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Chapter 9 [1]

Chapter 9 [1]. Patient Safety. 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]

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Chapter 9 [1]

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  1. Chapter 9[1] Patient Safety

  2. 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] ETM 591

  3. Agenda • 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 ETM 591

  4. Current Patient Safety Goals[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 ETM 591

  5. Objectives From the Assessment of Safety Cultures ETM 591

  6. How to Implement a Patient Safety 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) ETM 591

  7. How to Develop Patient Safety 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 ETM 591

  8. Common Safety Analysis Methods • Technic of Operation Review (TOR) • Fire Drill • Seat Belt Checks • Seeking Feedback ETM 591

  9. Common Safety Analysis Methods • Root Cause • Analysis (RCA) • Also known as: • “The 5 Why’s” ETM 591

  10. Common Safety Analysis Methods • Root Cause Analysis (RCA) ETM 591

  11. Common Safety Analysis Methods 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. • Hazard Operability Analysis (HAZOP) * Human Element is NOT the focus! ETM 591

  12. Common Safety Analysis Methods • Hazard Operability Analysis (HAZOP) ETM 591

  13. Common Safety Analysis Methods • Failure Modes and Effect Analysis (FMEA) • Per System: • Item(s) • Function(s) • Failure(s) • Effect(s) of Failure • Cause(s) of Failure • Current Control(s) • Recommended Action(s) ETM 591

  14. Common Safety Analysis Methods ETM 591

  15. Common Safety Analysis Methods • Fault Tree • Analysis (FTA) ETM 591

  16. Common Safety Analysis Methods • Fault Tree Analysis (FTA) ETM 591

  17. Summary • 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 ETM 591

  18. 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 Where to Get More Information ETM 591

  19. Dr. Joan Burtner burtner_j@mercer.edu Jason Coggins Jermaine Early Eric Hudnall Joshua Smith Where to Get More Information ETM 591

  20. [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. References ETM 591

  21. Questions? ETM 591

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