Repuhis ni 2 Phifiopines Department oi Hee! OFFICE OF THE SECRETARY Buse os 1, San Peal Avenue Sta pines Tel Nos. 632) 711-9502, 711-8802 an inte No (632) 743-182 July 30, 2008 ADMINISTRATIVE ORDER No. 2008 -_ 002% * "SUBJECT: NATIONAL POLICY ON PATIENT 1 RATIONAI Patient Safely is defined as “the prevention of harm to patients thru the prevention avoidance and amelioration of risk. adverse outcomes or injuries stemming from the processes of health car?” (Unstitute of Medicine, 2000). It is the degree to which the risk of an intervention and risk in the care environment are reduced for a patient and other persons, including health care providers, In May 18, 2002, the 55" World Health Assembly (WHA) recognized the need to promote patient safety as a fundamental principle of all health systems. Member states were urged to pay closest possible attention to the problem of patient safety and establish or strengthen science-based systems necesstry far improving patient's safety and the quality of health care, including the monitoring of drugs, medical equipment an cchnolo, In response to the call of the World Health Assembly, the Philippines is reinforcing ar institutionalizing the implementation of quality assurance where patient safety is regarded as one of the key dimensions of quality care. It is critical in the development of systems to improve alth outcomes in the Fourmuka One for Health. the country however. need to consolidate the ns of these eflorts, strengthen a nation-wide reporting system of adverse events, and institute a mechanism that would encourage disclosures about said events. Likewise. there is a dire need to encourage more research into patient safety, epidemiological studies of risk factors, effeetive protective interventions, assessment of associated cost of damag and protection, In ‘line with the objectives of Fourmula One f sustained f Health; to secure more, better and neing for Health, assure the quality and affordability of health goods and services: ensure access to and availability of essential and basic health packages and improve performance of the health system, the Department of Health and the Philippine Health Insurance Corporation (PHIC) affirm its commitment to patient safety policies and objectives thru the DOH mandate, the Fourmula (F1) One for Health, and thru the Philippine Health Insurance Corporation (PHIC) Benchbook to adopt the Fifiy- filth World Heelth Assembly's resolution in formulating guidelines for the implementation of a Patient Safety ProgramI. GOAL AND OBJECTIVES al: To ensure that patient safety is institutionalized as a fundamental principle of the health care delivery system in improving health outcomes. Objectives: 1. "To establish a comprehensive patient salty program in all levels of the health care delivery system thu effective governance. 2. To develop the critical capacity of the health care workers in the h the implementation of standards, guideline: patient safety 3. To sustain and continuously improve mechanisms that nurtures a culture of safety thru appropriate strategies. alth facilities for rams, relative.t0 . systems, training progi COVERAGE AND SCOPE This policy shall apply to all government and private health care facilities providing preventive, promotive, curative and rehabilitative care IV. DEFINITION OF TERMS A. Adverse Event - an untoward, undesirable and usually unanticipated event such as death of a patient, an employee or a visitor in a health care organization. It is an injury caused ‘by medical management rather than by the underlying condition of the patient, incilents such as patient falls or improper administration of medications are also considered adverse events even if there is no permanent effect on the patient, B. Culture of Safety- an integrated pattern of individual and organizational behavior, based oon shared béiiefs and values that continuously seck to minimize patient harm that may result from the process of care delivery ment and organizational C. sLatent Failure an error precipitated as a consequence of man: processes that poses the greatest danger to complex systems. Latent failures carmnot be foreseen but, if detected. they can be corrected before they contribute to mishaps, D, 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 10 do so because of chance or because itis intercepted. Its also called potential adverse event. F, No Blame Culture ~a non- punitive encouraging voluntary reporting of adverse events F. Patient Safety Solution — any syst ability to prevent or mi » design or intervention that has demonstrated the te patient harm stemming from the processes of health care G. Risk — is any exposure to a harmful event. It is direetly related to hazard and vulnerability and. inversely, to capacity :H. Risk Management ~ clinical and administrative activities undertaken to identify. evaluate. nd reduce the risk of injury to patients, staff and visitors and the risk of loss to the nization itselt 1. Root Cause Analysis — a process for identifying the basic or causal factor(s) that underlie variation in performance, including the occurrence or possible occurrence of a sentine! event J. Safety Assessment — refers to the identi foreseeable potential harm. injury or of such potential harm and to asses “safety measures to.be done. tion of sources or routine and reasonably ecident, to estimate the probability and magnitude: s the quality and extent of the required protection and Sentinel Event — an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. It is any process variation for which recurrence would camy a significant chance of a serious adverse outcome (PIC Benchbook). Serious injury specifically includes loss of limb or function, The phrase “or the risk thereof includes any provess variation for whieh @ recurrence would carry a significant chance of a serious adverse outcome. Such events are called sentine! because they signal the need for immediate investigation and response. V. GENERAL POLICY STATEMENTS A. The establishment and maintenance of a culture of patient safety in an organization is the responsibility of its leadership. B. Enabling/support mechanisms/strate in the health facilities: ies shall be in place to ensure patient safety C. The implementation of the Patient Safety Program for all facilities shall be anchored on both DOH licensing and PHIC accreditation standards, D. ‘The key priority areas in patient safe include but not limited to proper patient identification, assurance of blood safety, safe clinical and surgical procedures provision and maintenance of safe quality drugs and technology, strengthening of infection control standards. maintenance of the environment of care standards and energy! waste management standards. VI. IMPLEMENTING MECHANISM A. CONCEPTUAL FRAMEWORK OF THE PATIENT SAFETY PROGRAM The F1 framework aims to int tient safety into the Continuing Quality Improvement (CQN) Program in health facilities and further align with the objectives of the DOH sectoral reforms, (Fournvula One for Health Framework: Annex A)