PATIENT

SAFETY
 Content
■ INTRODUCTION
■ INSTITUTION OF MEDICINE ( IOM ) IMPERATIVES, PRIORITIES AND COMPETENCIES
■ PATIENT SAFETY CULTURE SURVEY
■ JUST CULTURE
■ ROLE QF BOARD IN PATIENT SAFETY
■ HEALTHCARE SAFETY PROGRAM DEVELOPMENT
■ HEALTHCARE SAEETY AND TECHNOLOGY
■ HEALTH CARE SAFETY NOSOCOMIAL INFECTION
■ NEVER EVENT
■ PATIENT SAFETY AS QUALITY MEASURE
■ ORGANIZATIONS HAVING AN IMPACT ON HEALTHCARE SAFETY
■ MEDICATION ERRORS
 Introduction of Patient Safety
■ INTRODUCTION

 Patient Safety: is the absence of preventable harm to a patient during the process of Healthcare.

 Patient Safety Practice: is a type of process or structure whose application reduces the Probability of
adverse events resulting from exposure to healthcare system.

 Accreditation and regulatory agencies such as Joint Commission are supporting the movement to
reduce errors.

 Mistake-proofing (Poka-Yoke): the use of processor design features to prevent errors or the negative
impact of errors (Grout, 2007).

 There are many proposed solutions to improving patient safety, from computerizing order entry
systems (CPOE) to having patients indicate on their bodies, using markers, the area to be operated
on.

 To increase patient safety, healthcare organizations need to conduct a thorough analysis of where
and how patients are at risk for potential medical errors.
 Six Key Areas of Patient safety:

■ Safe Structure
■ Safe environment
■ Safe equipment
■ Safe processes
■ Effect of staff
■ Effect of leadership & Culture
 Approaching patient safety within an organization requires a
review in Six key areas:

■ Safe structure: involves reviewing whether the facilities are

designed to promote safety, right supplies are being ordered,
and policies/ procedures address safety considerations.

■ Safe Environment includes an assessment of lighting,

temperature, noise levels. surfaces, storage and ergonomics.

■ Safe equipment/technologies include an examination of

labels, instructions. and safety features to be sure that
potential errors can be avoided when using various devices.
 Approaching patient safety within an organization requires a
review in Six key areas:

■ Safe Processes include an assessment of whether redesign

would improve safety by looking at some factors: complexity,
inconsistencies, and time constraints.
■ The effect of people (i.e., staff) on patient safety requires
attention to many factors. For example, employee attitudes,
motivation, health, education, training and cognitive
functioning can have an impact upon the likelihood of a
medical error.
■ The leadership/culture can drive safety issues when there is a
willingness to allocate appropriate resources (e.g., staff
equipment), analyze processes, implement changes, support
non-punitive error-reporting, and promote evidence-based
practice.
 Domains of Patient safety:

■ Risk management
■ Team work
■ Safety climate
■ Job satisfaction
■ Optimal personal factor
■ Stress recognition
 INSTITUTION OF MEDICINE ( IOM ) IMPERATIVES, PRIORITIES AND COMPETENCIES

■ To Err is Human
■ Changing the Health care Delivery System
■ Policy and Healthcare Quality
 To Err is Human

■ To Err Is Human: Building a Safer Health System, clearly caught the

attention of providers, payers, and consumers by showing the direct relationship between quality of care
and patient outcomes. Further, Becher and Chassin have pointed out that patients suffer harm because
of three types of quality issues:

 Underuse is when patients do not receive beneficial health services (e.g., 5o% of heart attack
victims fail to receive beta-blockers).

 Overuse would be when patients undergo treatment or procedures from which they do not
benefit (e.g., 50% of X rays in back pain patients are unnecessary).

 Misuse is when patients receive appropriate medical services that are provided poorly, exposing
them to added risk of preventable complications.
 Changing the Health care Delivery System

■ The IOM (2001) stated that healthcare frequently harms and routinely
fails to deliver its potential benefits and that care was not being provided
using the best scientific knowledge

■ The report suggested an agenda for "crossing the chasm" by changing

the healthcare delivery system. The agenda for “Crossing the chasm” by
changing the healthcare delivery system “ The Agenda includes the
following components”
 Changing the Health care Delivery System
 Health care professionals, regulators, and consumers should commit to six aims (STEEEP) for
improvement that can raise the quality of care to unprecedented levels.

 Clinicians, patients, and healthcare organizations need to adopt a new set of principles to guide the
redesign of care processes.

 The government must identify a set of priorities to focus initial efforts, provide resources to stimulate
innovation, and initiate the change process.

 Healthcare organizations need to design and implement more effective support processes to make
change in the delivery of care possible.

 An environment needs to be created that fosters and rewards improvement by creating an

infrastructure to support evidence-based practice, facilitates the use of information technology, aligns
payment incentives, and prepares the work force to better provide care to patients in the context of
ever-expanding knowledge and rapid change.
 Changing the Health care Delivery System
■ The IOM's Committee on Quality of Health Care in America established aims for the 21st- century
healthcare system. The committee proposed six improvement aims (Key Quality Dimensions). They
suggested that healthcare at a minimum should be

■ Safe avoid injuries to patients from care that is intended to help them
■ Timely reduce waits and avoid harmful delays for both who receive and who give care
■ Effective provide care based on scientific knowledge to all who could benefit
■ Efficient avoid waste, including waste of equipment, supplies, ideas and energy
■ Equitable care should not vary in quality because patients' personal characteristics such as gender,
ethnicity, geographic location and socioeconomic status.
■ Patient-centeredd care should be respectful and responsive to patient preferences, needs, and values.
Changing the Health care Delivery System

■ The IOM has also defined the core competencies required for
healthcare professionals as they relate to quality and safety. These
competencies include:
1. Provide patient-centered care
2. Work in interdisciplinary teams
3. Employ evidence based practice
4. Apply quality improvement
5. Utilize informatics
 Policy and Healthcare Quality

■ The National Association for Healthcare Quality (NAHQ), in its Code of Conduct
and Standards of Practice for Healthcare Quality Professionals, proposes that
healthcare quality professionals agree to uphold and promote the dignity of the
profession and be committed to :

1. Practicing the profession with honesty, integrity, and accountability.

2. Maintaining the level of competency as outlined in the Standards of Practice for Healthcare
Quality Professionals.
3. Seeking the trust and confidence of all customers
4. Supporting the Standards of Practice for Healthcare Quality Professionals and Respecting all laws,
and avoiding involvement in any false, fraudulent or deceptive activity.
5. Promoting the right of privacy for all individuals and protecting the maintenance of Confidential
information to the fullest extent permitted by law.
 Policy and Healthcare Quality

6. Using expertise to inform employers or clients of possible positive and negative

outcomes of management decisions in an effort to facilitate informed decision making
7. Giving credit for the work of others to whom it is due

8. Aiding the professional development and advancement of colleagues using Certified

Professional in Healthcare Quality (CPHQ) designation only after passing the written
examination and adhering to standards established by the Healthcare Quality
Certification Board (HQCB), and continuing to maintain those standards through the
recertification process.

9. Maintaining membership in professional organizations as a means of promoting quality

and professional growth, avoiding the use of such membership for the sole purpose of
solicitation of business or for personal financial gain (NAHQ, 2004).
 PATIENT SAFETY CULTURE SURVEY

■ The most important patient safety issues facing healthcare organizations

today are.
 Maintain a culture of safety
 Identifying organizational champions
 Deploying and sustaining patient safety strategies
 Determining key drivers for patient safety programs
 Ensure the adoption of current safety-related technologies

■ The First step in creating a culture of safety is to assess the readiness

of an organization to implement healthcare safety practices.
 PATIENT SAFETY CULTURE SURVEY

■ Safety of hospitals culture can be assessed by using Patient Safety Culture

Survey (from AHRQ). This 12~area survey was released initially in 2008 as a
result of 400 hospitals, a new report 2012 (1128 hospital, >1/2 million staff)
indicate many areas of Improvement:

 Non-punitive Response to Error (65% positive response)

 Handoffs and Transition (45% positive response)
 Staffing (56% positive response)
 PATIENT SAFETY CULTURE SURVEY
■ When survey has been administered and results obtained, the healthcare quality
Professional may plan actions for improvement. Key steps for action planning are:

1. Review and understand the survey results.

2. Communicate and discuss the results throughout the organization.

3. Develop action plans with a focus on improvement opportunities.

4. Communicate action plan and expectations.

5. Implement action plan.

6. Track progress to determine the effectiveness.

7. Share what works, both internally and externally.

 JUST CULTURE
■ Fair and Just Culture : is the concept used to reconcile the tension between “no blame and “blame”
This concept is useful to create a culture of accountability while respecting the fundamental need to
maintain a system focus and a trusting workforce.

■ The Characteristics of this culture are :

 This culture can make the system safer.
 Emphasize the importance of learning from mistakes rather than reduce personal accountability.
 Emphasize the fact of medical errors are inevitable, but still we have to report it.
 Encourage healthcare provider to self-report errors and near misses.
 This culture acknowledges that even competent professionals make mistakes or create Shortcuts, but it has
zero tolerance for reckless behavior.
 Organizations apply just culture, usually assign blame-free (non-punitive) reporting Culture.
 This culture support disclosure of successes and failures.
 ROLE OF BOARD IN PATIENT SAFETY
■ The patient safety program should be aligned with the mission, vision, core values, and goals of the
organization.
■ Safety can be integrated into strategic planning. IHI outlines six things all boards should consider in their
efforts to improve quality and reduce harm.
1. Setting aims: set specific aim to reduce harm.

2. Getting data and hearing stories: select and review progress toward safer care in each meeting

3. Establishing and monitoring system-level measures: identify group of measure, update it, monitor it, and
make it transparent to all.

4. Changing the environment, policies, and culture: commit to establish and maintain fair and just culture for
all who experience avoidable harm.

5. Learning, starting with the board: learn how the best board works with the leader to reduce harm.

6. Establish executive accountability: oversee the effective executive plan to reduce harm.
 HEALTHCARE SAFETY PROGRAM DEVELOPMENT

■ Every Healthcare Organization needs a written plan for patient safety program that
integrates patient safety goals into organizational activities. In addition,
organizations must identify and individual (officer) or group (safety committee) to
carry out and manage all safety initiatives in a safety plan

■ Healthcare quality professionals can develop a patient safety program by:

1. Using comparative data
2. Working collaboratively to improve compliance with JCI-NPSGS, NQF – endorsed measure, Leapfrog safe practice and
other measures (e.g. AHRQ, NHSN)
3. Assisting all the services and programs to identify and mitigate risk and hazard
4. Enhance adverse event, sentinel event, and peer review processes
5. Promoting transparency and dissemination of results across their organization.
 HEALTHCARE SAFETY PROGRAM DEVELOPMENT

6. Organizational strategic plan (mission, vision) should be considered first when developing
patient safety plan, risk management or quality management plan

7. Patient safety officer/ patient safety committee can use OVR, KPI, Patient’s Complaint, Risk
Assessment and strategic goal to develop patient safety plan/ program

8. Patient safety plan should include efforts to reduce harm (this is number one goal)

9. During patient safety plan development, including cross-functional team will help in developing
comprehensive safety plan

10. Patient safety plan should include the results of RCA, HFMEA, and patient safety culture survey
 HEALTHCARE SAFETY AND TECHNOLOGY
■ Various technological solutions have been proposed to enhance patient safety
program such as:

 Electronic Medical Records

 Computerized Provider Order Entry (CPOE)
 Computerized Decision Support
 Bar Code Medication Administration (ECMA)
 Radiofrequency Identification Systems (RFID)
 Smart Intravenous Pumps
 IT-Based Sign-Out Systems,
 Picture Archiving And Communication Systems (PACS)
 Handheld Ultrasound
 HEALTHCARE SAFETY AND TECHNOLOGY
■ The benefits of healthcare IT are limitless and the major benefit is promoting patient
safety through reduce or mitigate risk/harm. Nevertheless, still some concerns arise
of using health IT which includes:

 The need for increase standardization

 Increase needed time for some technology
 Funding
 Privacy
 Cultural concern
 Create new opportunities for errors
 HEALTH CARE SAFETY NOSOCOMIAL INFECTION
■ The three major aspects of the infection prevention and control (IPC)
program are; Surveillance, prevention, and control.

■ The prevention and control methods used in IPC program include:

 Policy and procedure to prevent and control infection
 Defined barrier precautions
 Ongoing staff education
 System for waste identification
 Decontamination, disinfection, and sterilization
 Report to public health officials
 Use of personal protective equipment
 Monitoring of CLABSI, VAP, CAUTI, SSI, MDR Infection
 Identify communicable disease and control outbreak when identified

■ The most important factor in reduction of health care associated infection is hand hygiene
 NEVER EVENT
■ It is in excusable adverse event “should never happen” and should be reported.
■ NQF in cooperation with Leapfrog Group create a list of 29 Serious Reportable
Adverse Event “Never Events"
■ The Leapfrog Group offers four actions following a never event:
1. Apologize to the patient
2. Report the event
3. Perform a root cause analysis
4. Waive costs directly related to the event
 PATIENT SAFETY AS QUALITY MEASURE
■ Measuring safety outcomes allows us to quantify attributes of structures and processes that protect
the patient from injury.
■ Clinical patient safety performance measures

 Number of sentinel events

 Number of repeated sentinel events
 Reported significant medication errors
 Patient fall with injury rate
 Number of serious injuries/death associated with device
 Missing medication dose rate
 Device-associated bloodstream infection rate
 MRSA
 Pediatric nosocomial respiratory infection rate
 Nosocomial respiratory infection rate
 ORGANIZATIONS HAVING AN IMPACT ON HEALTHCARE
SAFETY

■ National Quality Strategy (NQS)

– It has three aims; better care, healthy people/communities, and affordable care
■ National Quality Forum (NQF)
– The main three areas supported by NQF are public reporting; provide safety practices and
errors disclosure.
– In 2003 NQF endorsed a set of safe care practices (Updated to 34 in 2010) should be
universally used in clinical areas to reduce the risk of harm to customers.

■ Joint Commission (JCI)

– It established national patient safety goals (NPSGs) and update it annually.
 ORGANIZATIONS HAVING AN IMPACT ON HEALTHCARE
SAFETY

■ Leapfrog Group
– Was created in part to catalyze patient safety activities. But, it has neither accreditation nor
regulatory authority.
– It uses its contracting power to promote safe practices through simple transparency or steering
patients toward institutions it deems to be better performers.
– In 2001 Leapfrog recommended three “safe practices":
■ CPOE
■ Having full-time intensivists provide critical care
■ Favoring high volume providers (In areas evidence link higher volume to better out comes)
 ORGANIZATIONS HAVING AN IMPACT ON HEALTHCARE
SAFETY
Institute for Healthcare Improvement (IHI)
– A nonprofit support and consulting organization.
– In 2005 it launched “Campaign to save 100,000 lives"
– In 2006 it launched a campaign to “Prevent 5 million cases of harm”
– Although IHI lacks regulatory authority and is not a payer, its campaign succeeded and
Generated significant change
 NATIONAL PATIENTS SAFETY GOALS 2014

■ Role of the Quality Management Professional

 Patient safety must be the first priority.
 Use a system approach (system thinking)
 Bridge the Gap (after gap analysis and identifying the opportunities for
improvement)
 Optimize the service (through STEEEP)
■ JCAHO’S NATIONAL PATIENT SAFETY GOALS

 NPSGs established to help accredited organizations address specific areas of concern in regards to
patient safety.
 The goals are recommended (Evidence-based or Expert-based recommendations) by a multi-
disciplinary advisory group. Each year the group reviews the content to determine whether some
goals should be deleted and whether new ones should be added as priority safety practice areas.
 Accredited organizations must meet all the goals, also may suggest goals for review by the
advisory group.
 The accreditations are more than one type given to different facilities (e.g. Ambulatory Health
Care, Disease-Specific Care, Home Care, Hospitals.etc.), but each facility needs to fulfill
specific/required NPSGS, not all.
■ International Patient Safety Goals (IPSG)

 Goal 1: Identify patients correctly

 Goal 2: Improve effective communication
 Goal 3: Improve safety of high-alert medications
 Goal 4: Ensure correct – site, correct procedure, correct
patient – surgery
 Goal 5: Reduce the risk of healthcare – associated infections
 Goal 6: Reduce the risk of patient harm resulting from falls
 MEDICAL ERRORS INTRODUCTION

The IOM report “To Err is Human” in 1999 stating that 40-98,000
patients die from medical errors annually.

■ Why are errors so difficult to be reduced in healthcare?

 Complexity of modern health care.
 The reliability of most health care delivery systems rest on people.
 Design of current risk reporting systems.
 Modes of mental functioning- automatic vs. problem solving.
 The blame trap.
 System causes of error.
 Active and latent failure.
 II. FACTORS CAUSING ERRORS.

 large work loads

 Time pressure
 High patient acuity Fuzzy boundaries
 Fuzzy boundaries
 Inexperienced staff
 Multiple hand - 0ffs
 Constant interruption
 Lack of rewarding system
 Sentinel Events.

 Serious adverse events = Sentinel event

 They are infrequent, undesirable, serious event that is significant enough to trigger
further investigation each time it occurs
 It is an unexpected occurrence involving death or serious physical or psychological
injury, or the risk thereof. Include loss of limb or function.
 Patient outcome is significantly worse than anticipated, and it occurs in the presence or
absence of negligence
 The first action to be taken is to ensure that patient is receiving the appropriate
treatment
 The initial management step is to report it to the appropriate individuals e.g. risk
manager
 Sentinel Events.

 Its called sentinel because they signal the need for immediate investigation and
response
 Must always be zero occurrence, 100% analysis, followed by root cause analysis
 RCA should focus on process and system aiming to identify gaps in patient care process
 The term sentinel event and errors are not same, not all sentinel event occur because
of errors and not all errors results in sentinel events
 Example: Patient suicide in hospital, wrong site surgery, death from medication error
 Note: Death or serious injury from wrong blood transfusion consider as sentinel
event, but hemolytic reaction post blood transfusion is not
 What is the difference between adverse event and
sentinel event?.
 Adverse event may have a variety of meanings, ranging from care that results in a
minor injury to a patient to a devastating outcome for a patient

 A near miss occurs when there is a deviation from the standard of care but there is
no injury
 How to write on incident report?
 Brief objective recitation of the event.
 The information should be factual and objective.
 Only facts known at the time.
 No speculation about how the incident occurred or what injury possibly
resulted.
 Not contain blameful, accusatory, or finger-pointing language.
 Should never be kept as part of the medical record.
 Use colored paper to identify incident report From the medical record
 The reporter should have no conflict of interest.
 What is the incident report process ?
■ Every institution should have a policy in place outlining how and to whom an adverse event should be reported.
1. Forward to the nurse manager or supervisor of the unit where the incident occurred (to take immediate action in response).

2. From there the incident report may be forwarded to the quality management/ risk Management department.

3. Then, the incident report will be reviewed and evaluated by using of severity code, and if needed, an investigation of the incident will occur.

4. The investigation may range from relatively simple (a review of the medical record) to Complex (with interviews of involved staff and an expert
review) action.

5. After investigation, if any corrective action needed, then we have to decide who should be engaged to formulate the corrective action plan and
be accountable for its completion.

6. Then communicate the event and corrective action with the concerned population to prevent further future recurrence.

7. After finalization of this process, we have to reserve an evidence for some of adverse events that could have the potential for litigation.
 IV. SENTINEL EEVENTS REPORTING TO JCAHO

 To maintain JCAHO accreditation, medical facilities must comply with the JCAHO sentinel event policy,
JCAHO encourages but does not require health care organizations to report sentinel events to JCAHO.
 In the absence of voluntary reporting, JCAHO may become aware of a sentinel event by some other
means, such as communication from a patient, family member, or employee of the organization or
through the media.
 In any case, if JCAHO becomes aware of a reviewable sentinel event. the organization must prepare and
submit a root cause analysis.
 A root cause analysis focuses primarily on systems and processes, not individual performance
 A root cause analysis leads to an action plan. under which the organization implements steps to reduce
future risks and monitors the effectiveness of those improvements.
 The organization must complete the necessary documents within 45 days of a sentinel event of which
JCAHO is aware. JCAHO then will review the analysis and action plan to determine whether they are
acceptable.
 lf the submission is not acceptable, the organization is at risk of being placed on Accreditation watch by
the JCAHO Accreditation Committee and ultimately could lose its accreditation.
 VI. PATIENT CENTEREDNESS
■ Patient Centered Care: involving patients and their families in the design of new care models and in
decision making about individual options for treatment.
■ Patient-centered communication has been shown to improve clinical outcome. Various public and
private entities have launched several initiatives to support consumer engagement. An example:
 AHRQ: Talking Quality. It's a source and guide for the organizations that produce and
disseminate reports to consumers about the quality of care they provide.
 SPEAK UPTM. It’s an initiative to empower consumers to become active, involved, and informed
participants on healthcare (lunched by Joint Commission).
Speak UP
SPEAK UPTM
Speak up if you have questions or concerns, and if you don’t understand, ask again, It’s
your body and you have a right to know.
Pay attention to the care you are receiving. Make Sure you’re getting the right
treatments and medications by the right health care professionals. Don’t assume anything.
Educate yourself about your diagnosis, the medical tests you are undergoing, and your
treatment plan.
Ask a trusted family member or friend to be your advocate.
Know what medications you take and why you take them. Medication errors are the most
common health care mistakes.
Use a hospital, clinic, surgery center, or other type of health care organization that has
undergone a rigorous on site evaluation against established state-of-the-art quality and
safety standards, such as that provided by the Joint Commission.
Participate in all decisions about your treatment. You are the center of the health care
team.
 MEDICATION ERRORS
INTRODUCTION

■ Medication Error; is any preventable event that may cause or lead to inappropriate medication use or patient harm while
the medication is in the control of the healthcare professional patient or consumer.

■ Such events may be related to professional practice healthcare products procedures and systems including prescribing
order communication product labeling packaging and nomenclature compounding dispensing distribution administration
education monitoring and use.

■ Adverse Drug Event (ADE):- Harm experienced by a patient as a result of medication. It includes both errors and side
effects of the medication.

■ Only 10 – 20% of healthcare errors are reported. Of the errors that are reported, 90-95% results in no harm to patient.

■ A report from the United States Pharmacopeia (USP) indicates that, confusion because of look- alike or sound-alike
accounts for approximately 5-15% of all reported errors.
 MEDICATIONS ERROR CATEGORY INDEX:

■ The USP creates an error reporting program “MEDMARX" to facilitate analysis

of medication errors in the institutional setting. This anonymous, confidential,
internet-accessible program allows hospitals and other health care facilities to
report, Hack, and share medication error data in a standardized format,

■ MEDMARX uses the National Coordinating Council for Medication Error

Reporting and Prevention (NCC MERP) taxonomy, which includes an index for
categorizing error events by severity and outcome and allows the capture of
both potential and near-miss events as well as harmful errors.
NCC MERP Index
NCC MERP Index for Categorizing Medication Errors
Category A: Circumstances or events that have the capacity to cause error No Error

Category B: An error occurred but the error did not reach the patient (An “error of omission” does reach the
patient) Error No Harm
Category C: An error occurred that reached the patient but did not cause patient harm
Category D: An error occurred that reached the patient and required monitoring to confirm that it resulted in
no harm to the patient and/or required intervention to preclude harm

Category E: An error occurred that may have contributed to or resulted in temporary harm to the patient and
required intervention. Error Harm
Category F: An error occurred that may have contributed to or resulted in temporary harm to the patient and
required initial or prolonged hospitalization
Category G: An error occurred that may have contributed to or resulted in permanent patient harm.
Category H: An error occurred that required intervention necessary to sustain life

Category I : An error occurred that may have contributed to or resulted in the patient’s death Error death
 MEDICATION ERROR REDUCTION IN THE INSTITUTIONAL SETTING

■ Language is inherently inexact, and communication errors form the basis

for many medication errors and therapeutic misadventures.
1. Prescribing
2. Transcribing
3. Preparing and Dispensing
4. Administering
5. Monitoring
 MEDICATION ERROR REDUCTION IN THE INSTITUTIONAL SETTING

■ Over 13% of all reported errors were associated with these communication selections, with
the majority of the errors (nearly 63 %) reaching the patient.
■ High-Alert Drugs should receive more caution during administration. These drugs defined as
medications which could cause an immediate life threatening condition for the patient if an
error in administration occurs. The main High-Alert Drugs identified by JACHO are:
– Concentrated electrolytes including KCI, and NaCl> 0.9 %)
– Insulin
– Opiates, narcotics, and patient controlled analgesia (PCA)
– IV anticoagulants, such as Heparin
Errors may occur at any node:
■ Prescription
■ Transcription
■ Preparation and Dispensing
■ Administration
■ Monitoring
 Strategies to reduce medication errors in each node

■ Prescribing Process Errors Prevention (eg. wrong drug, dose, patient...etc.)

– Conduct a FMEA
– Standardizing dosing protocol
– Use standard abbreviations
– Use CPOE and decision support framework
– Change management

■ B. Dispensing Process Errors Prevention;

– Standardized concentrations for all IV medications.
– Use commercially prepared solutions.
– Dispense a unit-of-use.

■ C. Administering Process Errors Prevention;

– Be familiar with the institution's policies and procedures for medication administration
– Preprinted and standardized infusion rate charts
– Bar coding and identification techniques
– Use programmable infusion devices, independently confirmed by two individuals.
– Documentation of the medication infusion adjustments.
– Infusion tubing should be traced. from the infusion bag to the point of delivery
– Avoid free flow, IV administration cassettes that offer anti-free-flow mechanisms should be used
routinely.
 MEDICATION ERROR REDUCTION IN THE OUTPATIENT
SETTING

■ The major two medication safety concerns in outpatient pharmacy are:

■ Look-alike drugs
 Reason: Outpatient pharmacies still stock drugs alphabetically, and may be found
right next to each other.
 Solution: using computerized bar codes is a good way to minimize this error.
■ Telephone orders
 Reason:- “Cardiem” and “Cardizem” can be easily confused when a doctor calls in
a prescription to a pharmacy.
 Solution:- Read back and record the order.
 PATIENT SAFETY INDICATORS
■ PSIs: DEFINITIONS AND BENEFITS

■ Patient safety indicators (PSIs): screen for problems that patients experience as
a result of exposure to the healthcare system and that are likely amenable to
prevention by changes at the system or provider level.
■ PSIs are priceless, download free tools used to collect baseline patient safety
data, proactively identify safety issues, prioritize performance improvement,
support root cause analysis, and monitor change initiatives post
implementation.
■ PSIs are not used for credentialing or as a performance evaluation tool
(evaluation of system safety, not individuals).
 AHRQ QUALITY INDICATOR LEVELS

■ Provider – Level Indicators: provide a measure of the potentially

preventable complication for patients who received their initial care and
the complication of care within the same hospitalization. Provider – level
indicators include only those cases where a secondary diagnosis code
flags a potentially preventable complication
Area-Level Indicators:

■ capture all cases of the potentially preventable complication that occur

in a given area either during hospitalization or resulting in subsequent
hospitalization. Area-level Indicators are specified to include principal
diagnosis, as well as secondary diagnoses, for the complications of care
 AHRQ QUALITY INDICATOR MODULES

■ Quality indicators are divided into four groups:

– Prevention Quality Indicators: These indicators consist of "ambulatory care sensitive conditions,"
hospital admissions that may have been avoidable if appropriate outpatient care had been rendered or
that reflect conditions that could be less severe, if treated early and appropriately.
– Inpatient Quality Indicators: These indicators reflect quality of care inside hospitals and include inpatient
mortality; utilization of procedures for which there are questions of overuse, underuse, or misuse; and
volume of procedures for which there is evidence that a higher volume of procedures is associated with
lower mortality.
– Patient Safety Indicators: These indicators focus on potentially preventable instances of complications
and other iatrogenic events resulting from exposure to the health care system.
– Pediatric Quality Indicators: Identifying potentially preventable complications and iatrogenic events for
pediatric patients treated in hospitals and preventable hospitalizations are the main focus of the PDIs.
 INTEGRATING PSIs INTO A PATIENT SAFETY PROGRAM

■ Hospitals can successfully evaluate and integrate PSIs by taking into account the following six components:

■ 1. Learning about PSIs;

 After reviewing each PSI in detail, a hospital can determine which measures are meaningful and enhance its existing
patient safety program. These selected measures can be reviewed in detail with team leaders, and senior managers.
■ 2. Medical records coding;
 ICD-Coding provides codes to classify diseases and a wide variety of signs, symptoms, abnormal findings, complaints, social
circumstances and external causes of injury or disease. Every health condition can be assigned to a unique category and
given a code, up to six characters long.
 ICD-Coding system is designed to promote international comparability in the collection, processing, classification, and
presentation of these statistics. (Annual minor and three-yearly major updates are published by the WHO).
■ 3. Patient safety program evaluation;
 Identify any redundancies between PSIs and other collected data.
 Prioritize those PSIs that may improve care.
 Determine how to analyze and integrate PSI data into decision-making activities.
 Discuss the results of the analysis with administrators, and staff.
 Agreement on the type and value of the PSI data collected.
 INTEGRATING PSIs INTO A PATIENT SAFETY PROGRAM

■ 4. Information technology;
 Evaluate the impact of integrating the PSI tool into internal systems.
 Using an application developed by the hospitals current vendors.
 Determine how adding a new process affects current data flows.
 Establish timelines for implementation.
 Develop and deliver PSI reports.
■ 5. PSI testing,
 Before disseminating PSI information to the hospital, the data should be tested and trialed for a small
audience (e.g.. ICU).
 Review reports with this audience and investigates their concerns seriously, then generalize it if objective is
met.
■ 6. Implementation:
 Develop plan for data dissemination to committees, administrators, and external customers, if
appropriate. The implementation plan should include;
 Educational sessions about PSIs, their methodology, and ways to use.
 Integration of PSIs into existing clinical review programs.
 Develop a satisfaction survey.
 USE OF PSI DATA

■ The value of PSIs as a screening tool can be used to identify trends and
priorities within a hospital. Psi; helps to;
1. Prioritize cases for review.
2. Evaluate the burden placed on the hospital.
3. Build a case for a performance improvement project.
4. Identify resources needed to make changes