Professional Documents
Culture Documents
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.
Recipients of care
Systems for therapeutic action designed to preempt/rescue from failure Preparation on: illness understanding, accessing care systems, advocacy
Methods: CQI on: competence communication, A patient safety model of health care Emmanuel et al 2008 teamwork
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
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
Psychomotor
- Hands
Senses
- Vision - Hearing
I N T E R F A C E
Input Devices
- Buttons
Output
- Display - Sound
Human factors
Importance of human factors has been recognized for a long time in: aviation nuclear power
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
Errors
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
Attentional slips of action Skill -based slips and lapses Lapses of memory
Errors
Rule -based mistakes
Mistakes
Reason
Fatigue
24 hours of sleep deprivation has performance effects ~ blood alcohol content of 0.1%
Dawson Nature, 1997
Performance level
S A F E
Dont forget .
If youre
H ungry A ngry L ate or T ired ..
H A L T
Error traps
Hindsight Bias
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
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
systems approach
* the new look
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
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
Reasons - Defences
VA NCPS
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
Causes of incidents
Patient factors Task and technology factors Individual factors Team factors Work environment factors Other factors
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
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
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
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
Protective equipment
gloves aprons face masks
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
Please bring these to the notice of the Quality & Clinical Pharmacy deptts. Extremely important. The responsible person fills in an Incident Report..
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.
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. .
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
Remember
Never leave Medicines unattended. Lock them in bedside cabinets. Label all Open In Use Vials.
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
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.
Thank you!!!
www.powerofteamworkmovie.com