Patient Safety
Dr.Abhimanyu Bishnu
Patient safety is a healthcare discipline that emphasizes the reporting, analysis, and prevention of medical error that often lead to adverse healthcare events.
Methods: CQI on info, hardware, plant, policy
Recipients of care
Systems for therapeutic action designed to preempt/rescue from failure Preparation on: illness understanding, accessing care systems, advocacy
Workers: teams trained to preempt / rescue from / manage failure
Methods: CQI on: competence communication, A patient safety model of health care Emmanuel et al 2008 teamwork
Knowledge & Expertise
Patients
experience of illness social circumstances attitude to risk values preferences
Clinicians
diagnosis disease etiology prognosis treatment options outcome probabilities
Coulter A Picker Institute 2001
Important:
understand the multiple factors involved in failures avoid blaming practise evidence-based care maintain continuity of care for patients be aware of the importance of self-care act ethically everyday
Human factors
Human factors definition
the study of all the factors that make it easier to do the work in the right way apply wherever humans work also sometimes known as ergonomics
Human factors
acknowledges: the universal nature of human fallibility the inevitability of error assumes that errors will occur
designs things in the workplace to try to minimize the likelihood of error or its consequences
Human factors design principles
Psychomotor
- Hands
Senses
- Vision - Hearing
I N T E R F A C E
Input Devices
- Buttons
Output
- Display - Sound
US Department of Veteran affairs
Human factors
Importance of human factors has been recognized for a long time in: aviation nuclear power
Importance in health care?
only recently been acknowledged as an essential part of patient safety a major contributor to adverse events in health care all health-care workers need to have a basic understanding of human factors principles
Health care is increasingly complex
We cope quite well with complexity
Health-care workers are quite good at compensating for some of the complex and unclear design of some aspects of the workplace equipment physical layouts
Because the human brain is .
very powerful very flexible good at finding shortcuts (fast) good at filtering information good at making sense of things
Sometimes though our brain is too clever
Are the lines crooked or straight?
Optillusions.com
Look at the chart Say the colour of the word, not the word itself
Why is it hard?
Optillusions.com
The fact that we can misperceive situations despite the best of intentions is one of the main reasons that our decisions and actions can be flawed such that
Human beings make silly mistakes
Regardless of their experience, intelligence, motivation or vigilance, people make mistakes
Traps in health care?
look-alike and sound-alike pharmaceuticals equipment design, e.g. infusion pumps hand-offs and shift of level of care lack of verification during procedures/ medication
Avoidable confusion is everywhere
US Department of Veteran affairs
Look-alike, sound alike drugs
Name Confusion- 25% of all medication errors
The context of health care
When errors occur in the workplace the consequences can be a problem for the patient
a situation that is relatively unique to health care
Errors
One definition of human error is human nature
Error is the inevitable downside of having a brain!
What is an error?
the failure of a planned action to achieve its intended outcome a deviation between what was actually done and what should have been done
Reason
A definition that may be easier to remember is:
Doing the wrong thing when meaning to do the right thing. Runciman
Attentional slips of action Skill -based slips and lapses Lapses of memory
Errors
Rule -based mistakes
Mistakes
Know ledge -based mistakes
Reason
Error and outcome
error and outcome are not inextricably linked: harm can befall a patient in the form of a complication of care without an error having occurred many errors occur that have no consequence for the patient as they are recognized before harm occurs
Situations associated with an increased risk of error
unfamiliarity with the task* inexperience* shortage of time inadequate checking poor procedures poor human equipment interface
Vincent
* Especially if combined with lack of supervision
Individual factors that predispose to error
limited memory capacity further reduced by: fatigue stress hunger illness language or cultural factors hazardous attitudes
Fatigue
24 hours of sleep deprivation has performance effects ~ blood alcohol content of 0.1%
Dawson Nature, 1997
Stress and performance
Performance level
Area of optimum stress Low stress Boredom
High stress Anxiety, panic Stress level
The relationship between stress and performance
Yerkes, R. M., & Dodson, J. D. (1908) The relation of strength of stimulus to rapidity of habit-formation.
Journal of Comparative Neurology and Psychology, 18, 459-482
A performance-shaping factors checklist
I Illness M Medication
prescription, alcohol & others
S A F E
Stress Alcohol Fatigue Emotion
Jensen, 1987
Dont forget .
If youre
H ungry A ngry L ate or T ired ..
H A L T
Removing error traps
a primary function of an incident reporting system is to identify recurring problem areas - known as error traps (Reason) identifying and removing these traps is one of the main functions of error management
Error traps
Hindsight Bias
Before the Incident
After the Incident
Modified from Cook, 1997
Apply human factors thinking to your work environment
1. 2. 3. 4. 5. 6. Avoid reliance on memory Make things visible Review and simplify processes Standardize common processes and procedures Routinely use checklists Decrease the reliance on vigilance
Human factors engineering is about designing the workplace and the equipment in it to accommodate for limitations of human performance
Summary
errors are inevitable
there are situations that can increase the likelihood of error
recognize them for your patients sake - and yours!
attention to human factors principles can lead to a reduction in error or its consequences
Errors
medical error is a complex issue, but error itself is an inevitable part of the human condition learning from error is more productive if it is considered at an organizational level
Examples
order medications electronically
hand off information
If all of these tasks become easier for the health-care provider, then patient safety can improve.
Systems thinking
A system
any collection of two or more interacting parts, or
an interdependent group of items forming a unified whole
NPSEF (p. 202)
A complex system
many interacting parts difficult if not impossible to predict the behaviour of the system based on a knowledge of its component parts
Health care is a complex system
Complexity = increased chance of something going wrong!
Two schools of thought regarding iatrogenic injury
o traditional or person approach
* the old culture * just try harder
systems approach
* the new look
You may encounter a bit of both in your journey
Person approach
see an errors as the product of carelessness remedial measures directed primarily at the error-maker o o o o naming blaming shaming reassigning
Perspectives on error
An individual failing?
Not often the case
o o o o o people dont intend to commit errors
only a very small minority of cases are deliberate violations
wont solve the problem - it will make it worse countermeasures create a false sense of security
weve fixed the problem
clinicians will hide errors may destroy many clinicians inadvertently
the second victim
Systems approach
Investigate Analyze Correct Prevent
Why investigate?
the more we understand how and why these things occur, the more we can put checks in place to reduce recurrence
strategies might include:
education new protocols new systems
Multiple factors usually involved
patient factors provider factors task factors technology and tool factors team factors environmental factors organizational factors
Reasons Swiss cheese model of accident causation
Example- Acute Respiratory Distress Syndrome (ARDS)
Reasons - Defences
VA NCPS
Clinical risk management
Why clinical risk is relevant to patient safety
clinical risk management specifically is concerned with improving the quality and safety of health-care services by identifying the circumstances and opportunities that put patients at risk of harm and acting to prevent or control those risks
4-step process to manage clinical risks
identify the risk assess the frequency and severity of the risk reduce or eliminate the risk cost the risk
Incident Reporting
Near miss: Process variation which did not affect the outcome but for which recurrence carries a significant chance of serious adverse outcome, eg.patient falls in bathroom but is immediately supported by the accompanying nurse. Adverse event: Unanticipated, undesirable or potentially dangerous occurrence in a healthcare organization, eg. patient fall resulting in minor bruising; wrong medication resulting in a change of prescription.
Sentinel event: An unexpected event which involves death or serious physical and psychological injuries to a patient or employees, eg. patient fall resulting in internal head injury; patient suicide; infant abduction;wrong surgery done etc.
Incidents
Confirmed transfusion reactions Serious adverse drug events Medication errors Discrepancies between properative and postoperative diagnosis Adverse events associated with sedation and anaesthesia Infectious disease outbreaks Equipment- related Incidents Patient Falls in Ward Staff falls in Ward Needle Stick Injury Complaints by Patients and / or Relatives Cancellation of elective surgery Assault or battery of patients by employees or other persons
Incident monitoring
involves collecting and analysing information about any events that could have harmed or did harm anyone in the organization a fundamental component of an organizations ability to learn from error
Incident form pathway
Incident Reporting Form
Causes of incidents
Patient factors Task and technology factors Individual factors Team factors Work environment factors Other factors
Root Cause Analysis
Engaging with patients and carers
SEGUE framework
( Northwestern University)
o o o o o
Set the stage Elicit information Give information Understand the patients perspective End the encounter
Performance requirements
actively encourages patients and carers to share information shows empathy, honesty and respect for patients and carers communicates effectively obtaining informed consent shows respect for each patients differences, religious and cultural beliefs, and individual needs describes and understands the basic steps in an open disclosure process apply patient engagement thinking in all clinical activities demonstrates ability to recognize the place of patient and carer engagement in good clinical management
Gaining an informed consent
the diagnosis the degree of uncertainty in the diagnosis risks involved in the treatment the benefits of the treatment and the risks of not having the treatment information on recovery time name, position, qualifications and experience of health workers who are providing the care and treatment availability and costs of the services required
Harvard framework
preparing initiating conversation presenting the facts actively listening acknowledging what you have heard responding to any questions concluding the conversation documentation
SPIKES
o Sharpen your listening skills o Pay attention to patient perceptions o Invite the patient to discuss details o Know the facts o Explore emotions and deliver empathy o Strategize next steps with patient or family
Robert Buckland
Minimizing infection through improved infection control
What is the urgency?
We can no longer rely on antibiotics increased rates of nosocomial infections infected patients: stay longer in hospital die treated with more toxic and less effective drugs prone to surgical site infections
Campaigns to decrease infection rates
WHO Clean hands are safer hands campaign Centers for Disease Control and Prevention campaign to prevent antimicrobial resistance in health-care settings Institute for Healthcare Improvement 5 million lives campaign
Main causes of infection
person-person via hands of health-care providers patients and visitors personal equipment (e.g. stethoscopes, personal digital assistants) and clothing environmental contamination airborne transmission carriers on the hospital staff rare common-source outbreaks
Main types of infections
urinary track infections usually associated with catheters Surgical site infections blood stream infections associated with the use of an intravascular device pneumonia associated with ventilators other sites
Main types of infections
Burke J Infection control-a problem for patient safety New Eng Journal of Medicine
Prevention in hospitals
make sure- visibly clean increased cleaning during outbreaks use hypochlorite and detergents
Prevention through handwashing
how to clean hands rationale for choice of clean hand practice technique for hand hygiene protecting hands from decontaminates promoting adherence to hand hygiene guidelines
Protective equipment
gloves aprons face masks
Safe disposal of sharps
keep handling to a minimum do not recap needles; bend or break after use discard each needle into a sharps container at the point of use do not overload a bin if it is full do not leave a sharp bin in the reach of children
Act to minimize spread of infection
before contact with each and every patient:
clean hands before touching a patient clean hands before an aseptic task
after contact with each and every patient:
clean hands after any risk of exposure to body fluids clean hands after actual patient contact clean hands after contact with patient surroundings
My 5 moments for hand hygiene- WHO
Medication Safety
Medication
Definition: A chemical substance intended for use in the diagnosis, cure, investigation, treatment or prevention of disease.
Process in Medication
1. Prescription 2. Transcription 3. Dispensing 4. Administration & Documentation
Medication Errors (MEs)
1. Prescription 2. Transcription 3. Dispensing 4. Administration & Documentation
Wrong Drug (Look alike)
Orders for Vancomycin
Medication Errors
Please bring these to the notice of the Quality & Clinical Pharmacy deptts. Extremely important. The responsible person fills in an Incident Report..
Data will be collected and presented at the Quality Steering Committee.
All such Measures are used as Quality Indicators for evaluating statistically significant improvement.
Prescription
Drugs are ordered in Physician Order Sheet Document correct date,time and signature. Write in CAPITALS Mention i) Drug name , ii) Dose, iii) Route, iv) Frequency DISCONTINUE medication with date, time and signature. Dose changes to be done with date, time and signature. For discontinued medications cross out drug and after the last dose given
Contd
Use standard abbreviations. Write the date of new medication. Verbal orders to be used only in emergency situations e.g. Code Blue. Always use leading zeros for decimal points. E.g. .5 mg Digoxin ------- Incorrect Digoxin 0.5mg PO OD -------Correct
Contd
Orders should be legible, clear and with date, time and signature.
Can you read this???
All antibiotics to be charted in clinical chart. In case of antibiotic prescribed, no. of days should be mentioned. E.g. Inj. Cefrom 1gm iv BD ---- day 2 in clinical chart.
Transcription/ Indenting
Definition: Something written, especially copied from one medium to another as a type written version of dictation, as done in case of indenting a medicine ( copying drug order from drug chart to computer).
Transcription/ Indenting
Always spell check and indent. Verify correct name, UHID no. and bed no. Mention allergies in remarks column. Any doubt regarding medicine to be clarified with the prescriber.
Dispensing
Medications dispatched from from pharmacy.
Dispensing
No substitute or opened medication to be received. All medications to be received by T/L or assigned nurse. Check medications for their dose, expiry and quantity after receiving. All medications received should be kept under lock in bedside of the patient. Temperature of the fridge for medicine storage to be maintained at 2-8 degree celsius. Narcotics are stored under lock.
Administration
Process of giving drug used in the diagnosis, treatment, or prevention of a disease or as a component of a medication.
Administration
Always remember: Right patient Right drug Right dose Right route Right time Right documentation Self medication is not allowed. All medications to be known and checked and signed by 2 nurses. Prepare and label the medications. In case of antibiotics, a sensitivity test need to be done before administration.
Food drug reaction (FDR) and drug and drug Contd reactions (DDR) should be known. All medication dosage, indication, side effects, precautions and route should be known. Some high-risk medications are Vancomycin Digoxin IV Phenytoin Chemotherapeutic drugs Theophylline Warfarin Heparin Narcotics IV Iron Morphine Fentanyl Inj Insulin Some high alert medications are Concentrated electrolytes e.g. KCL, MgSO4, 10% dextrose.
Contd
Transdermal patches should be dated and timed on the patch and document. Remove old patches, clean the remaining medication from the skin. Administer all medicines one by one and observe for 5 minute for any allergy. Ensure that patient has taken oral medicine completely.
Contd
Iron to be started only after test by the doctor. Base line investigations for high risk medications e.g. PTT, ACT for heparin infusion. Monitoring of patients getting high risk medications.
Documentation
Process of transferring data or action into paper or computer record.
Documentation
Document the medication given with time, signature/name and emp ID no. Document the effect of medication if any. Incident forms to be filled in case of any medication errors. If medication is not given on time, it is considered as medication error.
Use standard timings for medication administration: OD 10AM, HS 10 PM, TDS OR 8 hrly 6 AM, 2 PM, 10 PM, BD OR 12 hrly 10am 10pm, OD warfarin 6PM/4PM, BD diuretics 6AM- 4PM. QID 6hrly 6AM- 12N - 6 PM 12MN. 4 hrly 0200- 0600 1000 1400 1800 2200 0200.
For making medication label, write: name of the medication, dilution, dosage, date, time, name and emp no. of the nurse making the medication. Record any known allergy. All medication can be administered with 1 hr e.g. If medication is to be given at 8.00am the nurse can give the medication between 7.00am to 9.00 am and document the exact time of administration like 8.25 am.
Medication Reconciliation
Collect accurate list o f the all possible current medications Compare it with the list against Admission Transfer Discharge The prescribes shall document the reconciliation process on the medication reconciliation list document in the comments section. Reason for holding, discontinuing or changing dose / frequently Any other pertinent medication information. Nurse shall enquire with the consultant regarding the use of current medication and these medications if available with patients to be sent to pharmacy for verification.
Home Medication & Self Administration No self medication of any kind is allowed in hospital. .
Adverse Drug Reaction (ADR)
Definition: Any harm associated with the use of drug at normal dose.
ADR levels
Level 1 ADE/ADR occurred but required no change in treatment with suspected drug Level 2 Drug held, discontinued or changed but no antidote or additional treatment needed. Level 3 Drug held, discontinued or changed AND/OR antidote or other treatment required. Level 4 ADE / ADR required patient transfer to an intensive care setting Level 5 ADE / ADR caused permanent harm to the patient Level 6 ADE / ADR either directly or indirectly led to the patients death
ADRs
Document all ADRs on ADR Form-send to Clinical Pharmacy. Please report suspected or confirmed ADRs on ADR Form. Incident Form to be filled for levels 4,5 and 6
Read Back Policy
Read back, verify, document verbal orders Applicable for; a) Code Blue Situation b) Critical Lab Values: The staff nurse has to read the value back to confirm and duly sign her name and clock no. and write the name and emp no. of the person who has given the report. c) Insulin orders: Eg: 29/04/08 6:00am 40 units Read back to Dr. -----------, signature, name of the staff and emp no.
Remember
Never leave Medicines unattended. Lock them in bedside cabinets. Label all Open In Use Vials.
Patient safety and invasive procedures
The main causes of adverse events associated with invasive procedural and surgical care
poor infection control methods inadequate patient management failure by health-care providers to communicate effectively before, during and after operative procedures
Requirements
follow a verification process to eliminate wrong patient, wrong side and wrong procedure practise operating room techniques that reduce risks and errors ( time-out, briefings, debriefings, stating concerns) participate in an educational process for reviewing surgical mortality and morbidity
Teamwork
A team is.
a distinguishable set of two or more people who interact dynamically, interdependently and adaptively towards a common and valued goal/objective/mission, who have been each assigned specific roles or functions to perform, and who have a limited lifespan of membership.
Eduardo Salas
What types of teams do you find in health care?
Many different teams are found in health care: o multiprofessional/drawn from a single profession o co-located/distributed o transitory or long standing
How do teams improve patient care?
o teams represent a pragmatic way to improve patient care o teams can improve care at the level of:
o o o o the organization the patient outcomes and safety the team as a whole the individual team member
What makes for a successful team?
Effective teams possess the following features: o a common purpose o measurable goals o effective leadership and conflict resolution o good communication o good cohesion and mutual respect o situation monitoring o self-monitoring o flexibility
Requirements
Practical tips to improve teamwork include:
o o o o o o o always introducing yourself to the team reading back/closing the communication loop stating the obvious to avoid assumptions asking questions, checking and clarifying delegating tasks to people not to the air clarifyng your role using objective (not subjective) language
Requirements
o learning and using peoples names o being assertive when required o if something doesnt make sense, finding out the other persons perspective o doing a team briefing before undertaking a team activity and a debriefing afterwards o when conflict occurs, concentrating on what is right for the patient, not who is right
Communication
A number of techniques have been developed to promote communication in health care including: o o o o SBAR (Situation, Background, Assessment, Recommendation) call-out check-back handover/handoff
In conclusion.
QUALITY AND PATIENT SAFETY
Quality & Patient Safety
Thank you!!!
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