Coordinator of Care Member of the Profession

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Coordinator of CareMember of the Profession

• Patient Safety

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How Do We Define Patient Safety
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National Patient Safety Goals

• The purpose of The Joint Commissions National
  Patient Safety Goals (NPSGs) is to promote
  specific improvements in patient safety.
• The Requirements highlight problematic areas in
  health care and describe evidence and
  expert-based solutions to these problems.
• The Requirements focus on system-wide solutions,
  wherever possible.

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National Patient Safety Goals

• Goal 1
• Improve the accuracy of patient identification
• Goal 2
• Improve the effectiveness of communication among
  caregivers
• Goal 3
• Improve the safety of using medications
• Goal 4
• Reduce the risk of health care associated
  infections
• Goal 5
• Improve on checking medications patients are
  taking

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National Patient Safety Goals

• Goal 6
• Prevent patients from falling
• Goal 7
• Help patients to be involved in their care
• Goal 8
• Identify patient safety risks
• Goal 9
• Watch patients closely for changes in their
  health and respond quickly if they need help
• Goal 10
• Prevent errors in surgery

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Advancing Patient Safety

• Reporting Sentinel Events

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Sentinel Event

• An adverse unexpected occurrence involving death
  or serious physical or psychological injury to
  the patient.

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Sentinel Events

• Medication Error
• Suicide while an inpatient
• Procedure Complication
• Wrong Site Surgery
• Surgical instrument or object left in a patient
  after surgery or another procedure.
• Death due to use of Restraints
• Falls
• Blood Transfusion reactions or death
• Infant abduction or discharge to wrong person
• Delayed treatment

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How to Decrease Sentinel Events
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Root Cause Analysis

• What is it?
• A Root Cause Analysis is an analysis method,
  which can be used to identify the factors that
  cause adverse events.
• The RCA process is a critical feature of any
  safety management system because it enables
  answers to be found to the questions posed by
  high risk, high impact eventsnotably
• what happened
• why it occurred
• what can be done to prevent it from happening
  again.

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Root Cause Analysis

• RCA assumes that systems and events are
  interrelated. An action in one area triggers an
  action in another, and another, and so on.
• By tracing back these actions, you can discover
  where the problem started and how it grew into
  the symptom you're now facing.

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Types of Causes

• Physical causes - Tangible, material items failed
  in some way (for example, a car's brakes stopped
  working).
• Human causes - People did something wrong. or did
  not doing something that was needed. Human causes
  typically lead to physical causes (for example,
  no one filled the brake fluid, which led to the
  brakes failing).
• Organizational causes - A system, process, or
  policy that people use to make decisions or do
  their work is faulty (for example, no one person
  was responsible for vehicle maintenance, and
  everyone assumed someone else had filled the
  brake fluid).

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The Root Cause Analysis Process
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Step One Define the Problem

• What do you see happening?
• What are the specific symptoms?

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Step TwoCollect Data

• What proof do you have that the problem exists?
• How long has the problem existed?
• What is the impact of the problem?

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Step ThreeIdentify Possible Causal Factors

• What sequence of events leads to the problem?
• What conditions allow the problem to occur?
• What other problems surround the occurrence of
  the central problem?

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Step FourIdentify the Root Cause(s)

• Why does the causal factor exist?
• What is the real reason the problem occurred?

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Step FiveRecommend and Implement Solutions

• What can you do to prevent the problem from
  happening again?
• How will the solution be implemented?
• Who will be responsible for it?
• What are the risks of implementing the solution?