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Improving Patient Safety

Crossing the Quality Chasm

SAFETY IN HEALTHCARE

  • In the 2001 IOM report Crossing the Quality Chasm: A New Health System for the 21st Century
  • safe healthcare is one of the six dimensions of healthcare quality.

Safety programs

Case

Healthcare facilities have had safety programs in place for many years. The purpose of these programs is to provide an environment in which hazards are eliminated or minimized for employees, staff, patients, and visitors.

Activities

Safety is promoted via several activities,

Risk management

Emergency preparedness

Activities

hazardous materials management,

Radiation safety,

Environmental safety and hygiene, security, and preventive maintenance.

When an error occurred

The person involved usually was blamed for being careless, incompetent, or thoughtless.

Organizations focused on training and hiring competent people, believing they would be less likely to make mistakes. This reliance on healthcare professionals to perform faultlessly was misguided

Error occurred

Patient safety

Patient safety improvement

Patient safety improvement initiatives are an important component of a healthcare organization’s overall quality management effort.

PREVENTING MISTAKES

PREVENTING MISTAKES

Most mistakes are not intentional but occur because a process is complex. Even simple patient care processes are complex in terms of the variables involved

The hospital process of obtaining a blood specimen for laboratory testing

Example 1

Example 1

The method used to order the test (handwritten or electronic),

1.

The patient’s location

2.

The method used to collect the specimen

3.

The type of vials used to store the blood

4.

The method of laboratory analysis and The manner in which results are reported

5

Figure

Make errors impossible

Make errors impossible

  • Heating devices that shut off automatically so they are not left on all day
  • Circuit breakers that trip when circuits are overloaded
  • Computer disks that have overwrite protection

A hospital’s medication administration process

A hospital’s medication administration

Patient Safety Topics and System-Level Measures

System-Level Measures

Patient Safety Topics

Patient Safety

Topics

  • Malfunction of a medical device resulting in actual or potential patient injury
  • Diagnostic or testing problem (e.g., delay in testing or reporting, failure to report significant abnormal results, wrong test ordered)

Report

Report

Bar Graph of Incidents

Bar Graph of

Patient Incidents

Practices

These groups identified the following five practices as important to increasing the quantity and quality of employee incident reports (O’Leary and Chappell 1996)

  • Protect people involved against disciplinary proceedings (as far as practical).
  • Allow confidential reporting or de-identify the reporter.
  • Separate the agency or department collecting and analyzing the reports from those that have the authority to institute disciplinary proceedings and impose sanctions.
  • Provide rapid, useful, accessible, and intelligible feedback to the reporting community.
  • Make reporting easy.

Practices

AHRQ

AHRQ, the federal entity responsible for administering the PSO(patient safety organizations) provisions of the Patient Safety Act, is starting the PSO selection process

IMPROVING PATIENT SAFETY

Practice

Projects aimed at improving patient safety follow the same steps as any other project:

1. Define the improvement goal.

2. Analyze current practices.

3. Design and implement improvements.

4. Measure success

Rapid cycle improvement (RCI) was used to improve patient satisfaction

RCI

An outpatient clinic could use RCI to reduce prescription errors Two improvement models

are used by healthcare organizations for the explicit purpose of making patient care safer:

failure mode and effects analysis and root cause analysis.

Case

Failure Mode And Effects Analysis

Failure Mode

Failure mode and effects analysis (FMEA) is a proactive risk assessment technique that involves a close examination of a process to determine where improvements are needed to reduce the likelihood of adverse events (McDermott, Mikulak, and Beauregard 1996).

Technique

Technique

The technique is considered proactive because the improvement project is undertaken to prevent an adverse event. The FMEA technique promotes systematic thinking about the safety of a patient care process in terms of the following questions:

  • ​​ What could go wrong?
  • ​​ What will be the result if something goes wrong?
  • ​​ What needs to be done to prevent a bad result when something does go wrong?

The goal of an FMEA project is to find these hazards and make process changes to reduce the risk of error. FMEA is a formal and systematic assessment process, but individuals informally use FMEA almost every day.

FMEA

FMEA Steps

FMEA

Steps

FMEA Steps in Relationship to PDSA Cycle

FMEA Steps

First Two Steps in Hospital Laboratory Testing Process and Failure Modes

Testing Process

Potential failure modes

A criticality score is assigned to each potential failure on the basis of the following criteria:

  • Frequency: the probability that the failure will occur
  • Severity: the degree of harm the patient would experience if the failure o occurred
  • Detection: the likelihood that the failure will be detected before patient harm occurs

Potential failure modes

Calculate Score

Calculate Score

Each of these criteria is rated on a scale of one to five, with one as the lowest possible rating and five as the highest. Once the rating process is complete, a criticality score is assigned to each potential failure.

This score is calculated by multiplying the frequency score by the severity score by the detection score.

score = Frequency score X severity score X detection score

ROOT CAUSE ANALYSIS

ROOT CAUSE ANALYSIS

Root cause analysis (RCA) has been used for many years in other industries.

Example

NASA’s (2003) use of RCA to investigate the Space Shuttle Columbia disaster

Safety improvement teams use RCA after an adverse event has occurred to determine system deficiencies that led to the event. The six steps involved in RCA follow the Plan-Do-Study-Act Cycle

Improvement

RCA Steps in Relationship to PDSA Cycle

RCA Steps

near miss

near miss is an incident that did not result in death or injury but could have; only by chance was the patient not harmed.

near miss

High-Level Flowchart of Event

High-Level

Flowchart of Event

Cause and Effect Diagram for Wrong-Site Surgery

Wrong-Site

Surgery

PATIENT ENGAGEMENT IN SAFETY

  • A patient safety observation by authors of the IOM (1999) report To Err Is Human involved the role of patients in preventing medication errors:
  • Patients themselves also could provide a major safety check in most hospitals, clinics, and practice. They should know which medications they are taking, their appearance, and their side effects, and they should notify their doctors of medication discrepancies and the occurrence of side effects.

PATIENT ENGAGEMENT IN SAFETY

Errors in Saudi Arabia

The aim of the study (lshaikh, M., Mayet, A., & Aljadhey, H. (2013)) was to explore the reporting rate of medication errors and the factors associated with the root causes of these errors in a large tertiary teaching hospital in Saudi Arabia.

This study was conducted at the University Teaching Hospital, Riyadh, Saudi Arabia.

All incidence/variable reports of medication errors were documented in a hospital web-based medication error form designed to capture information on all aspects.

Medication errors were reviewed and reported at quarterly intervals over one year (November 2009 to October 2010).

Study Approach

Result

  • The medication error rate over the 1-year study period was
  • 0.4% (949 medication errors for 240,000 prescriptions).
  • During this period, 14 (1.5%) errors were categorized as resulting in any harm to the patient (all category E). Medication errors were reported predominantly at the prescribing stage of the medication process (89%).
  • The most common types of errors were prescribing (44%) and improper dose/quantity (31%). Antibiotics (12%), antihypertensive agents (10%), and oral hypoglycemic agents (8%) were the pharmacological classes of medication most commonly involved with errors. Nonspecific performance deficit (43%), knowledge deficit (28%), and illegible or unclear handwriting (17%) were the main reported causes of error.

Results

Conclusion

Medication errors are underreported in a tertiary

teaching hospital in Riyadh, Saudi Arabia. Future studies should evaluate the effectiveness of interventions to stimulate medication errors

reporting by health-care providers.

Conclusion

1. Spath, P., & DeVane, K. A. (2009). Introduction to healthcare quality management (Vol. 2). Chicago, IL: Health Administration Press.‏

2. Al-Abbadi, H. A., Basharaheel, H. A., Alharbi, M. R., Alharbi, H. A., Sindi, D., & Bamatraf, M. (2019). Patients’ perspectives of surgical safety before and after their elective Surgeries at King Abdulaziz University Hospital, Jeddah, Saudi Arabia. Cureus, 11(11).‏

3. Kaldjian, L. C., Jones, E. W., Wu, B. J., Forman-Hoffman, V. L., Levi, B. H., & Rosenthal, G. E. (2008). Reporting medical errors to improve patient safety: a survey of physicians in teaching hospitals. Archives of internal medicine, 168(1), 40-46.‏

4. Alshaikh, M., Mayet, A., & Aljadhey, H. (2013). Medication error reporting in a university teaching hospital in Saudi Arabia. Journal of patient safety, 9(3), 145-149

References

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