Risk Management

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Group Members
Lim Keng Li 10A558E Liu Weihua 10A561H Nur Shida Zainal Abidin 10A569A Xu Shuhui 10A580R Hussni Bin Satiman 10A361G Li Jie 10A364W Santhiya Sammugam 10A369Y
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Objective
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Introduction Risk management Problems identify Root cause analysis Strategies Key performance index Conclusion

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RISK MANAGEMENT

Managing risks proactively

Making an assessment of what can possibly go wrong, developing a plan to manage these risks, acting on the plan, harnessing the efforts of the team and 4/29/12 then recognizing improvements

It is simply not acceptable for patients to be harmed by the same health care system that is supposed to offer healing & comfort
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(Kohn, Corrigan & Donaldson, 1999, cited in

Mr. Siva aged 75 years old is scheduled for elective haemorrhoidectomy and sigmoidoscopy the next morning. Senior Staff Nurse (SSN) Ong was required to serve tab lorazepam 10mg to him at 2200 hours on the night before the operation as premedication. Mr. Siva informed SSN Ong that he would take the medication later as he was not sleeping 4/29/12 yet. SSN Ong left the medication on the

At 0600 hours the next morning, SSN Ong instructed Enrolled Nurse (EN) Siti to administer fleet enema to Mr. Siva. EN Siti had a hard time waking Mr. Siva to administer the fleet enema as he was sleeping really soundly but EN Siti was able to administer the fleet enema to him eventually. As Mr. Siva was still sleeping after the fleet enema, EN Siti put up the bed rails and left 4/29/12 the cubicle.

At 0630 hours, Senior Staff Nurse (SSN) Ong was informed by EN Siti that Mr. Siva had a fall. On investigation, Mr. Siva was seen lying face down on the floor, bleeding from his forehead. He was quickly assisted back to his bed. A physical examination was done by SSN Ong and revealed that Mr. Siva had sustained a 2cm cut at his right forehead.
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According to Mr. Siva he claimed that he wanted to go to the toilet after the fleet enema and decided to climb over the bed rail. He felt giddy and fell on his way to the toilet. Mr. Siva was seen by the ward doctor and his surgeon who confirmed that he required toilet and suture to his forehead instead of haemorrhoidectomy and sigmoidoscopy as this elective operation may be cancelled due to his head injury. Mr. Siva informed SSN Ong that he had taken the
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Identify the Problems!!

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Not well orientated on how to use bed rail Dosage for Lorazepam is a very high dose Left medication on patients locker follow up on consumption of

4/29/12 No

No explanation regarding purpose of medication Patient was not monitored after given sedation Did not seek approval before administration of fleet enema was not informed that he may need to go to the toilet after the

Patient 4/29/12

Treat the risk Evaluate and priorities the risk

Analysis the risk Identify the risk Establish the context

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The Clinical Risk Management Process

Communication and Consultation

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Clearly defined objectives for communication Identification of work flows and perspectives need to be taken into account during the risk management process Development of communication strategies to be used during the risk management process Processes to be used to measure and evaluate the effectiveness of the organization's communication programs.

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Fishbone
Pt refused listen to staff

Patient
Staff never explains the precaution of med

Staff
No knowledge about the effect of sedative Assume pt already knows Time limited Assume Dr always right No habit of doing that No monitor pt after heavy dose of sedative

Pt climbed up from cot side Pt confused Pt went to toilet without telling staff Pt took medicine at wrong time Pt did not bother staff Not familiar of cot side bed

Staff has no knowledge about it Staff never checks the dosage with Dr before serve

Pt refused listen to staff

Pt did not know

Pt had no knowledge of medicine

Pt forgot to take

Pt refused listen to staff

Fall
Not familiar/compliance with the hospital policy* Long service Time limited No proper training Faulty on the cot side bed Lack of maintenance Lack of proper assessment

No immediate action Time limited Risky environment Time limited No habit of doing that

Short cut practice

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Policy

Environment

Policy*-medication administration & fall prevention

Strategies to Improve Patients Safety

v v v v

Revision of hospital policies Change Champions Educational Sessions Carrying out the policies (Reminders & Identification Systems Audit & Feedback

Identific ation

Interven tion

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Evaluati on & monitori

Identification

Revision of hospital policies

v

Recommendations by

Evidenced-based studies MOH guidelines other hospitals guidelines Incidents Reports, error rates learning from experiences, root cause analysis

Incidences

Implementing protocols according to patient needs Using triggers to implement protocols

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Identification

Revision of hospital policies

v v

Environmental Safety Plan Operational

Develop safety plan on maintain safe environment Include physicians & employees Conduct walk-around inspections Correct identified risks Encourage reporting unsafe or potentially hazardous

conditions Immediately remedy high risk situations

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Identification

Change Champions

v v v v

Multi-disciplinary team Oversee the planning Implementation of interventions to promote safety Senior staffs to encourage nurses to comply to strategies.

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Intervention

Educational Sessions
v

Workshops for nurses on:

Hospital Policies: Fall Risk reassessment, 5

rights of medication administration. medications correctly tools

Importance of Fall Prevention, administering Fall Risk and medication errors preventions
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Intervention

Reminders & Identification Systems

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Mandatory Fall Risk Assessment Tool Assessing and reassessing patient and modifying as appropriate Reminders Strategies

Wrist tag Fall risk identifiers at bed 4/29/12Side effects highlighted with drug package

Evaluation & monitoring

Audit & Feedback

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Internal & external ward audits Incidences Report (Medication errors & Falls)
Reporting (internal and external) Measuring/monitoring error rates

Feedback from the ground

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F C all hecklis t
Complete falls risk assessment Document falls risk rating and strategies Educate patients, families and staff Call buzzer, walking aids and belongings in reach Bed low, brakes on Reduce clutter Well-fitted, non-slip footwear

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CRITERIA Bed in lowest position

- We aim for the bed to be in the lowest position if appropriate All beds were in the lowest position possible

RESULTS

Brakes locked on - All bed brakes were locked Buzzer within reach - all patients could reach their buzzer Chair appropriate height. I.e. patient can sit on chair with feet resting on the floor
Twelve patients had chairs at their bedside. All chairs were of an appropriate height

Safe access to all personal needs i.e. within arms reaches

One patient was unable to access their personal needs

Non-essential items removed from the bedside

Three patients had non-essential items beside the bed, possibly impacting on safety

Patient able to mobilize independently. Walking aid not within reach

All patients who were able to mobilize independently had their walking aid within reach

Patient requires assistance to mobilize. Walking aid not within reach Four patients with a mobility aid were noted to require assistance to mobilize None of these patients were able to reach their walking aid

Bed rails down- We aim to have bed rails down if appropriate

Two patients did have their rails up

If bed rails up-Documented reason for falls in care plan

Both patients using bed rails were noted to have bed rail use documented on the care plan

Falls risk assessment form completed

Two patients did not have a falls risk assessment form completed

Falls risk rating on care plan completed

Of the 21 charts reviewed, two patients did not have a falls risk rating documented as they were on a clinical pathway Eight patients had a LOW Falls Risk Rating Seven patients had a MEDIUM Falls Risk Rating Four patients had a HIGH Falls Risk Rating

Key performance index of fall mangement % to meet % of staff who has received fall management education 100% % of high risk patients with risk assessment form 100% % of high risk patients with action plan 100% % of high risk patients being audited weekly (depending on the number of identified patients) Num of patients who had a fall Immediate intervention provided to patient who had a fall List the interventions provided: EHOR reported 4/29/12 Yes/No

100% within (5-10)mins

If all these strategies are in place

Mr Siva would not had fall because SSN Ong ( ) would have the knowledge ( ) and information to identify ( ) Mr Siva as a high risk for fall patient ( ) due to sedative drug and would alert EN Siti ( ) to prevent a fall incident in her ward ( ). Mr Siva will be taught by SSN Ong on fall prevention and will be mindful of his surroundings such as call bell.( ).
Change champion Identification system Audit Education 4/29/12 Fall prevention policy Reminder system Environmental Safety Plan

If all these strategies are in place

Mr Siva would not had fall because SSN Ong (Change champion) would have the knowledge ( ) and information to identify ( ) Mr Siva as a high risk for fall patient ( ) due to sedative drug and would alert EN Siti ( ) to prevent a fall incident in her ward ( ). Mr Siva will be taught by SSN Ong on fall prevention and will be mindful of his surroundings such as call bell.( ).
Change champion Identification system Audit Education 4/29/12 Fall prevention policy Reminder system Environmental Safety Plan

If all these strategies are in place

Mr Siva would not had fall because SSN Ong (Change champion) would have the knowledge (Education) and information to identify ( ) Mr Siva as a high risk for fall patient ( ) due to sedative drug and would alert EN Siti ( ) to prevent a fall incident in her ward ( ). Mr Siva will be taught by SSN Ong on fall prevention and will be mindful of his surroundings such as call bell.( ).
Change champion Identification system Audit Education 4/29/12 Fall prevention policy Reminder system Environmental Safety Plan

If all these strategies are in place

Mr Siva would not had fall because SSN Ong (Change champion) would have the knowledge (Education) and information to identify (Identification system) Mr Siva as a high risk for fall patient ( ) due to sedative drug and would alert EN Siti ( ) to prevent a fall incident in her ward ( ). Mr Siva will be taught by SSN Ong on fall prevention and will be mindful of his surroundings such as call bell.( ).
Change champion Identification system Audit Education 4/29/12 Fall prevention policy Reminder system Environmental Safety Plan

If all these strategies are in place

Mr Siva would not had fall because SSN Ong (Change champion) would have the knowledge (Education) and information to identify (Identification system) Mr Siva as a high risk for fall patient (Fall prevention policy) due to sedative drug and would alert EN Siti ( ) to prevent a fall incident in her ward ( ). Mr Siva will be taught by SSN Ong on fall prevention and will be mindful of his surroundings such as call bell.( ).
Change champion Identification system Audit Education 4/29/12 Fall prevention policy Reminder system Environmental Safety Plan

If all these strategies are in place

Mr Siva would not had fall because SSN Ong (Change champion) would have the knowledge (Education) and information to identify (Identification system) Mr Siva as a high risk for fall patient (Fall prevention policy) due to sedative drug and would alert EN Siti (Reminder system ) to prevent a fall incident in her ward ( ). Mr Siva will be taught by SSN Ong on fall prevention and will be mindful of his surroundings such as call bell.( ).
Change champion Identification system Audit Education 4/29/12 Fall prevention policy Reminder system Environmental Safety Plan

If all these strategies are in place

Mr Siva would not had fall because SSN Ong (Change champion) would have the knowledge (Education) and information to identify (Identification system) Mr Siva as a high risk for fall patient (Fall prevention policy) due to sedative drug and would alert EN Siti (Reminder system ) to prevent a fall incident in her ward (Audit). Mr Siva will be taught by SSN Ong on fall prevention and will be mindful of his surroundings such as call bell.( ).
Change champion Identification system Audit Education 4/29/12 Fall prevention policy Reminder system Environmental Safety Plan

If all these strategies are in place

Mr Siva would not had fall because SSN Ong (Change champion) would have the knowledge (Education) and information to identify (Identification system) Mr Siva as a high risk for fall patient (Fall prevention policy) due to sedative drug and would alert EN Siti (Reminder system ) to prevent a fall incident in her ward (Audit). Mr Siva will be taught by SSN Ong on fall prevention and will be mindful of his surroundings such as call bell. (Environmental Safety Plan).
Change champion Identification system Audit Education 4/29/12 Fall prevention policy Reminder system Environmental Safety Plan

References
Bates, D. W., Leape, L. L., Cullen, D. J., Laird, N., Petersen, L. A., Teich, J. M., Burdick, E., Hickey, M., Kleefield, S., Shea, B., Vliet, M. V. & Seger, D. L. (1998). Effect of computerized physician order entry and a team intervention on prevention of serious medication errors. JAMA [Online serial], 280(15), 1311-1316. Available: h http://www.safetyleaders.org/SafePracticeArticles/effect_of_cpoe_an d_a_team_intervention.pdf (2011, March 23) v Center for Health Care Strategies. (2007). Care Management Definition and Framework. America: New Jersey. v Crowther, A. (2004). Nurse managers: A guide to practice. Melbourne: Ausmed Publications Pty Ltd. v Department of Health Government of Western Australia. (2009). Clinical Risk Management Guidelines for the Western Australian Health System Series No.8 [Online serial]. Available: h http://www.safetyandquality.health.wa.gov.au/docs/clinical_risk_man/ Clinical_risk_man_guidelines_wa.pdf (2011, March 23)
v

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References
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Koh S.L.S., Hafizah N., Lee J.Y., Loo Y.L., Muthu R., (2009) Impact of a fall prevention programme in acute hospital settings in Singapore. Singapore Med J, 50(4), 425-432. Kuhn A. M., Youngberg B. J. (2002). The need for risk management to evolve to assure a culture of safety. Qual Saf Health Care, 15(11), 158162. Stuart E., Kirstine K., Martin P. (2002). Improving Patient Safety: Insights from American, Australian and British Healthcare. United Kingdom: Department of Health.

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