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Patients Safety 2 Dr. Paul Adlai Quitiquit September 15, 2012 Definitions of common safety errors: 1.

Slips - An action conducted that is not intended; Observable; Unintentional. eg. Physician chooses an appropriate medication but writes 10mg when the intention was to write 1 mg because he is talking to someone else. 2. Mistakes - A plot action. A plot that is already wrong from the beginning so the effect is also wrong. eg. Selecting the wrong drug because the diagnosis is wrong. Instead of giving something to control the bleeding, you gave a blood thinner. - Either can be equated to problems to the patient. - It is important not to equate slip as minor. - Patient can die from slips as well as mistakes. - Cant make slip as an excuse. - There should be safety protocols to prevent slips from occurring. (Cant do anything from mistakes because it is already wrong from the beginning) Safety = Absence of Errors? - Even if errors are present, the patient will still have safety issues. - Safety definition: Freedom from accidental injury. - From the patients perspective the primary safety goal is to prevent accidental injuries during their stay in the hospital. - Lower risks of accident. WHO Definition: - Patient safety: prevention of inadvertent harm by understanding the causative factors. - Risk and vulnerabilities are identified and controlled to provide the safest medical practice environment. - Interventions are designed with the focus on the system, or the entire working environment, rather than the individual. - Patient safety only started in 2004 bill is rising due to errors, which actually is not the fault of the patient. Why patients safety? Why is it important? - Patients know that their ailments may not always be cured, but they dont expect to be advertently harmed due to medical care. - The blame train approach to medical errors and close calls doesnt work well. - Your specialty board exam may have questions on human factor engineering techniques. What would work better? - The problem is not the bad people. - The problem is that the system needs to be made safer. Role of professionals - Become active leaders in encouraging and demanding improvements in patient safety. - Incorporate patients safety in the training program.

- Setting standards convening the communication. - eg. Pamphlets, Manuals Improve access to accurate timely information: - The medications and other therapy should be available at the point of patient care. - Have a pharmacist available on nursing units and rounds. - Patient with allergies should have color-code wristbands. - Track errors and near misses and report them regularly. - Accelerate laboratory turn around time. - These are just recommendations. Improve the accuracy of patient identification: - The policies say health care providers are to check at least two patient identifiers before providing care treatment or services. - eg. Look at the patients name and look at their medical records. Ask the patients name not only looking at the record. (State your name. Dont ask something that is answerable by yes or no) - These identifiers should be used to validate a patients identity. Verbal Orders - Person to person verbal orders should never be taken. - It should always be written. - Telephone orders are read-back for verification. (In the hospital we dont allow telephone orders but sometimes it is done. The only allowed verbal orders are just procedures but not medications) - Promptly reporting abnormal lab values, x-rays and other diagnostic results to a responsible licensed caregiver are vital for patients safety. Abbreviations - Only use abbreviations that are standard. - Be aware of look alike or sound alike drugs. - Label all medications and medication containers. - Indicate the name and room of the patient. (Even on the medication package itself) Writing the prescription Reconciliation process: Three basic steps: 1. Verify collect an accurate medication history. Make sure youre writing the right medication. 2. Clarify with the physician who gave the order. That he wrote really the drug. 3. Reconcile with the document or the patients chart. Reduce the risk of healthcare associated infections - Follow the Center of Disease Control (CDC) guidelines for hand hygiene. - Happy birthday (one happy birthday = 15 seconds) - Know when to use hand hygiene. - ie. Not only done after the procedure but done before and after. Reduce the risk of patient harm resulting form falls.

- Hospital staffs use a leaf magnet to identify inpatients at-risk of falling. (Patients with problem on balance) - Everyone can help. If you see the leaf look inside to make sure that the patient is safe and secured. Policy for safe disposal of contaminated articles and sharps - (needles, syringes, blades) What else is being done? - Frequent fire and disaster drills - Bomb threat policies and drills - Inspection of all equipment. - eg. hospital beds, patient-lifting equipments. - Make sure gas containers are safe, infusion pumps and monitoring equipments. What can employees do to promote patient safety? - Report any potentially dangerous patient situation to your supervisor. (Natatakot sila magreport baka sila ang mapagbintangan) - Know about and participate in performance improvement processes in your department or unit. - Take annual mandatory trainings. It will help you identify safety issues. (Sometimes they take this lightly because they think this will not happen to them) - Dont take shortcuts. - Use checklists. - Ask co-workers to complete double checks. Conclusion: Be an advocate for our patients. Patient safety is everyones job. By Betina Ramos