Participants will provide hands-on practice to demonstrate experienced safety measures that can be implemented at hospital. Finally, the instructor will present significant safety measures to the entire group as a method of sharing everyone’s experiences during this workshop.
§ HIPPOCRATIC OATH I will prescribe regimens for the good of my patients according to my ability and my judgment and ”never do harm” to anyone.
§ Improving Patient Safety means reducing patient harm.
§ Hospitals were founded to give care to those who need it and to keep patients safe is their moral duty
§ “ Working Together Towards Patient Safety” What is Patient Safety? Patient Safety is the avoidance, prevention and amelioration of adverse outcomes/ injuries stemming from the process of health care
2. Policy on Patient Safety Goal: To ensure that the patient safety is institutionalized as a fundamental principle of the health care delivery system in improving health outcomes.
3. Patient Safety Plane. PURPOSE OBJECTIVE: To provide a planned, ongoing, comprehensive, coordinated and integrated Hospital- wide mechanism to objectively and systematically monitor and evaluate the safety of patient care, promptly identify and resolve problems, plan education to improve patient safety and to reduce medical errors throughout the organization.
4. The essential elements of the program include:
• The integrated Patient Safety Committee, supported by the CEO, have the authority to recommend changes and take necessary actions in order to make improvements to patient care services provided.
5. Responsibility for Patient Safety activities are shared by the Medical Staff Departments, Patient Care Services, the Clinical Support Services and all other hospital departments
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•being a leader and advocating for change; •generating and sharing knowledge and expertise; •supporting Member States in their implementation of patient safety actions. Our vision
•Every patient receives safe health care, every time, everywhere.
5s WHO Project Patients for Patient Safety Catalyze Technology for Patient Safety Research for Patient Safety countries’ action
International safety of care Special projects:
Assuring Medication Accuracy at Transitions in Care;
Communication During Patient Care Handovers;
Improved Hand Hygiene to Prevent Health Care-Associated Infections;
Performance of Correct Procedure at Correct Body Sites
Impact will be measured using the following tools: Root cause analyses of indicator events and other adverse events
Patient safety indicators Cultural assessments Economic impact indices.
Patients know that their ailments may not always be cured, but they don’t expect to be inadvertently harmed during their medical care.
• The “blame and train” approach to medical errors and close calls doesn’t work well.
• human factors engineering techniques tease out root causes of medical errors and close calls.
* Playing the Blame Game:
An Ineffective strategy for improving patient safety
• Preventing inadvertent harm to patients requires use of human factors engineering principles.
• In other high hazard jobs such as airplane flying and running nuclear reactors, systems have been developed to minimize risks based on the science of human factors engineering.
• Broaden dimensions
• human factors engineering
• fatigue & stress management
• effective communication
• shared awareness
• briefings, debriefings
• workload distribution
• graded assertiveness
• A voluntary (without jeopardy) reporting culture
• Recurring statutory examinations
• Systems development
• Safety analysis of data
• Acceptance that staff make mistakes • Role of teamwork
§Improve the accuracy of patient identification.
§Improve the effectiveness of communication among caregivers
.§Improve the safety of using medications.§
Reduce the risk of healthcare associated infections.
§Accurately and completely reconcile medications across the continuum of care
.§Reduce the risk of patient harm resulting from falls.
§Special emphasis on ,Dangerous abbreviations, infection control, “Look alike and sound-alike” medications, time out
§ There is a direct link between work environment and patient safety
§ Therefore, if not addressing work environment, we are not addressing patient safety
§ Healthy work environments do not just happen
§ Therefore, if we do not have a formal program in place addressing work environment issues, little will change
§ Creating healthy work environments requires changing long-standing cultures, traditions and hierarchies
§ Therefore, though everyone must be involved in the creation of healthy work environments, the onus is on organizational, departmental and unit leaders to ensure that it happens
• Adequate light• Adequate ventilation, exhaust fan• Stairs with hand rails
• Slip preventing floors• Fire extinguishers and fire alarms• Prevent noise pollution
• Heavy and fixed beds• Safe wheel chairs and trolleys
• No water logging in bathrooms• Call bell system for patients
• Adequate no. of bed screens to maintain privacy of the patient.
1. Illegible Writing prescription by doctors.
2. Wrong medicines or wrong does or wrong patient.
3. Wrong injection, wrong does or wrong patient, wrong route of administration.
4. Drip sets, air bubbles, over hydration, drip speed.
5. Oxygen flow check empty gas cylinders.
14. Clear, written medication guidelines.
15. Identification of each patient with Similar patient names
16. Proper handing taking over during change of shift.9. Look alike and Sound Alike “LASA”
· TIPS FOR IMPROVING PATIENT SAFETY1. Constitution of Patient Safety Committee
· .2. Develop clear policies and protocols for patient safety.
· 3. Discuss regularly patient safety initiative within hospital staff.
· 4. Orientation, Re-orientation hospital staff on patient safety
· 5. Encourage transparency in the regular death review.
· 6. Non- punitive incident reporting by staff.
· 7. Each department to devise their own patient safety protocols.
· 8. Investigate each accident/ incident reported and take remedial measures
· .9. Review, monitor & evaluate. safety procedures regularly
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