeasuringChange

Accreditation

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How to Implement a Patient Safety How to Implement a Patient Safety Program (8-Step Process)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)

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How to Develop Patient Safety How to Develop Patient Safety Measures (6-Step Process)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

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Common Safety Analysis MethodsCommon Safety Analysis Methods

Technic of Operation Review (TOR)

Fire Drill Seat Belt Checks

Seeking Feedback

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Common Safety Analysis MethodsCommon Safety Analysis Methods

Root Cause Analysis (RCA)

Also known as:“The 5 Why’s”

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Common Safety Analysis MethodsCommon Safety Analysis Methods

Root Cause Analysis (RCA)

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Common Safety Analysis MethodsCommon Safety Analysis Methods

Hazard Operability Analysis (HAZOP)

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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 MethodsCommon Safety Analysis Methods

Hazard Operability Analysis (HAZOP)

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Common Safety Analysis MethodsCommon Safety Analysis Methods

Failure Modes and Effect Analysis (FMEA) Per System:

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•Item(s) •Function(s) •Failure(s) •Effect(s) of Failure •Cause(s) of Failure •Current Control(s) •Recommended Action(s)

Common Safety Analysis MethodsCommon Safety Analysis Methods

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Common Safety Analysis MethodsCommon Safety Analysis Methods

Fault Tree Analysis (FTA)

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Common Safety Analysis MethodsCommon Safety Analysis Methods

Fault Tree Analysis (FTA)

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SummarySummary

– 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

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Where to Get More InformationWhere 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_for_the_poor_and_underserved/v020/20.1.dingham.html

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Where to Get More InformationWhere to Get More Information

Dr. Joan Burtner – burtner_j@mercer.edu

Jason Coggins Jermaine Early Eric Hudnall Joshua Smith

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ReferencesReferences

[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.

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Questions?Questions?

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