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An Imperative for Performance Improvement. PATIENT SAFETY. Neil G. Jaymalin, RN, MBAH, CQA February 26, 2010. Definition. Patient Safety is a new healthcare discipline that emphasizes the reporting, analysis, and prevention of medical error that often lead to adverse healthcare events.
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An Imperative for Performance Improvement PATIENT SAFETY Neil G. Jaymalin, RN, MBAH, CQA February 26, 2010
Definition • Patient Safety is a new healthcare discipline that emphasizes the reporting, analysis, and prevention of medical error that often lead to adverse healthcare events.
Fall Prevention Pressure Ulcers Hand Hygiene Surgical Fire Wrong Site / Patient Surgery • Patient Identification • Proactive Risk Assessment • Medication Safety • Patient Involvement • Staff Communication
Medication Safety • Accounted for 9.9% of the sentinel events reviewed by JCI • Policy cascade and promotion • High Alert Meds • PCA • SALAD • Labels • Reconciliation (Drug Profile)
Standards • Joint Commission – covers from prescription to administration including monitoring of medication effect to patient
Approach to Safety • Leadership driven culture of safety • Improve reporting of errors by establishing a non – blame environment • Evaluate where technology can help reduce the risk of medication error
Establish a fool proof method of controlling high alert medications • Patient Involvement • Establish a controlled formulary
Medication Error Reported medication error / total dispensed medication * 1000 Benchmark = 3.1 %
Practice Recommendation • Reporting • Safety Walkrounds • FMEA
Reporting • The primary purpose of patient safety reporting systems is to learn from experience. • It is important to note that reporting in itself does not improve safety. It is the response to reports that leads to change. • (WHO Guidelines for Adverse Event Reporting and Learning Systems, 2005)
Characteristics of Successful Reporting Systems (7) • Non-punitive • Reporters are free from fear of retaliation against themselves or punishment of others as a result of reporting. • Confidential • The identities of the patient, reporter, and institution are never revealed.
3. Independent • The reporting system is independent of any authority with power to punish the reporter or the organization. 4. Expert analysis • Reports are evaluated by experts who understand the clinical circumstances and are trained to recognize underlying systems causes.
5. Timely Reports • are analyzed promptly and recommendations are rapidly disseminated to those who need to know, especially when serious hazards are identified. 6. Systems-oriented • Recommendations focus on changes in systems, processes, or products, rather than being targeted at individual performance.
7. Responsive • The agency that receives reports is capable of disseminating recommendations. Participating organizations commit to implementing recommendations whenever possible.
Safety WalkRounds • A “Safety WalkRound” is a process whereby a group of senior leaders visit areas of a health-care organization and ask front-line staff about specific events, contributing factors, near misses, potential problems, and possible solutions.
Can often result in prompt changes that improve care and safety. • It also can lead to culture change, as the concerns of front-line staff are addressed. • front-line staff are engaged in continuous observation of hazards and solutions for discussion with senior leadership.
Leadership walkrounds are a low-cost way to identify hazards of concern to front-line staff and make needed changes. • Require no additional staff, equipment, or infrastructure.
Failure Modes and Effects Analysis • Failure modes and effects analysis (FMEA) is a widely used tool for proactively identifying process vulnerabilities. • It begins by systematically identifying each step in the process and then searches out “failure modes”, that is, noticing what could go wrong.
The next step is to evaluate how the failure mode could occur, and what are the “effects” of this failure. • If a failure mode could result in catastrophic effects, the process must be corrected or buffered. • The FMEA is a proactive tool, used to evaluate a new process, or an existing process for proposed design changes.
