Health Safety Officer Certificate


Introduction

Patient safety is to prevent harm to patients during the process of healthcare, Please do no harm”

Objectives

To highlight the main principles and strategies of health care, as a requirement for passing NEBOSH certification for the year 2018.

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.

Activity Time
  1. ORIGIN OF PATIENT SAFETY CONCEPT

§ 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

  1. Department Chiefs of all hospital departments are responsible for the ongoing education, monitoring, and evaluation in preventing, detecting and correcting medical errors within their departments Summary WHO SURGICAL SAFETY CHECKLIST • The primary benefit of the checklist may be to engage the medical team. • By using the checklist, we may be gaining the ability to open communication by the medical team, to encourage teamwork behaviors, & to develop discipline in the team. • Reducing sentinel error 35

 

  1. 36. INSTALLATION HAZZARDS1. Regular checking of equipments2. Proper earthling to avoid shock3. Regular maintenance & repair4. Training of nurses & technical staff5. How do you control hazards?• Preventing inadvertent harm to patients requires use of human factors engineering principles.6. The “hierarchy of hazard control:”• Eliminate hazard• Guard against hazard• Train to avoid hazards• Warn against hazards

 

  1. 37. NEW DEVICES• Acceptance, safety inspection, compatibility, education, procedures, and appropriate purchasing documents (including loan agreements).• When in doubt, have CE (Certified Equipment)check, supply chain management .(SCM),

 

  1. 38. WHY REPORTING MEDICAL DEVICE PROBLEMS• Prevent future problems and protect patients, staff, families, and visitors• Achieve performance improvement goals• Assist Risk Management with claims or litigation• Provide information to manufacturers and/or Food and Drug Administration• Publicize report for the general good of patients and health care providers• Effect changes in policies and procedures of procurement

 

  1. 39. WHEN TO REPORT• When you think a device has or may have caused or contributed to any of the following outcomes (for a patient, staff member or visitor): – Death – Serious injury – Minor injury – Close calls or other potential for harm

 

  1. 40. INDIVIDUAL’s ROLE• Identify actual and potential problems, adverse events, close calls with medical devices• Report the problem or adverse event to your supervisor, according to policy and procedure• Make sure your report includes details• Remove the device, keep all affected items, save the packaging
1st day  5:00- 9:00 PM
  1. The information collected addresses the requirements of NEBOSH for a Patient Safety Program.
  2. •Appropriate actions are taken to resolve identified problems and/or identified opportunities to improve patient care and non-clinical services rendered.
  3.  •The information derived from each department’s monitoring, evaluation and improvement activities is shared with other departments as deemed necessary by the Department Chief and is integrated with information obtained from other hospital-wide patient safety activities as appropriate.
  4.  •The Patient Safety program is reviewed annually to assure the program’s objectives are attained and that improvement to patient care and service delivery is made.
  5. II. DEFINITIONS OF TERMS The following definitions are uniformly used in the hospital’s Incident Report, Sentinel Event and other relevant environment of care and medication use policies.
  6.  •Sentinel Event Unexpected incident involving death or serious physical or psychological injury, or the risk thereof. The fundamental objective of sentinel event reporting is corrective in nature and the identification of appropriate actions to prevent recurrence.
  7.  •Near Miss or “close call” An event or situation that could have resulted in an accident, injury, or illness, but did not, either by chance or timely intervention. It is a serious error or mishap that has the potential to cause as adverse event but fails to do so because of chance or because it is intercepted.
  8.  •Latent Failure An error precipitated as a consequence of management and organizational processes that poses the greatest danger to complex systems. Latent failures cannot be foreseen but, if detected, they can be corrected before they contribute to mishaps.
  9.  •No Blame Culture A non-punitive encouraging voluntary reporting of adverse events.
  1. •Risk Is any exposure to a harmful event. It is directly related to hazard and vulnerability and, inversely, to capacity. PATIENT INVOLVEMENT• Patient Advocate – For friends and family – Willingness to go with the patient to appointments, be with them in the hospital and clinics – Listening and taking notes – Speak up when necessary to clarify an issue and to ask a question – Question when something does not seem right in the hospital, nursing homes, clinics, etc.
  2. 57. PREVENT MEDICAL ERRORS BY MEDICAL STAFF Communication & coordination deficits drive errors§Application of Aviation Safety concepts & skills are being introduced in healthcare§Strong Correlation between Teamwork results in: •Improved Patient Outcomes •Patient Satisfaction •Staff Satisfaction •Reduced Errors •Reduce malpractice claims •Reduce ‘Blame culture’
  3. 58. vTWO-CHALLENGE RULE :§It is your responsibility to assertively voice your concern at least two times to ensure that it has been heard§The member being challenged must acknowledge§Provide supporting information with second challenge§If the outcome is still not acceptable use ‘CUS’ Concern, Un comfortable , Stop Take a stronger course of action “Empower any member of the team to “stop the line” if he or she senses or discovers an essential safety breach.”
  4. 59. EFFECTIVE COMMUNICATION
  5. Communication Breakdowns Contributing Factor in43% of adverse surgical eventsvPivotal Factor in 65% of Sentinel Events (3,000events 1995-2005) (Joint Commission on Accreditation of Healthcare Organizations. (2006)vPrimary contributing factor in adverse events 70-80%of root cause analysis (National Center for Patient Safety(2006). Root Cause Analysis Database)v Common in: •Medical errors •Medical malpractice cases •Adverse surgical events •Adverse medical events •Sentinel events
  6. 60. ADVERSE INCIDENT REPORTING• Complete and submit• Notify Risk Management• Drug controller notification if Medical Device or Medication• Begin Root Cause/Intensive analysis to examine process changes that may prevent future events• Take preventing measures for future near miss.
  7. 61. PEER REVIEWvMonitor and improve physician care of patientsvAccomplish by: •Open, non-punitive discussion •Review and discuss alternatives •Disseminate to ALL physicians •Monthly review schedule Move towards: review previous 48 hour record (Code Blue) •Could this event have been prevented? •Were signs of deterioration missed? Elevated BP, dropping BP Elevated HR, dropping HR Elevated RR
  8. 62. HEALTH EXECUTIVE’S ROLE ü Set Culture üAccountability üMeasures üHigh Reliability/Redesign üCommunication and Teamwork üProfessional Development q Reliability principles: ü simplification ü standardization ü relation of humans to the work ü environment
  9. 63. BARRIERS TO IMPLEMENTATION SOURCE: INTERNATE
  10. 64. PRATICE OF PATIENT SAFETY ( WHO )1. Be aware of Look-Alike, Sound-Alike Medication Names.
  11. 2. Proper Patient Identification.
  12. 3. Explain in Detail During Patient Hand/Take- Over’s.
  13. 4. Performance of Correct Procedure at Correct Body Site.
  14. 5. Careful About Electrolyte Imbalance.
  15. 6. Assuring Proper Treatment During Shifting.
  16. 7. Avoid Catheter and Tubing, Wrong Connections .8. Single Use of Injection Syringes
  17. .9. Improved Hand Hygiene to Prevent Health Care- Associated Infections .
  18. 10. Proper Disposal of BMW and Good House Keeping.
  19. 11 Practice Surgical Safety Guide Lines.
2ND DAY 5:0 -9:0 PM
  1. HUMANE ERROR “ To Err Is HUMANE” “Human beings make mistakes because the systems, tasks and processes they work in are poorly designed.” (Professor Lucian Leap, testifying to the US President’s Commission on Consumer Protection and Quality in Health) ØEvery Error has a root cause and every cause has a solution. ØOne Un willful Error is a miss ØRepeated Error is a Crime. Errors can be prevented with Every one’s Initiative in the system.“HERE COMES THE ROLE OF PATIENT SAFETY
  2. §The mission of WHO Patient Safety is to coordinate, facilitate and accelerate patient safety improvements around the world by:

•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.

  1. Patient Safety Challenges : Solutions to improve1. Clean Care is Safer Care patient safety
  2. Safe Surgery Saves Lives High

5s WHO Project Patients for Patient Safety Catalyze Technology for Patient Safety Research for Patient Safety countries’ action

International safety of care Special projects:

  1. The solutions are: Managing Concentrated Injectable Medicines;

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.

  1. PATIENT SAFETY INITIATIVE•

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

 • teamwork

• Countermeasures

 • briefings, debriefings

• workload distribution

 • cross-monitoring

• graded assertiveness

 • checklists

  1. LESSONS FOR HEALTH FROM THE AIRLINE INDUSTRY • Statutory reporting of procedures

• A voluntary (without jeopardy) reporting culture

 • Recurring statutory examinations

• Systems development

 • Safety analysis of data

• Acceptance that staff make mistakes • Role of teamwork

  1. PATIENT SAFETY GOAL

§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

  1. Types of safety environmental medical surgical safety
  2.  Safety equipment patient safety electrical safety installation safety sanitation blood safety infection control laboratory safety bmw disposal
  3. WORK ENVIRONMENT SAFETY

§ 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

  1. ENVIRONMENTAL SAFETY

• Adequate light• Adequate ventilation, exhaust fan• Stairs with hand rails

• Window-door-closer

• 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.  MEDICAL SAFETY

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

3RD DAY 5:0-9:0 PM
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