PATIENT

SAFETY
STANDARDS
Dr Dr Dr Dr Y P Bhatia Y P Bhatia Y P Bhatia Y P Bhatia
Managing Director ASTRON Managing Director ASTRON Managing Director ASTRON Managing Director ASTRON
Founder Chairman INDIAN HEALTHCARE QUALITY FORUM Founder Chairman INDIAN HEALTHCARE QUALITY FORUM Founder Chairman INDIAN HEALTHCARE QUALITY FORUM Founder Chairman INDIAN HEALTHCARE QUALITY FORUM
PATIENT SAFETY PATIENT SAFETY PATIENT SAFETY PATIENT SAFETY
Definition: Definition: Definition: Definition:
Actions Actions Actions Actions taken by individuals taken by individuals taken by individuals taken by individuals and and and and
organizations to organizations to organizations to organizations to protect patients protect patients protect patients protect patients from from from from
being harmed by the effects being harmed by the effects being harmed by the effects being harmed by the effects of of of of health health health health being harmed by the effects being harmed by the effects being harmed by the effects being harmed by the effects of of of of health health health health
care care care care services. services. services. services.
FREEDOM from FREEDOM from FREEDOM from FREEDOM from Unintended Unintended Unintended Unintended Health Health Health Health
Care Errors / Injuries due to Medical Care Errors / Injuries due to Medical Care Errors / Injuries due to Medical Care Errors / Injuries due to Medical
Management Management Management Management
THE PARADOX:
First, do no Harm First, do no Harm First, do no Harm First, do no Harm
To Err is Human To Err is Human To Err is Human To Err is Human To Err is Human To Err is Human To Err is Human To Err is Human
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. Hospital incurred patient injury
. Adverse drug reaction
. Development of neurological deficit not present on admission
. Unexpected death (not an outcome of this disease)
4
. Unexpected death (not an outcome of this disease)
. Cardiac/respiratory arrest, low Apgar score
. lnjury related to abortion or delivery
. Hospital acquired infection/sepsis
Lack of Communication.Wrong / Delayed .Procedure
What ERRORS are What ERRORS are What ERRORS are What ERRORS are Patients Patients Patients Patients exposed to exposed to exposed to exposed to ? ?? ?
I. Products/ Technology I. Products/ Technology I. Products/ Technology I. Products/ Technology
Drugs Drugs Drugs Drugs: :: : Reactions. Failures Reactions. Failures Reactions. Failures Reactions. Failures
Devices: Devices: Devices: Devices: Injections ( Injections ( Injections ( Injections (75% of 2 Billions 75% of 2 Billions 75% of 2 Billions 75% of 2 Billions Unsterilized Unsterilized Unsterilized Unsterilized ) )) )
Machines ( Dialysis) Machines ( Dialysis) Machines ( Dialysis) Machines ( Dialysis)
Biological: Biological: Biological: Biological: Blood Blood Blood Blood
5
Biological: Biological: Biological: Biological: Blood Blood Blood Blood
II. Services II. Services II. Services II. Services: :: : Health/medical practices: Health/medical practices: Health/medical practices: Health/medical practices:
Inpatient HAI,, Inpatient HAI,, Inpatient HAI,, Inpatient HAI,, Medication Error, Medication Error, Medication Error, Medication Error, wrong surgery wrong surgery wrong surgery wrong surgery
Inpatient & Inpatient & Inpatient & Inpatient & Outpatient Outpatient Outpatient Outpatient
non non non non- -- - personal services; Communication; Longer stay personal services; Communication; Longer stay personal services; Communication; Longer stay personal services; Communication; Longer stay
III. Environment III. Environment III. Environment III. Environment of care: of care: of care: of care:
waste waste waste waste management management management management
RANGE OF HEALTH CARE ERRORS
Sentinel event = Serious incident
Minor incident
10%
H
a
r
m
6
Near miss = Could have caused
harm but it did not this time
1 : 29 : 300
PATIENT SAFETY AS A PUBLIC HEALTH RISK
A PROBLEM EVERYWHERE
The Relative RISK The Relative RISK The Relative RISK The Relative RISK
Deaths Per 100 Million Hours Deaths Per 100 Million Hours Deaths Per 100 Million Hours Deaths Per 100 Million Hours
Being pregnant Being pregnant Being pregnant Being pregnant 1 11 1
Traveling by train Traveling by train Traveling by train Traveling by train 5 55 5
7
Traveling by train Traveling by train Traveling by train Traveling by train 5 55 5
Working at home Working at home Working at home Working at home 8 88 8
Being in traffic Being in traffic Being in traffic Being in traffic 50 50 50 50
Flying on a commercial airplane 100 Flying on a commercial airplane 100 Flying on a commercial airplane 100 Flying on a commercial airplane 100
Being hospitalized Being hospitalized Being hospitalized Being hospitalized 2000 2000 2000 2000
PATIENT SAFETY:
THE ACCREDITORS TOOLS
Standards Standards Standards Standards
Data Data Data Data Data Data Data Data
Guidelines Guidelines Guidelines Guidelines
Patient Safety Goals Patient Safety Goals Patient Safety Goals Patient Safety Goals
Education Education Education Education
PATIENT SAFETY STANDARDS AND
JCI
Leaderships role in creating a culture of safety Leaderships role in creating a culture of safety Leaderships role in creating a culture of safety Leaderships role in creating a culture of safety
Proactive system design Proactive system design Proactive system design Proactive system design
Training/Orientation Training/Orientation Training/Orientation Training/Orientation Training/Orientation Training/Orientation Training/Orientation Training/Orientation
Communication Communication Communication Communication
CRITICAL STEPS TO IMPROVEMENTS
IN PATIENT SAFETY
Identification of all adverse events Identification of all adverse events Identification of all adverse events Identification of all adverse events
Analysis of each error to determine root causes Analysis of each error to determine root causes Analysis of each error to determine root causes Analysis of each error to determine root causes
Compilation of data about error frequencies and Compilation of data about error frequencies and Compilation of data about error frequencies and Compilation of data about error frequencies and
frequencies of root causes frequencies of root causes frequencies of root causes frequencies of root causes
Dissemination of derived information to permit Dissemination of derived information to permit Dissemination of derived information to permit Dissemination of derived information to permit
redesign of systems and processes redesign of systems and processes redesign of systems and processes redesign of systems and processes redesign of systems and processes redesign of systems and processes redesign of systems and processes redesign of systems and processes
Periodic assessment of effectiveness of risk Periodic assessment of effectiveness of risk Periodic assessment of effectiveness of risk Periodic assessment of effectiveness of risk
reduction efforts reduction efforts reduction efforts reduction efforts
1. 1. 1. 1. Potassium chloride Potassium chloride Potassium chloride Potassium chloride
2. 2. 2. 2. Policy issues Policy issues Policy issues Policy issues
3. 3. 3. 3. Policy issues Policy issues Policy issues Policy issues
4. 4. 4. 4. Policy issues Policy issues Policy issues Policy issues
5. 5. 5. 5. Policy issues Policy issues Policy issues Policy issues
6. 6. 6. 6. Wrong site surgery Wrong site surgery Wrong site surgery Wrong site surgery
7. 7. 7. 7. Suicide Suicide Suicide Suicide
8. 8. 8. 8. Restraint deaths Restraint deaths Restraint deaths Restraint deaths
9. 9. 9. 9. Infant abductions Infant abductions Infant abductions Infant abductions
10. 10. 10. 10. Transfusion errors Transfusion errors Transfusion errors Transfusion errors
21. 21. 21. 21. Medical gas mix Medical gas mix Medical gas mix Medical gas mix- -- -ups ups ups ups
22. 22. 22. 22. Needles & sharps injuries Needles & sharps injuries Needles & sharps injuries Needles & sharps injuries
23. 23. 23. 23. Dangerous abbreviations Dangerous abbreviations Dangerous abbreviations Dangerous abbreviations
24. 24. 24. 24. Wrong Wrong Wrong Wrong- -- -site surgery #2 site surgery #2 site surgery #2 site surgery #2
25. 25. 25. 25. Ventilator Ventilator Ventilator Ventilator- -- -related events related events related events related events
26. 26. 26. 26. Delays in treatment Delays in treatment Delays in treatment Delays in treatment
27. 27. 27. 27. Bed rail deaths & injuries Bed rail deaths & injuries Bed rail deaths & injuries Bed rail deaths & injuries
28. 28. 28. 28. Nosocomial Nosocomial Nosocomial Nosocomial infections infections infections infections
29. 29. 29. 29. Surgical fires Surgical fires Surgical fires Surgical fires
30. 30. 30. 30. Perinatal Perinatal Perinatal Perinatal deaths deaths deaths deaths
SENTINEL EVENT ALERT
10. 10. 10. 10. Transfusion errors Transfusion errors Transfusion errors Transfusion errors
11. 11. 11. 11. High Alert Medications High Alert Medications High Alert Medications High Alert Medications
12. 12. 12. 12. Op/post Op/post Op/post Op/post- -- -op complications op complications op complications op complications
13. 13. 13. 13. Impact of Impact of Impact of Impact of SE Alert SE Alert SE Alert SE Alert
14. 14. 14. 14. Fatal falls Fatal falls Fatal falls Fatal falls
15. 15. 15. 15. Infusion pumps Infusion pumps Infusion pumps Infusion pumps
16. 16. 16. 16. Proactive risk reduction Proactive risk reduction Proactive risk reduction Proactive risk reduction
17. 17. 17. 17. Home fires (O Home fires (O Home fires (O Home fires (O
2 22 2
therapy) therapy) therapy) therapy)
18. 18. 18. 18. Kernicterus Kernicterus Kernicterus Kernicterus
19. 19. 19. 19. Look Look Look Look- -- -alike/sound alike/sound alike/sound alike/sound- -- -alike drugs alike drugs alike drugs alike drugs
20. 20. 20. 20. Kreutzfeldt Kreutzfeldt Kreutzfeldt Kreutzfeldt- -- -Jakob disease Jakob disease Jakob disease Jakob disease
30. 30. 30. 30. Perinatal Perinatal Perinatal Perinatal deaths deaths deaths deaths
31. 31. 31. 31. Anesthesia awareness Anesthesia awareness Anesthesia awareness Anesthesia awareness
32. 32. 32. 32. Kernicterus Kernicterus Kernicterus Kernicterus #2 #2 #2 #2
33. 33. 33. 33. PCA by proxy PCA by proxy PCA by proxy PCA by proxy
34. 34. 34. 34. Intrathecal Intrathecal Intrathecal Intrathecal vincristine vincristine vincristine vincristine
35. 35. 35. 35. Medication reconciliation Medication reconciliation Medication reconciliation Medication reconciliation
36. 36. 36. 36. Wrong route / wrong tube Wrong route / wrong tube Wrong route / wrong tube Wrong route / wrong tube
37. 37. 37. 37. Emergency power failure Emergency power failure Emergency power failure Emergency power failure
38. 38. 38. 38. MRI MRI MRI MRI- -- -related injuries related injuries related injuries related injuries
39. 39. 39. 39. Pediatric medication errors Pediatric medication errors Pediatric medication errors Pediatric medication errors
40. 40. 40. 40. Assaults & homicides Assaults & homicides Assaults & homicides Assaults & homicides
INTERNATIONAL PATIENT SAFETY
GOALS (JCI)
Modeled on the National Patient Safety Goals of Modeled on the National Patient Safety Goals of Modeled on the National Patient Safety Goals of Modeled on the National Patient Safety Goals of
The Joint Commission The Joint Commission The Joint Commission The Joint Commission
JCI sought and received input on the goals from JCI sought and received input on the goals from JCI sought and received input on the goals from JCI sought and received input on the goals from
accredited hospitals, those seeking accredited hospitals, those seeking accredited hospitals, those seeking accredited hospitals, those seeking accredited hospitals, those seeking accredited hospitals, those seeking accredited hospitals, those seeking accredited hospitals, those seeking
accreditation, consultants, and surveyors accreditation, consultants, and surveyors accreditation, consultants, and surveyors accreditation, consultants, and surveyors
Feedback represents 19 different countries Feedback represents 19 different countries Feedback represents 19 different countries Feedback represents 19 different countries
Majority of respondents felt that the Goals are Majority of respondents felt that the Goals are Majority of respondents felt that the Goals are Majority of respondents felt that the Goals are
appropriate and achievable appropriate and achievable appropriate and achievable appropriate and achievable
INTERNATIONAL PATIENT SAFETY GOALS
(2011) AS JCI TOOL
Identify Patients Correctly Identify Patients Correctly Identify Patients Correctly Identify Patients Correctly
Improve Effective Communication Improve Effective Communication Improve Effective Communication Improve Effective Communication
Improve the Safety of High Improve the Safety of High Improve the Safety of High Improve the Safety of High- -- -Alert Medications Alert Medications Alert Medications Alert Medications
Ensure Correct Site, correct procedure, Correct Ensure Correct Site, correct procedure, Correct Ensure Correct Site, correct procedure, Correct Ensure Correct Site, correct procedure, Correct
Patient Surgery. Patient Surgery. Patient Surgery. Patient Surgery. Patient Surgery. Patient Surgery. Patient Surgery. Patient Surgery.
Reduce the risk of health care Reduce the risk of health care Reduce the risk of health care Reduce the risk of health care- -- -acquired acquired acquired acquired
infections infections infections infections
Reduce the risk of patient harm resulting from Reduce the risk of patient harm resulting from Reduce the risk of patient harm resulting from Reduce the risk of patient harm resulting from
falls falls falls falls
PATIENT SAFETY STANDARDS AND NABH
NABH standards are related to patient safety: NABH standards are related to patient safety: NABH standards are related to patient safety: NABH standards are related to patient safety:
COP COP COP COP COP7, COP 12 (d), , COP 12 (j), COP 13, COP7, COP 12 (d), , COP 12 (j), COP 13, COP7, COP 12 (d), , COP 12 (j), COP 13, COP7, COP 12 (d), , COP 12 (j), COP 13,
MOM MOM MOM MOM- -- - MOM 3 (e), MOM 4, MOM6, MOM 8 MOM 3 (e), MOM 4, MOM6, MOM 8 MOM 3 (e), MOM 4, MOM6, MOM 8 MOM 3 (e), MOM 4, MOM6, MOM 8
HIC HIC HIC HIC- -- - HIC 4 HIC 4 HIC 4 HIC 4
CQI CQI CQI CQI- -- - CQI 2, CQI 3, CQI 6 CQI 2, CQI 3, CQI 6 CQI 2, CQI 3, CQI 6 CQI 2, CQI 3, CQI 6 CQI CQI CQI CQI- -- - CQI 2, CQI 3, CQI 6 CQI 2, CQI 3, CQI 6 CQI 2, CQI 3, CQI 6 CQI 2, CQI 3, CQI 6
ROM ROM ROM ROM- -- - ROM ROM ROM ROM- -- - 5 55 5
FMS FMS FMS FMS- -- - FMS 2, FMS 5, FMS 6, FMS 7, FMS 8, FMS 9. FMS 2, FMS 5, FMS 6, FMS 7, FMS 8, FMS 9. FMS 2, FMS 5, FMS 6, FMS 7, FMS 8, FMS 9. FMS 2, FMS 5, FMS 6, FMS 7, FMS 8, FMS 9.
PATIENT SAFETY STANDARDS OF NABH -
COP
COP 7: Policies and procedures guide the care of
vulnerable patients (elderly, children, physically and/or
mentally challenged)
COP 12 (d): Documented policies and procedures exist to
prevent adverse events like wrong site, wrong patient
and wrong surgery and wrong surgery
COP 12 (j): The plan also includes monitoring of surgical
site infection rates
COP 13: Policies and procedures guide the care of
patients under restraints (physical and/or chemical)
PATIENT SAFETY STANDARDS OF NABH
MOM AND HIC
MOM 3 (e): Sound alike and look alike medications are
stored separately
MOM 4: Policies and procedures exist for prescription of
medications
MOM6: There are defined procedures for medication
administration. administration.
MOM 8: Patients are monitored after medication
administration.
HIC 4: The organization takes actions to prevent or
reduce the risk of Hospital Associated Infections (HAI) in
patients and employees.
PATIENT SAFETY STANDARDS OF NABH CQI
AND ROM
CQI 2: The organization identifies key indicators to
monitor the clinical structures, processes and outcomes
which are used as tools for continual improvement.
CQI 3:The organization identifies key indicators to
monitor the managerial structures, processes and
outcomes which are used as tools for continual
improvement.
outcomes which are used as tools for continual
improvement.
CQI 6: Sentinel events are intensively analysed.
ROM 5: Leaders ensure that patient safety aspects and
risk management issues are an integral part of patient
care and hospital management
PATIENT SAFETY STANDARDS OF NABH
FMS
FMS 2: The organizations environment and facilities
operate to ensure safety of patients, their families, staff
and visitors.
FMS 5: The organization has plans for fire and non-fire
emergencies within the facilities.
FMS 6: The organization has a smoking limitation policy. FMS 6: The organization has a smoking limitation policy.
FMS 7: The organization plans for handling community
emergencies, epidemics and other disasters.
FMS 8: The organization has a plan for management of
hazardous materials.
FMS 9: The organisation has systems in place to provide
a safe and secure environment.
PATIENT SAFETY MEASUREMENTS IN
NABH
Patient fall Patient fall Patient fall Patient fall
Patient Bed sores Patient Bed sores Patient Bed sores Patient Bed sores
Adverse Drug reactions Adverse Drug reactions Adverse Drug reactions Adverse Drug reactions
Medication errors Medication errors Medication errors Medication errors
Adverse events analysis Adverse events analysis Adverse events analysis Adverse events analysis
Sentinel and near miss event analysis Sentinel and near miss event analysis Sentinel and near miss event analysis Sentinel and near miss event analysis Sentinel and near miss event analysis Sentinel and near miss event analysis Sentinel and near miss event analysis Sentinel and near miss event analysis
Hospital acquired infection rates (RTI,UTI,IVDRI,SSI) Hospital acquired infection rates (RTI,UTI,IVDRI,SSI) Hospital acquired infection rates (RTI,UTI,IVDRI,SSI) Hospital acquired infection rates (RTI,UTI,IVDRI,SSI)
Variations observed in mock drills Variations observed in mock drills Variations observed in mock drills Variations observed in mock drills
Security related incidences including thefts Security related incidences including thefts Security related incidences including thefts Security related incidences including thefts
Our achievements of levels of Patient Safety Our achievements of levels of Patient Safety Our achievements of levels of Patient Safety Our achievements of levels of Patient Safety
Are Are Are Are
Directly Proportional To Directly Proportional To Directly Proportional To Directly Proportional To
Level of Compliances achieved in meeting the Level of Compliances achieved in meeting the Level of Compliances achieved in meeting the Level of Compliances achieved in meeting the
Standards Standards Standards Standards
LET US STRIVE TO ACHIEVE 100% COMPLIANCE TO LET US STRIVE TO ACHIEVE 100% COMPLIANCE TO LET US STRIVE TO ACHIEVE 100% COMPLIANCE TO LET US STRIVE TO ACHIEVE 100% COMPLIANCE TO
PATIENT SAFETY STANDARDS PATIENT SAFETY STANDARDS PATIENT SAFETY STANDARDS PATIENT SAFETY STANDARDS
BECAUSE BECAUSE BECAUSE BECAUSE
WE ALL NEED THEM WE ALL NEED THEM WE ALL NEED THEM WE ALL NEED THEM
THANK YOU FOR YOUR VALUABLE TIME
Hospital & Health Care Consultants
ypb@astronhealthcare.com