6/3/2017

Hospital Committees
Part 4
Prof (Col) Dr RN Basu
Adviser, Quality & Academics
Executive Director, AHA Kolkata

Safety committee Safety committee

• As per NABH, the hospital has a structured
patient safety programme (CQI 2)
• This safety programme is developed,
implemented and maintained by a
multidisciplinary committee called safety
committee
• Patient safety is “prevention of harm to
patients”
• Composition
– In safety committee all stakeholders
pertaining to safety are represented
– The committee consists of:
• Representation from management
• Major clinical departments
• Hospital engineer

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Safety committee Safety officer

• Nursing superintendent/Dy Nursing • A senior level officer will be nominated
superintendent as hospital safety officer
• Radiation safety officer
• The safety officer will coordinate and
• Representative from hospital laboratory
implement hospital safety programme
• Pharmacist
• Hazardous materials manager
• The safety officer should have knowledge
• Biomedical engineer
about patient safety as well as general
safety

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Safety committee Safety Committee

• Goals
– Maintain a safe environment and working condition for patients,
• The safety committee should meet at
personnel and visitors least quarterly
– Reduce and control environmental hazards and potential safety-
related risks in the entire hospital • The committee is required to develop
– Reduce and prevent incidents, accidents and injuries to patients,
staff and visitors hospital safety programme
– Provide education to all personnel on the risk and safety
management programme • The safety officer implements the
– Promote a culture of safety and develop the culture of reporting
in a non-punitive approach, throughout the hospital programme

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Patient safety Environment of Care

• There are basically two sources of patient • Activities that accomplishes safety from
harm:
environment of care are:
– Harm from environment of care
– Harm that may arise from delivery of health – Reduce and control the environmental
care hazards and risks
• Environment of care – Prevent accidents and injuries
– The goal of environment of care Programme is
to provide a safe, functional and effective – Maintain safe conditions for patients, staff
environment for patients, staff and visitors and visitors

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Environment of Care Environment of Care

• There are 7 areas included under the • Patient safety
Environment of Care:
– Helping to prevent slips, trips and falls
– Fire safety
– Utility Systems – Guarding against burns
– Medical Equipment – Lifting and moving patients safely
– Emergency Management – Protecting patients’ rights
– Safety
– Security
– Reporting all incidents immediately
– Hazardous Materials
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Environment of Care Environment of Care

• Security Management • Hazardous Materials and Waste
Management
– Wear your ID badge at all times
– Be aware of the hazardous materials in your
– Call security immediately if you need help workplace
– Park in assigned areas – Request a copy of a Material Safety Data Sheet
(MSDS) if you have questions on the hazardous
– Do not allow people in areas where they do chemicals in your area
not belong – Wear appropriate Personal Protective
Equipment before when handling hazardous
materials
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Environment of Care Environment of care

• Emergency Preparedness • Other Disaster Plans
– Various codes are used (Not standardized)
– Civil disturbance
– Examples:
• Code Yellow Disaster – Utility alert
• Code Red Fire
• Code Blue Medical Emergency – Community hazardous materials release
• Code Grey Severe Weather – Major communicable disease response
• Code Pink Neonatal Medical Emergency
• Code Violet Radiation Spill
– Emergency plans are part of hospital safety
manual
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Environment of Care Environment of Care

• Medical Equipment Management
– All new medical equipment must be evaluated
by Clinical Engineering
• Familiarise with the procedures for proper use of
equipment
• Immediately remove faulty equipment from service
and tag it for repairs
• Notify your supervisor if faulty equipment has
caused serious harm to patients or employees
• ECRI Institute issues top10 technology
hazards warning each year. For 2013 these
are:
– Alarm hazards
– Medication administration errors using
infusion pumps
– Unnecessary exposures and radiation burns
from diagnostic radiology procedures
– Patient/data mismatches in EHRs and other
health IT systems

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Environment of Care Environment of Care

– Interoperability failures with medical devices and
health IT systems • Utilities Management
– Air embolism hazards – Electricity
– Inattention to the needs of paediatric patients when
using “adult” technologies – Water
– Inadequate reprocessing of endoscopic devices and – Medical gas
surgical instruments
– Caregiver distractions from smartphones and other – Transportation system
mobile devices – HVAC
– Surgical fires

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Healthcare Delivery Process Patient Safety Solutions

• Medication management • With the growing recognition of safety
• Surgical safety problems in health care, WHO disseminates
• Laboratory safety “Solutions” for patient safety
• Radiation safety • Nine Patient Safety Solutions
• Hospital Associated Infection 1. Look-Alike, Sound-Alike Medication Names
2. Patient Identification
• Transfusion safety
3. Communication During Patient Hand-Overs
• Nursing care
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Patient Safety Solutions Hospital Safety Programs

4. Performance of correct Procedure at Correct Body
Site
5. Control of Concentrated Electrolyte Solutions
6. Assuring Medication Accuracy at Transition in Care
7. Avoiding Catheter and Tubing Mis-Connections
8. Single Use of Injection Devices
9. Improved Hand Hygiene to Prevent Health Care
Associated Infection
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• An annual safety plan will be developed by
the safety Committee
• The plan will be disseminated to all
concerned
• The plan will be reviewed every quarter
• The safety officer will carry out facility safety
round every 4 months to identify
environmental deficiencies, hazards, and
unsafe practices
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Hospital Safety Programs

• A summary report of findings and status of
improvement projects will be provided to the safety
committee
• Fire and Disaster Drills will be carried out every
quarter and deficiencies noted will be rectified
• Preventive maintenance of all life support equipment
will be done as per equipment management plan
• All incident reports and sentinel events will be
reviewed, Root Cause Analysis Done and Corrective
and Preventive actions taken

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Sexual Harassment at workplace Application of the Law

• To protect women from sexual harassment
an Act has been promulgated by the
Parliament:
• The Act is entitled:
– The Sexual Harassment f Women at Workplace
(Prevention, Prohibition and Redressal) Act No
14 of 2013
– The Act provides for the prevention and
redressal of complaints of sexual harassment
• The law applies to
– Women harassed in the workplace
– Women working as domestic workers,
– Daily wagers,
• temporary or permanent,
• full-time or part-time, as well as
• volunteers.
– The women may or may not be employed and can be of
any age.
– The law is only applicable to women and women only.

Other Conditions Considered as Sexual

What Sexual Harassment Includes
Harassment
• Sexual harassment includes any one or more • The following circumstances also count as sexual
harassment:
of the following unwelcome acts or behavior: – Implied or explicit promise of preferential treatment in
– Physical contact or advances employment
– A demand or request for sexual favours – Implied or explicit threat of detrimental treatment in
employment
– Making sexually coloured remarks – Implied or explicit threat about her present or future
– Showing pornography employment status
– Interferes with work or creates an intimidating/ hostile/
– Any other unwelcome physical, verbal or non- offensive work environment
verbal conduct of sexual nature – Humiliating treatment likely to affect the woman’s
health and safety

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Where the Act of Sexual Harassment
Can Occur
• The act of harassment can occur in the
workplace and
– While visiting a place arising out of or
during the course of employment
– This also includes:
• transportation provided by the office
• In these circumstances also a complaint
can be filed under this Act.
Composition
• The composition shall be as umder:
– A Presiding Officer
• Shall be a women employed at a senior level at
workplace from amongst the employees
– Two or more members from amongst
employees
• They should preferably be committed to the cause
of women, or
• Have experience in social work, or
• Have legal knowledge
Conciliation
• The Act provides:
– On the request of the woman
• An option exists for settlement between the
aggrieved woman and the responded
• This is done through conciliation
– However, money compensation cannot be
a basis for the settlement.
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Internal Complaints Committee
• Internal Complaints Committee
– Every employer of a workplace shall constitute a
committee for addressing the issue of sexual
harassment
– This will be done by an order in writing
– The committee is known as Internal Complaints
Committees
– The committee shall address the issue of sexual
harassment.
– There will also be a Local Complaints Committee for
each District where complaints can be filed.
• An aggrieved woman can file a complaint within 3 months
of the incident (or later if allowed by the committee)
Composition
– One member from amongst NGO, or
• Association committed to the cause of women, or
• A person familiar with the issues relating to sexual
harassment
• At least one-half of the total members so
nominated shall be women
• The Presiding Officer and other members
shall hold office not exceeding three years
Time Period and False Complants
• The inquiry has to be completed within 90 days.
• In case of malicious complaints or false
evidence,
– The Committee may take action against the
woman/person.
– However, simply not being able to prove an
allegation will not mean that it is a false/malicious
complaint.
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Confidentiality Prevention of Sexual Harassment

• Confidentiality and identity shall be • Preventive responsibility as per the Act
maintained of the – Employers’ responsibility
– aggrieved woman,
• To hold regular workshops/awareness
– respondent, programmes
– witnesses • Display the consequences of harassment in the
• Identity as well as other details of the workplace.
complaint cannot be published or disclosed • Every employer has a duty to provide a safe
to the public/media working environment to all employees

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