Understanding the case

Practice setting:

dr Arif private practice Hospital Spondylitis Spine Fracture

Health problem:

Understanding every new term in the case and your presentation

Public and private care Public and private practice Primary, secondary and tertiary care

Private/Individual Health Service

Public Health Service

Primary: Private practice (FP/GP) PHC (Puskesmas) Secondary Specialist physician Hospital type C, D Tertiary Sub specialist Hospital type A,B

Primary: Public Health Comunity Secondary DHO (Dinkes) Tertiary: Provincial (Dinkes Prop) National (Depkes)

(Patient) Inform Consent?

Aim: Patient consent (aware, understand and have full responsibility) about him/herself health condition and the treatment needed Not merely asking permission for medical treatment Parties: patient and health provider

Health Information System

Information Form Procedures and flow chart Person behind the system Information operator

The Information System Flow

Patient & Family

Physician
Medical Record

Hospital Admission Admission Procedures

Patient-Doctor Communication

Referral Letter

Refer Back

Referral Letter

Physician Identity Patient Identity Summary of examination Working diagnosis Current treatment Type and Need for further examination or treatment:

Type of radiology examination needed

Case Analysis

Describe the case: might use flow process diagram Identify proximate factor: direct causing factors:

Patient could not proceed the laboratory examination Proximate cause: referral letter not clear

Contributing factors: factors that lead to proximate cause:

Human resource issues: Was the staff adequately trained? Was the staffing adequate? Was there appropriate supervision? Information availability: Was necessary information available, accurate, and complete? Environmental issues: Did the physical environment contribute to the event? Are safeguards in place to minimize and address environmental risks? Leadership and culture: Did the organizational culture impair safe care? Communication among clinicians: Was communication among staff adequate?

The Final Patient Safety Incident

Lab examination do not proceed Diagnosed not established Incomplete or inappropriate treatment Un-prevented complication:

Fracture

: permanent disability, and cost

Process

Proximate Cause

Contributing Factors

Hospital admission

Admission and examination could not be proceed

Unclear referral letter:

Incomplete Hand writing

No clear information from doctor to patient Unclear admission procedures for insurance patient No refer back information to physician

What Happened

Why Did this Happen

Prevention Action

Proximate Cause Contributing Factors

Admission and Unclear referral letter: examination could not be Incomplete proceed Hand writing No clear information from doctor to patient Patient do not proceed the examination Painful feeling:
Long waiting time Uncomfortable waiting seat

Standardized referral form using checklist Provide : verbal ,written and repeat

Insurance

Type

Private : No risk pooling and sharing between member Social General : all kind of health service Specific : specific health service as listed and agreed General Population Specific Population: Vulnerable people (high risk) : woman, children, poor people

Service coverage (cakupan)

Insurance Member (target)

PATIENT SAFETY MANAGEMENT

A GUIDE FOR PRIMARY CARE PRACTICE

WHAT AND WHY

SOME BASIC TERM

Error - The failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim. Errors depend on two kinds of failure: The correct action does not proceed as intended. (Referred to as error of execution) The original intended action is not correct. (Referred to as an error of planning) Adverse (merugikan) Event an event that results in unintended harm by an act of commission or omission (kelalaian) rather than by the underlying disease or condition of the patient. Near Miss - an act of commission or omission that could have harmed the patient but did not cause harm as a result of chance, prevention, or mitigation (peringatan). Near misses are also synonymous with potential adverse events and close calls. Sentinel Event a type of adverse event, defined by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) as an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof(dari padanya). Serious injuries specifically include a loss of limb or

Near miss tidak menimbulkan harm Adverse diakibatkan kelalaian Sentinel diamsumsikan bukan kesalahan tapi nasib

1) During an emergency resuscitation in an ICU, the physician running the resuscitation gives a nurse a verbal order to administer a dose of epinephrine. Instead of administering the dose the physician intended, the nurse administers a dose 10 times stronger. The patient dies. 2) A surgeon plans to amputate a diabetic patients left foot. During the actual surgery, however, the surgeon amputates the patients right foot. 3) A severely depressed patient who has denied being suicidal is placed on close observation in a psychiatric unit. Fifteen minutes after an observation is logged, the patient is found hanging from an exposed water pipe. The patient used his belt as a noose.

4) A rural surgeon advises a woman with breast cancer to undergo a radical mastectomy, even though a surgeon at a distant university hospital has assured her that a lumpectomy is indicated. Because the rural surgeon is closer to her home and his services are paid for by the womans HMO, the patient undergoes the radical procedure and develops extremely painful lymphedema. 5) A pharmacist cant read a physicians handwriting on a prescription and instead of filling a prescription for a stomach acid-controlling medication; she fills it with an antipsychotic. The patient notices that the pills in the prescription dont look like the sample she got from the physician and asks the pharmacist about it.

TERMINOLOGY

GRADING

People Are Set-Up to Make Mistakes

Incompetent people are, at most, 1% of the problem. The other 99% are good people trying to do a good job who make very simple mistakes and it's the processes that set them up to make these mistakes.
Dr. Lucian Leape, Harvard School of Public Health

Need to Increase Focus on the Human Factors

Studies of adverse patient incidents have heightened our awareness of the need to redesign processes to prevent human errors. Its time for organizations to use cognitive ergonomics or human factors analysis to make health care services safer for patients.

How Can Safety be Improved?

Human errors occur because of:

Inattention Memory lapse Failure to communicate Poorly designed equipment Exhaustion Ignorance Noisy working conditions A number of other personal and environmental factors

Process Redesign Solutions

Make mistakes impossible

Auto-shut off heating devices Circuit breakers Ready-to-administer medications Over-write protected computer disks
Can you think of other mistake-proofing techniques?

Process Redesign Solutions

Design safer processes

Barriers or safeguards can prevent untoward events

X-ray confirmation of tube placement Mandatory repeat-backs Door alarms Surgical site confirmation

Can you think of other barriers or safeguards?

Process Redesign Solutions

Reduce harm caused by mistakes

People must be able to quickly recognize the adverse event and take action
Human interventions Response teams Backups Automation

Can you think of other methods for reducing patient harm?

PATIENT SAFETY MANAGEMENT

Patient Safety: Actions undertaken by individuals and organizations to protect health care recipients from being harmed by the effects of health care services

STEPS

CASE SCENARIO

PROCESS
Family Physician practice:

PROBLEM

PROXIMATE CAUSE

No information how to use Do not know insurance Assuming patient know Limited time Unclear referral letter Hand writing Incomplete information Un-standardized form Assuming patient know Limited time

No information how to manage the disease at home

PROCESS
Hospital Admission Officer :

PROBLEM
Could not understand the referral letter

PROXIMATE CAUSE
Unclear handwriting Incomplete information No clarification mechanism The intended health service was not covered by insurance No collaboration between ins & hosp Crowded patient No standard procedures No standard information

Insurance card do not work for the hospital

Unclear information how to use the insurance card

No referral back to physician

PROBLEM

PROXIMATE CAUSE

ACTION TO PREVENT
Hand book how to use insurance

No information how to use Do not know insurance Assuming patient know Limited time Unclear referral letter Hand writing Incomplete information Un-standardized form Assuming patient know Limited time

Standardized Form

No information how to manage the disease at home No follow up to patient

Provide written information Increase the doctor patient ratio

Take Action to Reduce Risk

Reactive: Investigate significant patient incidents (sentinel events). Proactive: Monitor patient safety and redesign high-risk processes to prevent a sentinel event from occurring.

Root Cause Analysis

A reactive (after-the-fact) activity

Example of sentinel event: An inpatient received 2 units of the incorrect type of blood. At the time the patients blood was drawn for a type/cross match, the sample was mislabeled with another patient's name. The transfusion was given to the patient whose name appeared on the type/cross match lab report, not the patient whose blood was in the lab specimen vial. Results of the analysis: The root cause of the event was the poorly designed system for labeling laboratory specimens. If not corrected, this problem could cause other incidents.

Root Cause Analysis Steps

1. 2. 3. 4. 5.

6.

Gather the facts. Choose team. Determine sequence of events. Identify contributing factors. Select root causes. Develop corrective actions & followup plan.

Examining the Safety of Processes

Failure mode, effects and criticality analysis (FMECA)

What could go wrong? How badly might it go wrong? What needs to be done to prevent failures?

FMECA Steps

Flow chart the process Brainstorm potential failures at each step in the process Determine the criticality of each failure (frequency x severity x detectability) Discover what causes critical failures