Transcript Sept23 Ch 9 Patient Safety Graduate Student Presentation rev2

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]
– At least 50% of medical equipment in most
developing countries is not in usable condition
[3]
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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
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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
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Objectives From the Assessment
of Safety Cultures
Profiling
Accreditation
Measuring
Change
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Benchmarking
Awareness
Enhancement
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How to Implement a Patient Safety
Program (8-Step Process)








Step 1:
Step 2:
Step 3:
Step 4:
Step 5:
Step 6:
Step 7:
Step 8:
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Perform safety climate survey
Educate staff members about safety education
Survey staff members in regard to safety concerns
Take an in-depth look
Plan and implement necessary improvements
Document the results
Share the stories
Repeat step 1 (safety climate survey)
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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
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Common Safety Analysis Methods

Technic of Operation Review (TOR)
Fire Drill
Seat Belt Checks
Seeking Feedback
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Common Safety Analysis Methods
Root Cause
Analysis (RCA)

Also known as:
“The 5 Why’s”
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Common Safety Analysis Methods

Root Cause Analysis (RCA)
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Common Safety Analysis Methods

Hazard Operability Analysis (HAZOP)
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.
* Human Element is NOT the focus!
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Common Safety Analysis Methods

Hazard Operability Analysis (HAZOP)
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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)
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Common Safety Analysis Methods
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Common Safety Analysis Methods
Fault Tree
Analysis (FTA)

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Common Safety Analysis Methods

Fault Tree Analysis (FTA)
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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
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Where to Get More Information

http://jama.ama-assn.org/cgi/content/full/280/16/1444

http://jama.amaassn.org/cgi/content/full/jama%3B287/15/1993

http://muse.jhu.edu/journals/journal_of_health_care_fo
r_the_poor_and_underserved/v020/20.1.dingham.html
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Where to Get More Information

Dr. Joan Burtner
– [email protected]




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Jason Coggins
Jermaine Early
Eric Hudnall
Joshua Smith
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References
[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.
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Questions?
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