COMPREHENSIVE MEDICAL SAFETY PROGRAM

1. COMPREHENSIVE MEDICAL SAFETY PROGRAM Sample Plan Premier Safety Institute July 2002

2. WHY DEVELOP A PROGRAM? • To improve the quality of care • JCAHO patient safety standards • Institute of Medicine Report has galvanized the public and payors (eg, The Leapfrog Group) • Legislation likely • Mandatory reporting system being developed (state/federal) • OSHA, state-OSHA plans (employee safety) • Other regulatory agencies

3. CRITICAL ELEMENTSCREATING A SAFETY CULTURE • Demonstrate top leadership commitment to safety • Swift and visible correction of unsafe conditions • Established procedures for reporting unsafe conditions • Anonymous • Non-punitive • Reward workers for following procedures • “Near misses” included • Involve frontline healthcare workers in identifying problems and solutions • Physician leader of program has authority to make necessary changes

4. WHY INCLUDE NEAR MISSES? • Must identify near misses to accurately estimate risk • Good opportunity to capture information via clinical information systems • Incident reporting systems • Fewer cultural issues • Anonymous • No direct harm for patient • No direct liability for harm • Potential liability in future patient nothing is done

5. VALUE OF A COMPREHENSIVE PROGRAM • Reduce fear of reporting errors/near misses, gather more data • Reduce errors through tracking, trending,analysis, and targeted improvement projects • Reduce errors through prevention • Improve quality as well as patient and employee satisfaction • Reduce costs associated with errors, including litigation • Marketing opportunity

6. CRITICAL COMPONENTS

7. ELEMENTS OF EMPLOYEE SAFETY • Blood and body fluid exposures • Latex allergies • Communicable disease exposures • Musculoskeletal injuries • Immunization program • Systematic review, follow-up, and reporting of employee incidents

8. ELEMENTS OF PATIENT SAFETY • Adverse drug events(ADE)/ medication errors (ME) • Restraint use • Nosocomial infections • Surgical mishaps • Pressure ulcers • Blood product safety/administration • Antimicrobial resistance • Immunization program • Falls • Blood stream - vascular catheter care • Systematic review, follow-up, and reporting of patient/visitor incident reports

9. ENVIRONMENTAL SAFETY • Product/drug recalls • Product malfunction • Construction and Infection Control Risk Assessment (ICRA) • Air quality • Proper air changes/hour in bone marrow transplant unit, OR, invasive procedure areas • Airborne infection isolation (AII) rooms • Water quality • Dialysis • Endoscopy • Ice machines

10. Key Work Group Members • Physicians • Epidemiology/Infection Control • Environment of Care • Risk Management • Corporate Compliance • Clinical Resource Management/Quality Improvement Services • Pharmacy • Procurement/Materials Management • Patient Services/Nursing • Information Services • Occupational Health Services/Employee Health • Laboratory • Ad Hoc Members

11. Key Committee Liaisons • Infection Control Committee • Environment of Care Committee • Medication Use and Therapeutics Committee • Value Analysis Team or Product Evaluation) • Blood Products Utilization/Laboratory • Other (Safer Sharps, Immunization Task Force, etc.) • JCAHO Steering Committee/Functional groups

12. SuggestedReporting Relationships • Medical Work Groups report regularly to leadership/quality/medical safety • Physician with responsibility for Medical Safety reports regularly to senior leadership

13. Next Steps • Draft model • Identify Work Group Members • Identify parameters to be measured (definitions, etc.)

14.  2002 Premier Safety Institute Web site www.premierinc.com/safety Adapted with permission, Tammy Lundstrom MD, Detroit Medical Center,Quality ServicesDetroit, MI July 9, 2002