Upload File

patient safety .by dr.gyanaranjan

23
Patient Safety In Public Health Care Institutions A Conceptual Postmortem & Critical Analysis By. Dr.Gyanaranjan Pradhan(PGDHM*) [email protected] Dr. S.Yasobant (MPH *) Clean Care is Safer Care

Upload: drgyanaranjan

Post on 14-May-2015

1.482 views

Category:

Health & Medicine


2 download

Report

Tags:

DESCRIPTION

A conceptual presentation of a abstract published in Health line- The journal of Indian association of preventive and social medicine ,Gujurat chapter,vol-3,March-2012 and also presented at PRISIM-2012, National conference on Hospital management-2012,Organised by ARVIND eye hospital,Madurai. THIS PRESENTATION MAINLY FOCUS ON HOW TO CREATE A CULTURE OF PATIENT SAFETY IN INDIA'S PUBLIC HEALTH CARE INSTITUTIONS BASED ON A NON INTER VENATION EXPLOITATIVE STUDY DESIGN.

TRANSCRIPT

Page 1: Patient safety .by dr.gyanaranjan

Patient Safety In Public Health Care Institutions

A Conceptual Postmortem &

Critical Analysis

By.

Dr.Gyanaranjan Pradhan(PGDHM*) [email protected]

Dr. S.Yasobant (MPH *)

[email protected]

* Pursuing

Clean Care is Safer Care

mailto:[email protected]
mailto:[email protected]
mailto:[email protected]
Page 2: Patient safety .by dr.gyanaranjan

Content To Be Covered

Objectives of presentation.

What is patient safety?

Public Heath Care Institutions in India.

Patient Safety and India.

Patient Safety In Public Health Care institutions

[email protected] [email protected]

mailto:[email protected]
mailto:[email protected]
mailto:[email protected]
Page 3: Patient safety .by dr.gyanaranjan

Content to be covered

Conceptual Postmortem of the issue :Factors

Responsible.

Result of Postmortem: Explore Various Dimensions Of Patient safety.

Critical analysis :Frame Work To Increase Patient Safety

Conclusion.

Patient Safety In Public Health Care institutions

[email protected] [email protected]

mailto:[email protected]
mailto:[email protected]
Page 4: Patient safety .by dr.gyanaranjan

Objectives of presentation

To know how unsafe our patients are.

Explore the hidden factors of patient safety along with most common factors

How to create a culture of patient safety

Managerial suggestions to overcome

Patient Safety In Public Health Care institutions

[email protected] [email protected]

mailto:[email protected]
mailto:[email protected]
Page 5: Patient safety .by dr.gyanaranjan

How much unsafe our patients are?

Number of doctor: 70,0000

Accidental death caused by doctors per year:

120,000 Hence Accident Per

Year/Doctor:17.14 * *Curtsey USA dept. Of Family

Welfare.

Number of gun owners:

80,000,000 Accidental death due to gun

:1500

Hence Accident Per Year Per

Gun:0.001875*

*Curtsey FBI

Doctors Are More Dangerous than Guns In USA…..

Conclusion: Doctors are 9000 times dangerous than Gun

Patient Safety In Public Health Care Institutions

Page 6: Patient safety .by dr.gyanaranjan

How much unsafe our patients are?

Health Care Industry is one of the Risk Industry….

Fatal Iatrogenic adverse event

Himalaya mountaineering

Chemical Industry

Medical Risk Total

Road Safety

Nuclear Industry

Cardiac Surgery

Micro light aircraft

Very un safe ..... Risk ….. Ultra safe

Railways

Commercial large jet aviation

Charted flight

Blood transfusion

Patient Safety In Public Health Care institutions

Page 7: Patient safety .by dr.gyanaranjan

What is patient safety? Do no harm 1st corner stone of medicine…

The prevention of errors and consequence adverse effects to patients associated with health care . (WHO)

Health care error : At various level ;At various aspects

From managerial………...To Clinical

Human Cause…………….To Instrumental

Policy Failure ……………...To System failure

Patient Safety In Public Health Care institutions

[email protected] [email protected]

mailto:[email protected]
mailto:[email protected]
Page 8: Patient safety .by dr.gyanaranjan

What is patient safety: Various dimensions

Freedom from accidental injury……

Patient Safety In Public Health Care institutions

Health care error

Diagnostic

Treatment

HAI

Medicine error Surgical error

Communication Equipment

Physical enviourment accidents

Transfusion (blood & fluid)

Page 9: Patient safety .by dr.gyanaranjan

Pri

mary care

23,236 PHC 1,46,026 Sub centre

3,346 CHC

4,400 DHC

242 Medical colleges 205 Dental colleges

Three tier health Delivery model in India A great challenge for patient safety

Patient Safety In Public Health Care institutions

Ref.k.Park20th ed.

Page 10: Patient safety .by dr.gyanaranjan

India‘s health care paradox For why patient safety is a ”?”

Patient Safety In Public Health Care institutions

Page 11: Patient safety .by dr.gyanaranjan

Patient Safety and India: legal aspects

Health to all or safe care to all?

No direct legal frame work: Constitution not provide special right to patients.

Sec-304 0f Indian penal code 1860: Space to complain against physician for negligence.

IMC professional etiquette and ethics regulation : Address the issue

Consumer act :Use some time

Patient Safety In Public Health Care institutions

Page 12: Patient safety .by dr.gyanaranjan

Patient Safety and India : Current scenario Time to think and progress

At corporate /private hospitals: Quite promising but still need more attention to create patient safety as a culture

Our focus public health care institutions: Not only disappointing but also a headache for all stake holders

Over burden the system: By increase visit to hospitals, burden of disease, out pocket and public spending , longer bed occupancy& queue in OPD.

Reduce faith on public health care system and growth of parallel market.

Vision gradually turned in to rhetoric or a utopian appeal-because something lack to

Vision Reality

Patient Safety In Public Health Care institutions

Page 13: Patient safety .by dr.gyanaranjan

Back ground of study : Just give a overview

Thanks to all who cooperate us

Non-interventional-explorative study design

Total number of public health care institutions cover:

1.Sub-cetre and Anganwadi: 6

2.PHC:6

3.CHC:4

4:DH:3

Patient Safety In Public Health Care institutions

[email protected] & [email protected]

mailto:[email protected]
mailto:[email protected]
Page 14: Patient safety .by dr.gyanaranjan

Postmortem of Patient safety Funny but a necessary

Patient Safety In Public Health Care institutions

Public health care Institutions

Overburden

Collapsed

Patient safety venerable

Death of patient safety in these organizations

Page 15: Patient safety .by dr.gyanaranjan

Why postmortem: Explore the cause

Not a natural death

The death is suspected due to Individual causes :Health care professionals and other

supportive enviourment

System causes : The health care delivery system and

work process

So there is need to find the exact cause

By

Conceptual postmortem

Patient Safety In Public Health Care institutions

Page 16: Patient safety .by dr.gyanaranjan

The Procedure of postmortem should not be biased

– Patient Safety In Public Health Care institutions

Open eye observation:

Silent data collection

Interacting with various stake holders of system

Secondary data Sources

[email protected] & [email protected]

mailto:[email protected]
mailto:[email protected]
Page 17: Patient safety .by dr.gyanaranjan

Findings of Postmortem You may not belief but true

Already well focused :But seems to be a nightmare.

Patient Safety In Public Health Care institutions

Number of issues :Represents interlinking factors

Various dimensions of factors: Multi facet interaction

Most common highlighted causes : Mask the root causes, So difficult to Addressed

[email protected] [email protected]

mailto:[email protected]
mailto:[email protected]
Page 18: Patient safety .by dr.gyanaranjan

Current Scenario :We all know Valuable clues towards solution

Patient Safety In Public Health Care institutions

Page 19: Patient safety .by dr.gyanaranjan

Critical analysis of Findings Not criticism but finding

Patient Safety In Public Health Care institutions

Issue-1:Human Resource: It’s dimensions

Inadequacy and

Inequitable distribution

Lack Competency

related to patient safety

Beehavioural change and poor attitude

towards patient safety

Required some special strategy to address

Page 20: Patient safety .by dr.gyanaranjan

Critical analysis of Findings Only findings are not enough

Patient Safety In Public Health Care institutions

Issue-2.Work Culture: Various dimensions

Un-supportive Work

enviourment

Lack of team work &

Leadership

Not people Centered

work culture

Required some special strategy to address

Page 21: Patient safety .by dr.gyanaranjan

Frame work to increase patient safety some hopeful suggestion

Patient Safety In Public Health Care institutions

Create a culture of patient safety in public

healthcare institutions: focus on system issues and individual issues.De-centralization of organizational structure and streamline

the management process.

The administrative power shifted from medicos to medicos specialized in healthcare management.

Allotment of resources and its proper distribution

Page 22: Patient safety .by dr.gyanaranjan

Patient Safety In Public Health Care institutions

Conclusion Not possible to conclude still we are not achieve the Goal

From Too Much Zeal For The New And Contempt For The Old; From Putting Knowledge Before Wisdom Science Before Art Cleverness Before Commonsense From Treating Patient As a Case And For Making Cure of Disease More Grievous Than The Endurance Thereof ; Good lord Deliver Us By: Robert hutichison

Page 23: Patient safety .by dr.gyanaranjan

Thanks to all Join Hands Creating a culture of patient safety

Patient Safety In Public Health Care institutions

Special Thanks

To

Prisim-2012

&

[email protected] & [email protected]

mailto:[email protected]
mailto:[email protected]

PENNSYLVANIA PATIENT SAFETY ADVISORYpatientsafety.pa.gov/ADVISORIES/Documents/200812_home.pdf · Pennsylvania Patient Safety Advisory About the Pennsylvania Patient Safety Advisory

Increase patient safety by improving backup power system reliability

PATIENT SAFETY Protecting Patient’s Right Protecting Patient’s Right General Patient Safety Measures General Patient Safety Measures Admission of the Patient

Contents Joint Commission National Patient Safety … · 2012-09-17 · Joint Commission National Patient Safety Goals, 2011. By Debora Pfeffer, ... Joint Commission National Patient

PENNSYLVANIA PATIENT SAFETY ADVISORYpatientsafety.pa.gov/ADVISORIES/Documents/201306_home.pdf · Produced by ECRI Institute and ISMP under contract to the Pennsylvania Patient Safety

CAEP Ottawa June 2014 - RPPEO · Patient Safety in EMS Little is known about the risks to patient safety in EMS Patient Safety in EMS Report Improve reporting by creating better

Airway Safety Webinar PresentationL - Patient Safety Movement · • 10 Minutes: Introduction to Patient Safety Movement Foundation and Actionable Patient Safety Solutions (APSS)

Improving patient safety by decreasing restraint use

Patients for Patient Safety M argaret Murphy, Patient Advocate External Lead Advisor Patients for Patient Safety WHO Patient Safety Beaumont Hospital Transplant

Recent Developments in Patient Safety and Scope of Patient Safety Special Interest Group Recent Developments in Patient Safety and Scope of Patient Safety

Enhancing Patient Safety and Outcomes: The Safe Patient Handling … Patient Safety... · Enhancing Patient Safety and Outcomes: The Safe Patient Handling Connection Presented by

Patient safety during fluoroscopically guided medical ... · Patient safety during fluoroscopically ... National Library of ... not be connected by patient or care providers 3/15/2012

Presented by: WRHA Quality, Patient Safety

Danish Society for Patient Safety Patient Safety The Danish Experience

Understanding Patient Safety Presented by Dr. Redouane Bouali Canadian Patient Safety Institute (CPSI) June 10th, 2010

Enhancing Patient Safety through Effective Communication Patient Safety... · Enhancing Patient Safety through Effective Communication Joint Commission Communication Standards •

NURSING EXCELLENCE€¦ · based on National Patient Safety Goals established by The Joint Commission. National Patient Safety Goal Safety goal identification number Manikin setup

Maryland Hospital Patient Safety Program Annual Report ... Patient... · Maryland Hospital Patient Safety Program FY13 Annual ... Maryland Hospital Patient Safety Program Annual Report

PATIENT SAFETY CULTURE AND PATIENT SAFETY … · 2 Patient Safety Culture and Patient Safety Implementation in Stella Maris Hospital during National Health Insurance Era Fridawaty

Patient Safety - Cape Fear ValleyImprovement/Patient Safety Plan. – The 2013 National Patient Safety Goals. – What CFV is doing to address the National Patient Safety Goals and

Presented by Director of Epidemiology/Patient Safety

Patient safety in Healthcare; Developing Patient Safety Culture by reporting adverse events and near misses and learning from the mistakes

ELECTRICAL SAFETY ANALYZER WITH PATIENT SIMULATOR … · ELECTRICAL SAFETY ANALYZER WITH PATIENT SIMULATOR ... ELECTRICAL SAFETY ANALYZER WITH PATIENT SIMULATOR . 2 PATIENT ... status

PATIENT SAFETY AND GAPS MANAGEMENT BY REGISTERED NURSES …dro.deakin.edu.au/eserv/DU:30066360/jones-patientsafety-2014A.pdf · PATIENT SAFETY AND GAPS MANAGEMENT BY REGISTERED NURSES

DoD Patient Safety Program Patient Safety Improvement Guide

ENGAGING PATIENTS IN PATIENT SAFETY · The Engaging Patients in Patient Safety – a Canadian Guide (Guide) was developed by the Canadian Patient Safety Institute, the Atlantic Health

Copyright 2007 Partners Radiology Patient Safety Training “Patient Safety in Radiology” Partners Radiology Patient Safety Team

Top 10 Patient Safety Concerns for Healthcare 2017 to benefit patient care by promoting the highest standards of safety, ... into patient safety, quality, and risk management ... usable

By:~ ~lflhtt; - The Patient Safety League

Patient Safety Systems (PS)...2019/07/01  · Patient and resident safety emerges as a central aim of quality. Patient safety, as defined by the World Health Organization, is the prevention

culture of patient safety - The Royal College of ... · patient safety performance.”2 An enabling patient safety culture is characterized by leadership that leads by example, transparent

Patient Safety Movement Foundation Presents · APSS #17 –Patient Safety Curriculum Patient Safety Curriculum for All Health Professionals May 8, 2019 Patient Safety Movement Foundation

PART 3—PATIENT SAFETY ORGANI- ZATIONS AND PATIENT SAFETY WORK

Patient Safety Evaluation System and Patient Safety Organization Fundamentals

Panel 1: Patient Safety Moderated by Scott Williams