2-Errors & Violation.ppt for accreditation
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The document discusses patient safety culture with a focus on identifying errors and violations in healthcare practices. It emphasizes the need for a shift from a blame culture to one that prioritizes safety and continuous improvement, outlining different types of errors and the situations that lead to them. Additionally, it highlights the importance of incident reporting and monitoring as essential tools for learning from mistakes and ensuring competency among healthcare providers.
2-Errors & Violation.ppt for accreditation
- 1. PATIENT SAFETY CULTURE Dr. Haitham El Hadidy Dr. Haitham El Hadidy General Manager General Manager School of Medicine – BUC School of Medicine – BUC Doctorate degree in Hospital Administration Doctorate degree in Hospital Administration 2
- 2. Suzanne’s medical history included caesarean sections, Two months later Suzanne presented to hospital suffering severe anal pain. A doctor performed an anal dilation under general anaesthesia and retrieved a surgical retractor . The doctor thought that the retractor had been left inside Suzanne after her caesareans and it had worked its way gradually through the peritoneum into the rectum. noted the presence of gross adhesions, or scarring, to the peritoneum, the instrument was most likely to have been left inside Suzanne during her caesarean and remained there.
- 3. WHY ARE WE HERE?
- 4. 1) Change the culture and systems of healthcare 2) Put emphasis on compliance with standards and on continuous improvement 3) Move from culture of “blame” to “safety”
- 6. The “perfectibility” model, which assumes that if health- care workers care enough, work hard enough, and are well trained, errors will be avoided. International experts, tells us that this attitude is simply International experts, tells us that this attitude is simply untrue untrue. .
- 7. What is Errors & Violation
- 10. What do we mean by What do we mean by “ “Error Error”? ”?
- 11. Non-deliberate Non-deliberate deviation from what deviation from what was intended: was intended: When someone is trying to do the right thing, but actually does the wrong thing.
- 12. The difference between what was actually done and what should have been done.
- 13. Two main types of failures
- 14. 1- Actions do not go as intended: 2- The intended action is the wrong one
- 15. 1- Actions do not go as intended:
- 16. Called error of execution and described as being either a: Slip, if the action is observable, An example of a slip is accidentally pushing the wrong button on a piece of equipment. lapse, if it is not. An example of a lapse is a memory failure, such as forgetting to administer a medication
- 18. 2- The intended action is the wrong one
- 19. When the intended action is actually incorrect called a ‘mistake’. (A mistake is a failure of planning). This can be either: ■Rule-based, when the wrong rule is applied, or ■knowledge-based, when a clinician does not take the correct course of action.
- 20. ■ A rule-based mistake: Getting the diagnosis wrong and so <<<<<<<< an inappropriate treatment plan. ■ Knowledge-based mistakes When providers are confronted with unfamiliar clinical situations.
- 22. What do we mean by What do we mean by “ “Violation Violation”? ”?
- 23. Individual health professionals are required to be accountable for their actions, maintain competence and practise ethically. They are required to act responsibly, many health professionals break professional rules, such as using incorrect hand hygiene techniques or letting junior and inexperienced providers work without proper supervision, cut corners and think that this is the way that things are done. Such behaviours are not acceptable. Reason studied the role of violations
- 24. Routine violations Example: fail to practise hand hygiene between patients because they feel they are too busy Optimizing violations Example: Senior professionals who let juniors perform a procedure without proper supervision because they are busy with their private patients. This category involves violations in which a person is motivated by personal goals, such as greed (the performance of unnecessary procedures.
- 25. Necessary violations Example: Because of time constraints, A person who deliberately does something they know to be dangerous or harmful does not necessarily intend a bad outcome, but poor understanding of professional obligations.
- 27. Incident that did not cause harm. Some call “near hits” because the actions may have caused an adverse event, but corrective action was taken just in time or the patient had no adverse reaction to the incorrect treatment.
- 28. Individual factors that Individual factors that predispose to error predispose to error
- 29. Limited memory capacity Fatigue, Stress, Hunger, Illness, language ,Cultural factors, Hazardous attitudes.
- 30. That was developed in the aviation industry is useful as a self- assessment technique to determine whether a health-care professional is fit for work. (Illness, Medication, Stress, Alcohol, Fatigue, Emotion) IM SAFE
- 31. Situation associated with Situation associated with increased risk of error increased risk of error
- 32. Unfamiliarity with the task (especially if combined with lack of supervision) Inexperience Shortage of time Inadequate checking Poorly designed procedures Poor human-equipment interface
- 33. ■ Inexperience It is very important that health-care providers do not perform a procedure on a patient, or administer a treatment for the first time without appropriate preparation and supervision by experienced staff.
- 36. ■ Time pressures Time pressures encourage health-care providers to cut corners and take shortcuts when they should not. ( e.g Not cleansing hands properly, or a pharmacist not taking the time to properly counsel someone receiving medication).
- 37. ■ Contingency teams Teams formed for emergent or specific events (e.g. cardiac-arrest teams, disaster-response teams, obstetric-emergency teams, rapid- response teams). The members of a contingency team are drawn from a variety of core teams.
- 38. ■ Inadequate checking Checking saves patients from receiving the wrong medications. Routinely check drugs and assist the other members of the health-care team in making sure each patient receives the correct dosage of the correct drug via the correct route
- 40. ■ Poor procedures Includes: • inadequate preparation, • inadequate staffing • inadequate attention to a particular patient. Some health-care providers may be required to use equipment without fully understanding how to use it.
- 41. ■ Inadequate information - Professional recoding the patient details accurately, in a timely way and in legible handwriting in the patient record (medical record) and up-to-date. Misinformation, incorrect and inadequate information are often factors contributing to adverse events.
- 42. Ways to learn from errors
- 44. Incident reporting and monitoring involve collecting and analyzing information about an adverse event that could have harmed or did harm a patient in a clinical setting. An incident-reporting system is a fundamental component of an organization’s ability to learn from error.
- 49. ■ Incident monitoring Continuous activity of health-care teams involves: Discussion about incidents as a routine item at the weekly staff meetings; A weekly review of areas where errors are known to occur; A detailed discussion about the facts of an incident and follow-up action required—this discussion should be educational rather than focusing on blame; Identification of system-related issues and problems to be addressed and made known.
- 51. Is an important component of patient safety. 1- Health-care providers must have attributes, such as compassion, empathy and a vocational aspiration to provide benefit to patients. These are necessary for safe and ethical practice.
- 52. 2- Health-care organizations are required to check that health- care providers have the appropriate qualifications and are competent to practice. The processes are as follows:
- 54. Accreditation
- 55. Is a formal process to ensure the delivery of safe, high-quality health care, based on standards and processes devised and developed by health-care professionals for health-care services.
- 57. Most countries require health-care providers to be registered with a government authority to help protect the health and safety of the public
- 58. Credentialing
- 59. The process of assessing and conferring approval on a person’s suitability to provide specific patient care and treatment services, within defined limits, based on an individual's license, education, training, experience, and competence.
- 60. Dormicum 2mg and Fentanyl 25 ug I.V ordered verbally. The nurse administered the 2 drugs according to physicians verbal order and then flushed the line with 5 ml normal saline (NS) >>> An Extra dose of 5 mg Dormicum was given to the patient due to diluted Dormicum (1mg/ml) was mistaken as NS Please administer dormicum and ventanyl for this patient
- 62. العدوى ومكافحة الجودة Lمقس إعداد 62 شكرا