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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 • • • • • • • • • • 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?