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Coordinator of Care
Member of the Profession
Patient Safety
How Do We Define
Patient Safety
National Patient Safety Goals
• The purpose of The Joint Commission’s 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.
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
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
Advancing Patient Safety
Reporting Sentinel Events
An adverse unexpected occurrence
involving death or serious physical or
psychological injury to the patient.
Sentinel Events
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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
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
events—notably:
• what happened
• why it occurred
• what can be done to prevent it from
happening again.
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.
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).
Step One:
Define the Problem
• What do you see happening?
• What are the specific symptoms?
Step Two:
Collect Data
• What proof do you have that the problem
exists?
• How long has the problem existed?
• What is the impact of the problem?
Step Three:
Identify 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?
Step Four:
Identify the Root Cause(s)
• Why does the causal factor exist?
• What is the real reason the problem
occurred?
Step Five:
Recommend 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?