1 / 71

Patient Safety

Patient Safety. Prevention of Medical Errors. Why are we here?. Concern over incidence of Medical Errors IOM Report (1999) To Err is Human, Building a Safer Healthcare System Statistics 44,000 – 98,000 Hospital deaths due to medical error each year. Why are we here?.

desiree-hahn
Download Presentation

Patient Safety

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Patient Safety Prevention of Medical Errors

  2. Why are we here? • Concern over incidence of Medical Errors • IOM Report (1999) • To Err is Human, Building a Safer Healthcare System • Statistics • 44,000 – 98,000 Hospital deaths due to medical error each year

  3. Why are we here? • To commit to paying greater attention to the problem • We make a difference one at a time • To evaluate current approaches • To build better systems to reduce the incidence of error

  4. Why are we here? • 2001 FL Legislative response • FS 456.013 • Mandates 2 hour course for ALL health care providers as part of licensure and renewal process • Course shall include the study of: • root-cause analysis • error reduction • error prevention • patient safety

  5. Why are we here? • FL BON Requirement • 64B9-5.011 • Continuing Education on Prevention of Medical Errors

  6. FL BON Requirement • Subject Areas: • Factors that impact the occurrence of medical errors • Recognizing error-prone situations • Processes to improve patient outcomes • Responsibilities for reporting • Safety needs of special populations • Public education

  7. Definitions • Error (IOM report): • The failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim • Error of Execution • Error of Planning

  8. Definitions • Adverse Events: • Injury caused by medical management rather than underlying disease condition • Unpreventable • Preventable

  9. Definitions • Medical Error • Preventable adverse events with our current state of medical knowledge • Not defined as intentional act of wrongdoing • Not all rise to level of medical malpractice or negligence

  10. Reporting Requirements • Florida Law requires all licensed facilities to: • Have Internal Risk Management and incident reporting system • Report Serious Adverse Events to: • AHCA Agency for Health Care Administration

  11. Joint Commission • National organization • Mission to improve the quality of care in healthcare institutions • Provides Accredited status to healthcare facilities

  12. Joint Commission • Defines Sentinel Event: • An unexpected occurrence involving death of serious physical or psychological injury or risk thereof

  13. Joint Commission • Sentinel events subject to review by Joint Commission • an event resulting in unanticipated death or major permanent loss of function not related to the underlying condition or if the event is one of the following:

  14. Suicide in setting with 24 hour care or within 72 hours of discharge • Unanticipated death of a full-term infant • Abduction of any patient • Discharge of infant to wrong family • Rape • Hemolytic Transfusion Reactioninvolving blood group incompatibilities

  15. Joint Commission • Requires: • Process in place to recognize sentinel events • Credible root cause analysis • Focus on systems not individuals • Risk reduction strategies • Internal corrective action plan • Measure effectiveness of process • System improvements to reduce risk

  16. Root Cause Analysis • Goal-directed, systematic process • uncovers basic factors that contribute to medical error • Focuses primarily on systems and processes and not individuals • Product of root cause analysis is an action plan to reduce risk of similar future events

  17. Root Cause Analysis • Gather facts • Assemble team • Determine sequence of events • Identify causal factors • Select root causes • Take corrective action and follow-up plan

  18. Joint Commission • Sentinel Event Statistics • Type • Setting • Outcome • Root Causes • And more • Sentinel Event Alerts • Periodic publication • Sharing information • To share information • To prevent medical errors/adverse events • Website: http://www.jointcommission.org/

  19. Sentinel Events by Type Dec. 31, 2006 • 1. Wrong Site Surgery (13.1%) • 2. Patient Suicide (12.8%) • 3. Op/Post-op Complication(12.1%) • 4. Medication Error (9.5%) • 5. Delay in Treatment (7.4%) • 6. Patient Fall (5.5%) • 7. Patient death/injury in restraints (3.8%)

  20. Sentinel Events by Setting Dec. 31, 2006 • 1. General Hospital (67.9%) • 2. Psychiatric Hospital (10.8%) • 3. Psych unit in general hosp. (4.9%) • 4. Behavioral health facility (4.6%) • 5. Emergency Dept. (3.9%) • 6. Long Term Care Facility (3.0%) • 7. Ambulatory Care (2.7%)

  21. Root Causes of ALL Sentinel Events 1995-2005 • 1. Communication • 2. Orientation / Training • 3. Patient Assessment • 4. Staffing • 5/6. Availability of Info; Competency / Credentialing • 7. Procedural compliance • 8. Environmental Safety / Security

  22. Root Causes of ALL Sentinel Events - 2006 • 1. Communication • 2. Patient Assessment • 3. Leadership • 4. Procedural Compliance • 5. Environ. Safety / Security • 6. Competency / Credentialing • 7. Orientation / Training • 8. Availability of Info

  23. Root Causes – Wrong Site Surgery 1995-2004 • 1. Communication • 2. Orientation / Training • 3. Procedural compliance • 4. Availability of Info • 5. Patient Assessment • 6. Leadership • 7. Competency / Credentialing • 8. Organizational Culture

  24. Root Causes – Wrong Site Surgery 2005 • 1. Communication • 2. Procedural compliance • 3. Leadership • 4. Competency / Credentialing • 5. Availability of Info • 6. Organizational Culture • 7. Orientation / Training • 8. Patient Assessment; Care Planning

  25. Root Causes – Wrong Site Surgery 2006 • 1. Procedural compliance • 2. Communication • 3. Leadership • 4. Availability of Info • 5. Competency / Credentialing • 6. Orientation / Training • 7. Patient Assessment; Organizational Culture • 8. Environmental Safety / Security

  26. Root Causes – Suicide 1995-2004 • 1. Environmental Safety / Security • 2. Patient Assessment • 3. Orientation / Training • 4. Communication • 5. Availability of Information • 6. Continuum of Care • 7. Competency / Credentialing • 8. Staffing levels

  27. Root Causes – Suicide 2005 • 1. Patient Assessment • 2. Environmental Safety / Security • 3. Communication • 4. Orientation / Training • 5. Competency / Credentialing • 6. Availability of Information • 7. Leadership • 8. Procedural Compliance & Continuum of Care

  28. Root Causes – Op/Post-op Complications 1995-2004 • 1. Orientation / Training • 2. Communication • 3. Procedural compliance • 4. Patient Assessment • 5. Staffing • 6. Competency / Credentialing & Availability of Info • 7. Care Planning • 8. Leadership

  29. Root Causes – Op/Post-op Complications 2005 • 1. Communication • 2. Patient Assessment • 3. Procedural compliance • 4. Care Planning • 5. Availability of Info • 6. Organizational Culture • 7. Competency / Credentialing • 8. Leadership

  30. Root Causes – Medication Error 1995-2004 • 1. Communication • 2. Orientation / Training • 3. Competency / Credentialing • 4. Staffing • 5. Procedural Compliance • 6. Availability of Info • 7. Patient Assessment • 8. Environmental Safety; Security & Leadership

  31. Root Causes – Medication Error 2005 • 1. Communication • 2. Procedural Compliance • 3. Competency / Credentialing • 4. Leadership; Patient Assessment; Orientation / Training • 5. Environ. Safety/Security • 6. Organizational Culture ; Staffing

  32. Root Causes – Delay in Tx. 1995-2004 • 1. Communication • 2. Patient Assessment • 3. Continuum of Care • 4. Orientation / Training • 5. Availability of Info • 6. Competency / Credentialing • 7. Staffing • 8. Care Planning

  33. Root Causes – Delay in Tx. 2005 • 1. Communication • 2. Patient Assessment • 3. Procedural Compliance • 4. Continuum of Care / Availability of Info • 5. Care Planning / Leadership • 6. Competency / Credentialing

  34. Root Causes – Patient Falls 1995-2004 • 1. Orientation/Training • 2. Communication • 3. Patient Assessment • 4. Environmental Safety / Security • 5. Care planning • 6. Leadership & Staffing • 7. Competency / Credentialing • 8. Availability of Info

  35. Root Causes – Patient Falls 2005 • 1. Patient Assessment • 2. Communication • 3. Environmental Safety / Security • 5. Leadership • 6. Procedural Compliance • 7. Orientation / Training; Care Planning • 8. Availability of Info; Competency / Credentialing

  36. Root Causes – Restraint Injury/Death 1995-2004 • 1. Orientation / Training • 2. Patient Assessment • 3. Communication • 4. Care Planning • 5. Staffing • 6. Competency / Credentialing & Availability of Info. • 7. Environmental Safety / Security • 8. Procedural Compliance • 9. Continuum of Care

  37. Root Causes – Restraint Injury/Death 2005 • 1. Communication; Patient Assessment • 2. Environmental Safety / Security • 3. Orientation / Training; Competency / Credentialing & Availability of Info. • 4. Procedural Compliance; Care Planning • 5. Leadership

  38. Now What? • Learn from Knowledge of: • Sentinel Event Statistics • Root Causes • Make Prevention a Priority • Make changes • Improve patient safety • Follow Joint Commission recommendations • Sentinel Event ALERT

  39. Wrong Site Surgery Prevention • Clearly mark the operative site and involve the patient in the process • Require oral verification of the correct site in the OR by each member of the surgical team • Develop verification checklist that includes all documents

  40. Wrong Site Surgery Prevention • Surgical teams consider taking a “time out” to verify patient, site, procedure using active communication • Ensure ongoing monitoring that verification process is followed

  41. Inpatient Suicide Prevention • Identify/Remove/Replace non-breakaway hardware • Weight test all breakaway hardware • Revise procedures for contraband detection and include family and friends in process

  42. Inpatient Suicide Prevention • Standardize suicide risk assessment/reassessment procedures • Enhance staff orientation and education • Ensure consistency in implementation of observation procedures

  43. Inpatient Suicide Prevention • Redesign, retrofit, or introduce security measures • Revise information transfer procedures • Implement education for family and friends regarding suicide risk factors

  44. Op/Post-Op Complications Prevention • Improve staff orientation and training • Educating and counseling physicians • Revising credentialing and privileging procedures • Clearly defining expected channels of communication

  45. Op/Post-Op Complications Prevention • Standardizing procedures across settings of care • Revising the competency evaluation process. • Monitoring consistency of compliance with procedures

  46. Op/Post-Op Complications Prevention • Implementing a teleradiology program • Correct placement of catheters and tubes should be verified with a test or x-ray

  47. Medication ErrorsPrevention • Recognize High Alert Meds: • Insulin • Opiates and Narcotics • Injectable Potassium Chloride • Intravenous Anticoagulants • Sodium Chloride Solutions above 0.9%

  48. Medication ErrorsPrevention • Follow the 5 (6) Rights of Medication Administration • Use 2 identifiers • Limit and institute “Read Back” policy of all verbal orders • Standardize Abbreviations

  49. Medication ErrorsPrevention • Joint Commission abbreviations on the DO NO USE list: • U for Unit – write unit • IU for International Unit – write international unit • QD, QOD – Write daily or every other day

  50. Medication ErrorsPrevention • Joint Commission abbreviations on the DO NO USE list: • Trailing zero (X.0 mg.) – write (X mg.) • Lack of leading zero (.X mg) - write (0.X mg) • MS, MSO4, MgSO4 - write morphine sulfate, magnesium sulfate

More Related