Transcript Patient Safety Goals - Duchess of Kent

Overview of
Malaysian Patient Safety Goals
Orientation Program Duchess of Kent Hospital
Dr Paul Chan
Deputy Director HDOK
Adv Dip (Med Sci), MBBS, MBA (Healthcare Management)
Introduction
• The Malaysian Patient Safety Goals are designed :
• To stimulate health care organizations in improving patient
safety .
• To outline important patient safety areas that need to be
improved
• To act as a “Performance Measurement” in areas that are
critical to a safe health care system.
• For Patient Safety Council to monitor and evaluate the status
of patient safety in the country.
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Introduction
• Philosophy of Patient Safety Goals
• “Patient safety shall be given prime importance in health care
and preventable adverse events should be avoided at all costs”.
• Scope:
• Applicable to all public and private health care facilities
• Hospitals, medical clinics, dental clinics
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Derivation of Goals, Indicators & Targets
 Goals originally based on WHO Patient Safety Program Areas
and JCI Patient Safety Goals
 PIs and targets are based on:
 Philosophy of goals, current MOH standards, statistics on previous
performance of Malaysian health care facilities and consensus decision
of Patient Safety Council Members, Officers from State Health
Departments, Hospital Directors, Clinicians and discussion with Sir
Liam Donaldson (Patient Safety Advisor to WHO Director General)
 Initially there were 15 goals, 59 PIs which were reduced to 29
PIs after first meeting and further reduced to:
 13 goals and 19 PIs – for hospitals
 4 goals and 6 PIs – for clinics
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Malaysian Patient Safety Goals
1)
2)
3)
4)
5)
6)
7)
To implement Clinical Governance
To implement WHO’s 1st Global
Patient Safety Challenge: “Clean
Care is Safer Care”
To implement WHO’s 2nd Global
Patient Safety Challenge: “Safe
Surgery Saves Lives”
To implement WHO’s 3rd Global
Patient Safety Challenge: “Tackling
Antimicrobial Resistance”
To improve the accuracy of patient
identification
To ensure the safety of transfusions
of blood and blood products
To improve medication safety
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8) To improve clinical communication
by implementing a critical test and
critical value program
9) To reduce patient fall
10)To reduce the incidence of
healthcare- associated pressure
ulcer
11) To reduce Catheter-Related
Bloodstream Infection (CRBSI)
12) To reduce Ventilator Associated
Pneumonia (VAP)
13) To implement the Patient Safety
Incident Reporting and Learning
System
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Clinical Governance Framework
Accountable
Continuous
Improvement
of Service
Quality
Clinical
Governance
High
Standards of
Care
Excellence in
Clinical Care
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Source : UK NHS
NHS
Goal, Indicator & Target
Goal
no
1
Goal
Indicator
Target
To implement Implementation of
Clinical Governance
Clinical
Clinical Governance implemented
Governance
Clinical governance
• A framework through which organisations are accountable for continually improving the
quality of their services and safeguarding high standards of care by creating an
environment in which excellence will flourish.
•Corporate accountability for clinical performance
• Compliance to Clinical Governance can be evaluated using “Clinical Governance
Assessment Tool” available in “Guideline on Achieving Excellence in Clinical
Governance” produced by Patient Safety Council Malaysia & MOH
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Goal, Indicator & Target
Goal no Goal
Indicator
Target
2
Hand hygiene
compliance rate
≥ 75% at
each audit
To implement
WHO’s 1st Global
Patient Safety
Challenge: “Clean
Care is Safer Care”
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Goal no
Goal
Indicators
3
To implement
WHO’s 2nd Global
Patient Safety
Challenge: “Safe
Surgery Saves
Lives”
1. Number of
wrong surgery
performed
zero
2. Number of
retained foreign
body
zero
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Target
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Goal no Goal
4
To implement
WHO’s 3rd
Global Patient
Safety
Challenge:
“Tackling
Antimicrobial
Resistance”
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Indicators
Target
Incidence rate of
MRSA infection
≤ 0.4% /month
Incidence rate of
ESBL – Klebsiella
pneumoniae
≤ 0.3%/month
Incidence rate of
ESBL-E.coli
infection
≤ 0.2%/ month
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Goal
no
Goal
Indicator
5
To improve the
accuracy of patient
identification
Compliance rate of 100%
at least 2
identifiers
implemented
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Target
11
Goal no
Goal
Indicators
6
To ensure the
safety of blood
and blood
products
No of transfusion error Zero
(actual)
No of ‘near misses’
during the transfusion
process
Target
-
Transfusion error (actual): wrong pack of blood or its product is given for the patient
Transfusion error (near miss): transfusion error that almost occur but prevented/
intervened resulting in no harm
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Goal no Goal
7
•
•
•
Indicators
To improve
1. No of medication
medication safety error (actual)
2. No of medication
error (near miss)
Target
Zero
-
Type of Medication error - Prescribing error, Omission error, Wrong time error,
unauthorized drug error, Dose error, Dosage form error, Drug preparation error , Route of
administration error, Administration Technique error, Deteriorated drug error, Monitoring
error, Compliance error
Medication error (actual) – An error occurred and reached the patient
Medication error (near miss) - An error occurred but the error did not reach the patient,
managed to be intervened
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Goal
no
Goal
Indicator
8
To improve clinical
% of critical value
communication by
notified within 30
implementing a
minutes
critical test and
critical value program
Target
100%
Definitions
Critical test: test which requires rapid communication of result.
Critical value: unexpected result that fall significantly outside the
normal range and has the potential for serious adverse outcome to the
patient if not dealt with promptly.
Criteria
Inclusion: critical list provided by hospital
(chemical pathology/ hematology tests)
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List of Critical Test - Haematology
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List of Critical Test – Chemical Pathology
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Goal
no
9
Goal
Indicators
Target
To reduce
patient fall
1. Number of fall
(adult)
10% reduction per
year based on
previous year’s data
as a baseline
2. Number of fall
(pediatrics)
10% reduction per
year based on
previous year’s data
as a baseline
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Goal no Goal
10
Indicator
To reduce the
Incidence rate
incidence of
of pressure
healthcareulcer
associated pressure
ulcer
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Target
≤3%
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Goal no
Goal
Indicator
11
To reduce Catheter- Rate of CRBSI
Related
Bloodstream
Infection (CRBSI)
Target
<5 per 1000
catheter days
Central Venous Catheter Care Bundle (CVC-CB)
It consists of five evidence-based procedures recommended by
CDC (Center of Disease Control and Prevention)
1. Hand hygiene
2. Maximal barrier precautions upon insertion
3. Chlorhexidine skin antisepsis
4. Optimal catheter site selection, with subclavian vein as the
preferred site for non-tunneled catheters
5. Daily review of line necessity with prompt removal of
unnecessary line
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Goal no Goal
Indicator
Target
12
Rate of VAP
<10 per
1000
ventilator
days
To reduce
Ventilator
Associated
Pneumonia (VAP)
*VAP: Ventilator Associated Pneumonia: Pneumonia that occurs after 48
hours of intubation
The ventilator care bundle has four key components:
1. Elevation of head of the bed to between 30- 45 degrees
2. Daily sedation vacation
3. Peptic ulcer disease prophylaxis
4. Deep venous thrombosis prophylaxis unless contraindicated
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Goal no Goal
Indicator/s
Target
13
Implementing of
Incident Reporting
system (including
RCA) or other
methods to
investigate the
incidents (e.g
clinical audit)
System
implemented
To implement the
Patient Safety
Incident Reporting
and Learning System
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[email protected]
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SUMMARY
• Malaysian Patient Safety Goals is ready for implementation nation wide this year June
2013
• Need to know what to do to ensure patients safety
• Prevent litigation
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