patient saftey
TRANSCRIPT
-
8/3/2019 Patient Saftey
1/21
PATIENTSAFETY
STANDARDS
DrDrDrDr Y P BhatiaY P BhatiaY P BhatiaY P BhatiaManaging Director ASTRONManaging Director ASTRONManaging Director ASTRONManaging Director ASTRON
Founder Chairman INDIAN HEALTHCARE QUALITY FORUMFounder Chairman INDIAN HEALTHCARE QUALITY FORUMFounder Chairman INDIAN HEALTHCARE QUALITY FORUMFounder Chairman INDIAN HEALTHCARE QUALITY FORUM
-
8/3/2019 Patient Saftey
2/21
PATIENT SAFETYPATIENT SAFETYPATIENT SAFETYPATIENT SAFETY
Definition:Definition:Definition:Definition:
ActionsActionsActionsActions taken by individualstaken by individualstaken by individualstaken by individuals andandandand
organizations toorganizations toorganizations toorganizations to protect patientsprotect patientsprotect patientsprotect patients fromfromfromfrome n arme y e e ec se n arme y e e ec se n arme y e e ec se n arme y e e ec s oooo eaeaeaea
carecarecarecare services.services.services.services.
FREEDOM fromFREEDOM fromFREEDOM fromFREEDOM from UnintendedUnintendedUnintendedUnintended HealthHealthHealthHealthCare Errors / Injuries due to MedicalCare Errors / Injuries due to MedicalCare Errors / Injuries due to MedicalCare Errors / Injuries due to MedicalManagementManagementManagementManagement
-
8/3/2019 Patient Saftey
3/21
THE PARADOX:
First, do no HarmFirst, do no HarmFirst, do no HarmFirst, do no Harm
To Err is HumanTo Err is HumanTo Err is HumanTo Err is Human
-
8/3/2019 Patient Saftey
4/21
6RPH([DPSOHVRI+DUP$GYHUVH(YHQWV
+RVSLWDOLQFXUUHGSDWLHQWLQMXU\
$GYHUVHGUXJUHDFWLRQ
'HYHORSPHQWRIQHXURORJLFDOGHILFLWQRWSUHVHQWRQDGPLVVLRQ
4
&DUGLDFUHVSLUDWRU\DUUHVWORZ$SJDU VFRUH
,QMXU\UHODWHGWRDERUWLRQRUGHOLYHU\
+RVSLWDODFTXLUHGLQIHFWLRQVHSVLV
/DFNRI&RPPXQLFDWLRQ:URQJ'HOD\HG3URFHGXUH
-
8/3/2019 Patient Saftey
5/21
What ERRORS areWhat ERRORS areWhat ERRORS areWhat ERRORS are PatientsPatientsPatientsPatients exposed toexposed toexposed toexposed to ????
I. Products/ TechnologyI. Products/ TechnologyI. Products/ TechnologyI. Products/ Technology
DrugsDrugsDrugsDrugs:::: Reactions. FailuresReactions. FailuresReactions. FailuresReactions. Failures
Devices:Devices:Devices:Devices: Injections (Injections (Injections (Injections (75% of 2 Billions75% of 2 Billions75% of 2 Billions75% of 2 Billions UnsterilizedUnsterilizedUnsterilizedUnsterilized ))))
Machines ( Dialysis)Machines ( Dialysis)Machines ( Dialysis)Machines ( Dialysis)
5
II. ServicesII. ServicesII. ServicesII. Services:::: Health/medical practices:Health/medical practices:Health/medical practices:Health/medical practices:
Inpatient HAI,,Inpatient HAI,,Inpatient HAI,,Inpatient HAI,, Medication Error,Medication Error,Medication Error,Medication Error, wrong surgerywrong surgerywrong surgerywrong surgery
Inpatient &Inpatient &Inpatient &Inpatient & OutpatientOutpatientOutpatientOutpatient
nonnonnonnon---- personal services; Communication; Longer staypersonal services; Communication; Longer staypersonal services; Communication; Longer staypersonal services; Communication; Longer stay
III. EnvironmentIII. EnvironmentIII. EnvironmentIII. Environment of care:of care:of care:of care:
wastewastewastewaste managementmanagementmanagementmanagement
-
8/3/2019 Patient Saftey
6/21
RANGE OF HEALTH CARE ERRORS
Sentinel event = Serious incident
Minor incident
10%
H
arm
6
Near miss = Could have caused
harm but it did not this time
1 : 29 : 300
-
8/3/2019 Patient Saftey
7/21
PATIENT SAFETY AS A PUBLIC HEALTH RISK
A PROBLEM EVERYWHERE
The Relative RISKThe Relative RISKThe Relative RISKThe Relative RISK
Deaths Per 100 Million HoursDeaths Per 100 Million HoursDeaths Per 100 Million HoursDeaths Per 100 Million Hours
Being pregnantBeing pregnantBeing pregnantBeing pregnant 1111
7
Working at homeWorking at homeWorking at homeWorking at home 8888
Being in trafficBeing in trafficBeing in trafficBeing in traffic 50505050
Flying on a commercial airplane 100Flying on a commercial airplane 100Flying on a commercial airplane 100Flying on a commercial airplane 100
Being hospitalizedBeing hospitalizedBeing hospitalizedBeing hospitalized 2000200020002000
-
8/3/2019 Patient Saftey
8/21
PATIENT SAFETY:
THE ACCREDITORS TOOLS
StandardsStandardsStandardsStandards
DataDataDataData
GuidelinesGuidelinesGuidelinesGuidelines
Patient Safety GoalsPatient Safety GoalsPatient Safety GoalsPatient Safety Goals
EducationEducationEducationEducation
-
8/3/2019 Patient Saftey
9/21
PATIENT SAFETY STANDARDS ANDJCILeaderships role in creating a culture of safetyLeaderships role in creating a culture of safetyLeaderships role in creating a culture of safetyLeaderships role in creating a culture of safety
Proactive system designProactive system designProactive system designProactive system design
ra n ng r entat onra n ng r entat onra n ng r entat onra n ng r entat on
CommunicationCommunicationCommunicationCommunication
-
8/3/2019 Patient Saftey
10/21
CRITICAL STEPS TO IMPROVEMENTS
IN PATIENT SAFETYIdentification of all adverse eventsIdentification of all adverse eventsIdentification of all adverse eventsIdentification of all adverse eventsAnalysis of each error to determine root causesAnalysis of each error to determine root causesAnalysis of each error to determine root causesAnalysis of each error to determine root causes
Compilation of data about error frequencies andCompilation of data about error frequencies andCompilation of data about error frequencies andCompilation of data about error frequencies andfrequencies of root causesfrequencies of root causesfrequencies of root causesfrequencies of root causes
Dissemination of derived information to permitDissemination of derived information to permitDissemination of derived information to permitDissemination of derived information to permitredesign of systems and processesredesign of systems and processesredesign of systems and processesredesign of systems and processes
Periodic assessment of effectiveness of riskPeriodic assessment of effectiveness of riskPeriodic assessment of effectiveness of riskPeriodic assessment of effectiveness of riskreduction effortsreduction effortsreduction effortsreduction efforts
-
8/3/2019 Patient Saftey
11/21
1.1.1.1. Potassium chloridePotassium chloridePotassium chloridePotassium chloride
2.2.2.2. Policy issuesPolicy issuesPolicy issuesPolicy issues3.3.3.3. Policy issuesPolicy issuesPolicy issuesPolicy issues4.4.4.4. Policy issuesPolicy issuesPolicy issuesPolicy issues5.5.5.5. Policy issuesPolicy issuesPolicy issuesPolicy issues6.6.6.6. Wrong site surgeryWrong site surgeryWrong site surgeryWrong site surgery7.7.7.7. SuicideSuicideSuicideSuicide8.8.8.8. Restraint deathsRestraint deathsRestraint deathsRestraint deaths9.9.9.9. Infant abductionsInfant abductionsInfant abductionsInfant abductions
21.21.21.21. Medical gas mixMedical gas mixMedical gas mixMedical gas mix----upsupsupsups
22.22.22.22. Needles & sharps injuriesNeedles & sharps injuriesNeedles & sharps injuriesNeedles & sharps injuries23.23.23.23. Dangerous abbreviationsDangerous abbreviationsDangerous abbreviationsDangerous abbreviations24.24.24.24. WrongWrongWrongWrong----site surgery #2site surgery #2site surgery #2site surgery #225.25.25.25. VentilatorVentilatorVentilatorVentilator----related eventsrelated eventsrelated eventsrelated events26.26.26.26. Delays in treatmentDelays in treatmentDelays in treatmentDelays in treatment27.27.27.27. Bed rail deaths & injuriesBed rail deaths & injuriesBed rail deaths & injuriesBed rail deaths & injuries28.28.28.28. NosocomialNosocomialNosocomialNosocomial infectionsinfectionsinfectionsinfections29.29.29.29. Surgical firesSurgical firesSurgical firesSurgical fires
SENTINEL EVENT ALERT
.... 11.11.11.11. High Alert MedicationsHigh Alert MedicationsHigh Alert MedicationsHigh Alert Medications12.12.12.12. Op/postOp/postOp/postOp/post----op complicationsop complicationsop complicationsop complications13.13.13.13. Impact ofImpact ofImpact ofImpact ofSE AlertSE AlertSE AlertSE Alert14.14.14.14. Fatal fallsFatal fallsFatal fallsFatal falls
15.15.15.15. Infusion pumpsInfusion pumpsInfusion pumpsInfusion pumps16.16.16.16. Proactive risk reductionProactive risk reductionProactive risk reductionProactive risk reduction17.17.17.17. Home fires (OHome fires (OHome fires (OHome fires (O2222 therapy)therapy)therapy)therapy)18.18.18.18. KernicterusKernicterusKernicterusKernicterus19.19.19.19. LookLookLookLook----alike/soundalike/soundalike/soundalike/sound----alike drugsalike drugsalike drugsalike drugs20.20.20.20. KreutzfeldtKreutzfeldtKreutzfeldtKreutzfeldt----Jakob diseaseJakob diseaseJakob diseaseJakob disease
....31.31.31.31. Anesthesia awarenessAnesthesia awarenessAnesthesia awarenessAnesthesia awareness32.32.32.32. KernicterusKernicterusKernicterusKernicterus #2#2#2#233.33.33.33. PCA by proxyPCA by proxyPCA by proxyPCA by proxy34.34.34.34. IntrathecalIntrathecalIntrathecalIntrathecal vincristinevincristinevincristinevincristine
35.35.35.35. Medication reconciliationMedication reconciliationMedication reconciliationMedication reconciliation36.36.36.36. Wrong route / wrong tubeWrong route / wrong tubeWrong route / wrong tubeWrong route / wrong tube37.37.37.37. Emergency power failureEmergency power failureEmergency power failureEmergency power failure38.38.38.38. MRIMRIMRIMRI----related injuriesrelated injuriesrelated injuriesrelated injuries39.39.39.39. Pediatric medication errorsPediatric medication errorsPediatric medication errorsPediatric medication errors40.40.40.40. Assaults & homicidesAssaults & homicidesAssaults & homicidesAssaults & homicides
-
8/3/2019 Patient Saftey
12/21
INTERNATIONAL PATIENT SAFETY
GOALS (JCI)
Modeled on the National Patient Safety Goals ofModeled on the National Patient Safety Goals ofModeled on the National Patient Safety Goals ofModeled on the National Patient Safety Goals of
The Joint CommissionThe Joint CommissionThe Joint CommissionThe Joint Commission
JCI sought and received input on the goals fromJCI sought and received input on the goals fromJCI sought and received input on the goals fromJCI sought and received input on the goals from,,,,
accreditation, consultants, and surveyorsaccreditation, consultants, and surveyorsaccreditation, consultants, and surveyorsaccreditation, consultants, and surveyors
Feedback represents 19 different countriesFeedback represents 19 different countriesFeedback represents 19 different countriesFeedback represents 19 different countries
Majority of respondents felt that the Goals areMajority of respondents felt that the Goals areMajority of respondents felt that the Goals areMajority of respondents felt that the Goals are
appropriate and achievableappropriate and achievableappropriate and achievableappropriate and achievable
-
8/3/2019 Patient Saftey
13/21
INTERNATIONAL PATIENT SAFETY GOALS
(2011) AS JCI TOOL
Identify Patients CorrectlyIdentify Patients CorrectlyIdentify Patients CorrectlyIdentify Patients Correctly
Improve Effective CommunicationImprove Effective CommunicationImprove Effective CommunicationImprove Effective Communication
Improve the Safety of HighImprove the Safety of HighImprove the Safety of HighImprove the Safety of High----Alert MedicationsAlert MedicationsAlert MedicationsAlert Medications
Ensure Correct Site, correct procedure, CorrectEnsure Correct Site, correct procedure, CorrectEnsure Correct Site, correct procedure, CorrectEnsure Correct Site, correct procedure, Correct
....
Reduce the risk of health careReduce the risk of health careReduce the risk of health careReduce the risk of health care----acquiredacquiredacquiredacquired
infectionsinfectionsinfectionsinfections
Reduce the risk of patient harm resulting fromReduce the risk of patient harm resulting fromReduce the risk of patient harm resulting fromReduce the risk of patient harm resulting fromfallsfallsfallsfalls
-
8/3/2019 Patient Saftey
14/21
PATIENT SAFETY STANDARDS AND NABH
NABH standards are related to patient safety:NABH standards are related to patient safety:NABH standards are related to patient safety:NABH standards are related to patient safety:
COPCOPCOPCOP COP7, COP 12 (d), , COP 12 (j), COP 13,COP7, COP 12 (d), , COP 12 (j), COP 13,COP7, COP 12 (d), , COP 12 (j), COP 13,COP7, COP 12 (d), , COP 12 (j), COP 13,
MOMMOMMOMMOM---- MOM 3 (e), MOM 4, MOM6, MOM 8MOM 3 (e), MOM 4, MOM6, MOM 8MOM 3 (e), MOM 4, MOM6, MOM 8MOM 3 (e), MOM 4, MOM6, MOM 8
HICHICHICHIC---- HIC 4HIC 4HIC 4HIC 4---- , ,, ,, ,, ,
ROMROMROMROM---- ROMROMROMROM---- 5555
FMSFMSFMSFMS---- FMS 2, FMS 5, FMS 6, FMS 7, FMS 8, FMS 9.FMS 2, FMS 5, FMS 6, FMS 7, FMS 8, FMS 9.FMS 2, FMS 5, FMS 6, FMS 7, FMS 8, FMS 9.FMS 2, FMS 5, FMS 6, FMS 7, FMS 8, FMS 9.
-
8/3/2019 Patient Saftey
15/21
PATIENT SAFETY STANDARDS OF NABH -
COP
COP 7: Policies and procedures guide the care of
vulnerable patients (elderly, children, physically and/or
mentally challenged)
COP 12 (d): Documented policies and procedures exist to
prevent adverse events like wrong site, wrong patient
COP 12 (j): The plan also includes monitoring of surgical
site infection rates
COP 13: Policies and procedures guide the care of
patients under restraints (physical and/or chemical)
-
8/3/2019 Patient Saftey
16/21
PATIENT SAFETY STANDARDS OF NABH
MOM AND HICMOM 3 (e): Sound alike and look alike medications arestored separately
MOM 4: Policies and procedures exist for prescription ofmedications
MOM6: There are defined procedures for medicationadministration.
MOM 8: Patients are monitored after medicationadministration.
HIC 4: The organization takes actions to prevent orreduce the risk of Hospital Associated Infections (HAI) inpatients and employees.
-
8/3/2019 Patient Saftey
17/21
PATIENT SAFETY STANDARDS OF NABH CQI
AND ROMCQI 2: The organization identifies key indicators tomonitor the clinical structures, processes and outcomeswhich are used as tools for continual improvement.
CQI 3:The organization identifies key indicators tomonitor the managerial structures, processes andoutcomes which are used as tools for continualimprovement.
CQI 6: Sentinel events are intensively analysed.
ROM 5: Leaders ensure that patient safety aspects andrisk management issues are an integral part of patientcare and hospital management
-
8/3/2019 Patient Saftey
18/21
PATIENT SAFETY STANDARDS OF NABH
FMSFMS 2: The organizations environment and facilities
operate to ensure safety of patients, their families, staff
and visitors.
FMS 5: The organization has plans for fire and non-fire
emergencies within the facilities. : e or an za on as a smo n m a on po cy.
FMS 7: The organization plans for handling community
emergencies, epidemics and other disasters.
FMS 8: The organization has a plan for management of
hazardous materials.
FMS 9: The organisation has systems in place to provide
a safe and secure environment.
-
8/3/2019 Patient Saftey
19/21
PATIENT SAFETY MEASUREMENTS IN
NABH
Patient fallPatient fallPatient fallPatient fall
Patient Bed soresPatient Bed soresPatient Bed soresPatient Bed sores
Adverse Drug reactionsAdverse Drug reactionsAdverse Drug reactionsAdverse Drug reactions
Medication errorsMedication errorsMedication errorsMedication errors
Adverse events analysisAdverse events analysisAdverse events analysisAdverse events analysis
Sentinel and near miss event analysisSentinel and near miss event analysisSentinel and near miss event analysisSentinel and near miss event analysis
Hospital acquired infection rates (RTI,UTI,IVDRI,SSI)Hospital acquired infection rates (RTI,UTI,IVDRI,SSI)Hospital acquired infection rates (RTI,UTI,IVDRI,SSI)Hospital acquired infection rates (RTI,UTI,IVDRI,SSI)
Variations observed in mock drillsVariations observed in mock drillsVariations observed in mock drillsVariations observed in mock drills
Security related incidences including theftsSecurity related incidences including theftsSecurity related incidences including theftsSecurity related incidences including thefts
-
8/3/2019 Patient Saftey
20/21
Our achievements of levels of Patient SafetyOur achievements of levels of Patient SafetyOur achievements of levels of Patient SafetyOur achievements of levels of Patient Safety
AreAreAreAre
Directly Proportional ToDirectly Proportional ToDirectly Proportional ToDirectly Proportional To
Level of Compliances achieved in meeting theLevel of Compliances achieved in meeting theLevel of Compliances achieved in meeting theLevel of Compliances achieved in meeting theStandardsStandardsStandardsStandards
LET US STRIVE TO ACHIEVE 100% COMPLIANCE TOLET US STRIVE TO ACHIEVE 100% COMPLIANCE TOLET US STRIVE TO ACHIEVE 100% COMPLIANCE TOLET US STRIVE TO ACHIEVE 100% COMPLIANCE TOPATIENT SAFETY STANDARDSPATIENT SAFETY STANDARDSPATIENT SAFETY STANDARDSPATIENT SAFETY STANDARDS
BECAUSEBECAUSEBECAUSEBECAUSE
WE ALL NEED THEMWE ALL NEED THEMWE ALL NEED THEMWE ALL NEED THEM
-
8/3/2019 Patient Saftey
21/21
THANK YOU FOR YOUR VALUABLE TIME
Hospital & Health Care Consultants