Patient Safety

Seven Steps to Achieve Patient Safety

Step 1: Build a Safety Culture

Not Who caused the Event

but
What caused the Event?

Seven Steps to Achieve Patient Safety

Step 1: Build a Safety Culture

Being open and fair.

Sharing information openly.
Fair treatment for staff when an event happened.
System approach to safety.
Accept the fact that people, process and equipment

will fail.
Finding out about system failure in an event.
( Best People Can Make the Worst Mistakes)

Seven Steps to Achieve Patient

Safety
Step 2: Patient Safety top leadership Priority

Promote quality patient care as a key

strategy

Respect patients values, preferences and expressed

needs.
Patients rights and responsibilities.
Provide the information, communication, and
education that people need and want.

(Patient Centered Care)

Team work and Multidisciplinary approach

Seven Steps to Patient Safety

Step 3: Integrate your risk Management
activity
Conduct organization wide assessment of the risk

( Safety check list and Quality rounds).

Evaluate clinical care ( clinical and CPGs Indicators.

Step 4 : Report Patient Safety Events and

Identify Trends.
Give recognition for reporting Events and

Safety-driven decision-making

Seven Steps to Patient Safety

Step5: Patients and Families Involvement in care decisions.
Patients are Participant not recipient of Care.
Make sure they understand all Portions of a Consent form.
Ensure that patients understand the education you provide to
them and their families ( get feedback).

Step 6 : Conduct Systemic Investigations following Events.

Event Reporting Process.

Root Cause Analysis

Quality Management & Patient

Safety Office responsible for
the continuous monitoring and
trending of all events.

Events involving patients and/or

visitors shall be reported within (24
hours) to the Quality Management &
Patient Safety Office.

Initial analysis for the event

to be done by the QMO to
determine event severity.

Risk Index 1 and 2

Communicated and discussed with the

performance improvement representative from
each department for further analysis and
feedback on monthly basis.

Receive a report of findings recommendations

and action plan to be submitted in the
performance improvement & patient safety
committee.

Quality Management & Patient Safety Office will

follow up action taken.

What is the
event severity
Index?

Risk Index 3 and 4

Sentinel Events

Communicated and discussed with the GD,

how will form an Ad-Hoc Committee to
investigate the Event. [Chairman from the
medical Board members]
Root Cause Analysis Reports for all sentinel
events shall be submitted to the medical board
for discussion and recommendations approval.
Director General will communicate approved
recommendations with the involved department
for implementation.
The effectiveness of process or system
improvement is monitored according to action
plan by the Quality Management and Patient
Safety Office.

Seven Steps to Patient Safety

Step7 : Implement Patient Safety Improvements

Continues monitoring for the effectiveness of
system Improvement.

JCIA Patient Safety Goals

Origin of JCIA Patient Safety Goals
Patient Safety Goals are derived from Sentinel

Events Data base; which contains aggregate

information on sentinel events reported to the Joint
Commission .
The Goals highlight problematic or high risk

areas in health care and describe evidence and

expert based solutions .

Sentinel Event Experience in the US

4064 sentinel events reviewed by the Joint
Commission, January 1995 through December 2006:
531 events of wrong site surgery.
520 inpatient suicides.

125 perinatal death/injury.

488 operative/post op complications.

94 transfusion-related events.

385 events relating to medication errors.

85 infection-related events.

302 deaths related to delay in treatment.

66 fires.

224 patient falls.

67 anesthesia-related events.

153 deaths of patients in restraints.

51 retained foreign objects.

138 assault/rape/homicide.

763 other

JCIA Patient Safety Goals

JCIA International Patient Safety Goals
Required for implementation as of 1st January 2008 in
all organization accredited by JCI under the
International Standards.
JCIA Chapter.
6 Goals .
21 Measurable Elements.

JCIA Patient Safety Goals

Scoring
All Goals requirements should be Fully

Met.

Incompliance with IPSGs will affect the

re-accreditation decision .
(Patient Safety Goals Implementation and Practice)

JCIA International Patient Safety Goals

PSG 1: Identify Patients Correctly.

PSG 2: Improve Effective Communication.

PSG 3: Improve the Safety of High-Alert Medications.
PSG 4 :Ensure Correct-Site, Correct-Procedure, CorrectPatient Surgery.

PSG 5: Reduce the Risk of Health Care Associated Infections.

PSG 6: Reduce the Risk of Patient Harm Resulting from Falls

Goal 1: Identify Patients Correctly

Right Patient

Right Care

Patient Safety Goals into Practice

Goal 1: Identify Patients Correctly
Key 1: Prior to any procedure or treatment use two
ways to identify your patients such as:
Patients Name & Patients MRN#

DONT USE
Patients Room Number or Patients date of Birth

Key 2: Patient Involvement in the Identification Process

is a Key.

Patient Safety Goals into Practice

Use two (2) ways to identify a patient while:
Giving medications.
Giving blood and blood products.

Taking blood samples.

Taking other samples for clinical testing.
Providing treatment or procedure.

Patient Safety Goals into Practice

Goal 2:Improve Effective Communication
Person Receiving the following:
Verbal orders.
Telephone orders .
Critical laboratory results.
Key 1: Read back what you have written down to confirm that
what has been written down and read back is accurate.
Key 2: Hand-off Communication, sign out should be documented
in patient chart.

Goal 2:Improve Effective Communication

Key 3:Any procedure done for patients and the
outcome of this procedure must be
documented in progress note .

Key 4: Discharge Summary.

Discharge Summary
Prepared at discharge , documented in the patient record and
contains:
Reason for admission.
Significant physical and other findings.
Significant diagnosis and co-morbidities.
Diagnostic and therapeutic procedures.
Significant medication and treatments.
Condition at discharge.
Discharge medications and ALL medications to be taken at home.
Follow up instructions.

( Continuity of Care)

Patient Safety Goals into Practice

Goal 3: Improve the Safety of High
Alert Medications.
Key 1: Concentrated electrolytes are not present in
patient care units unless clinically necessary in those
areas where permitted by policy.
High Alert Medication > 0.9% Concentration

Patient Safety Goals into Practice

Goal 3: Improve the Safety of High
Alert Medications.
Key 2: Using of Approved Abbreviation.
Key 3: Labeling of Concentrated electrolytes.

Patient Safety Goals into Practice

Goal 4:Ensure Correct-Site, Correct

Procedure, Correct-Patient Surgery
Key 1: Marking the Site of Surgery.
Key 2: Preoperative/Pre- procedure Verification

Process.

Key 3: Time-Out that is held immediately

before the start of the surgery/procedure.

Patient Safety Goals into Practice

Time out includes the following:
Correct procedure.
Correct patient.
Correct equipment.
Correct documents.
Correct surgical site.

Patient Safety Goals into Practice

Goal 5:Reduce the Risk
of Health Care
Associated Infections
Key 1: Hand Washing, Hand
Washing, Hand Washing
Clean Care.. Safe Care

Key 2: Strict Sterile Techniques

for any Invasive Procedure.

Patient Safety Goals into Practice

Goal 6:Reduce of Patient Harm
Resulting from Falls
Key 1: Fall Risk Assessment.
Key 2: Implementation of Fall Down Precaution.
Key 3: Patient and Family Education.

Patient Safety Goals into Practice

Thank You