Setting the Standards- Safeguarding our Patients

Transcription

1 Inaugural IMSN Conference 1 st Oct Networking for safety Setting the Standards- Safeguarding our Patients June O Shea and Paul Tighe

2 A hospital is no place to be sick Samuel Goldwyn

3 Outline Introduction & background JCI accreditation Who, what & why? Outline of JCI standards Spin-off from IMSN / JCI synergy Future partnerships

4 Introduction Private & Public Hospital representation Medication management experience from accreditation processes Networking for safety National standards Pharmacy (Pharmacy Act 2007) HIQA Draft National Standards for Safer Better Healthcare (2010) Collaborate with HIQA on medication safety standards?

5 What are standards? the criteria or set of rules that describe the expected levels of clinical and system behaviour as well as courses of action based on research and experience Davis 1997

6 What is accreditation? a process to provide a visible commitment by an organisation to improve the safety and quality of patient care, ensure a safe care environment and continually work to reduce risks to patients and staff Joint Commission

7 Accreditation Experience - Pilot site in 2001 for IHSAB - First full survey applied for JCI accreditation surveyed & accredited - survey by JCI in 2002 & accredited - 4 th survey in 2011

8 Joint Commission International (JCI) US-based non-profit organisation Focused on improving safety of patient care & organisation management through provision of accreditation & certification Work directly with healthcare organisations to achieve goals of providing quality clinical care and services in safe, efficient & well-managed facilities

9 Sharing Learning from Accreditation 17 Irish JCI accredited organisations Highest number in EU (59 total) All represented at IMSN Sharing medication safety initiatives & knowledge of medication safety standards

10 What is different? Role of pharmacy in medication management in organisation Proactive identification of risks Policies Training Quality methodology

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12 Overview of JCI standards Patient centered standards (8) Healthcare Organisation Management Standards (6) Focus on patient safety

13 WHO HIGH 5 s Concentrated Injectable Medicines JCI patient safety goal Medication Accuracy at Transitions in Care JCI standard Correct Procedure at the Correct Body Site Communication Failures during Patient Handovers Addressing Health Care-Associated Infections

14 JCI Patient Safety Goals (IPSG) 1. Identify Patients Correctly 2. Improve Effective Communication 3. Improve Safety of High-Alert Medications 4. Ensure Correct-Site, Correct-Procedure, Correct-Patient Surgery 5. Reduce Risk of Health Care Associated Infections 6. Reduce Risk of Patient Harm Resulting from Falls

15 JCI Patient Safety Goal 3 Improve the safe use of highalert medications Concentrated electrolytes New 4 th edition standards High-Alert medications specific to your organisation

16 IMSN work & JCI Patient Safety Goals Oral methotrexate safety alert Oxycodone alert Transdermal opioid medications Best practice guidelines for the safe use of potassium Insulin best practice guidance Briefing document on sound alike look alike drugs Briefing document on Vinca alkaloids In progress, medication and falls

17 JCI Medication Management & Use (MMU) standard MMU 4 Measurable element 6 Initial medication orders compared to the list of medications taken prior to admission, according to the organization s established process Facilitates medication reconciliation for each patient Draft National Standards for Safer Better Healthcare Medication management including safe prescribing & reconciliation (Standard 4.1 Criteria 4.1.8)

18 Mistakes are portals of discovery James Joyce

19 JCI Standards and medication safety Standard MMU 7.1 Medication errors, including near misses are reported through a process & time frame defined by organisation Draft National Standards for Safer Better Healthcare Service providers effectively document, report on & respond to safety incidents in a timely manner in line with national legislation, policy, guidelines & guidance. (Standard 4.2 Criteria 4.2.3)

20 JCI Standards and medication safety Measurable elements of Standard MMU Medication Error & Near Miss defined through a collaborative process 2. Medication Errors & Near Misses reported in a timely manner using an established process 3. Those accountable for taking action are identified 4. Organisation uses reporting information to improve medication use processes

21 Quality Improvement & Patient Safety (QPS) standard Standard QPS.8 The organisation uses a defined process for the identification and analysis of near-miss events Organisation must track, measure & monitor near miss events Draft National Standards for Safer Better Healthcare (Standard 4.2 Criteria & 4.2.4)

22 Quality approach What is your organisation s quality methodology? RCA and FMEA Performance indicators Self audit Tracer methodology

23 Setting standards Does it safeguard patients? Learning from Aviation industry Hygiene standards Standards for symptomatic breast disease services Organisational standards e.g. cardiac standards door to cath lab Performance indicators for medication safety

24 Strategic Partners IMSN sharing & communicating medication safety strategies nationally IMSN in unique position to become strategic partner in setting medication safety standards in Ireland Precedent in U.S.

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26 PATIENT

27 Conclusion Specific medication safety standards (as in JCI accreditation scheme) safeguard patients IMSN in unique position to assist with national medication safety standards A hospital is a place to be sick Paul Tighe and June O Shea

28 Contact Details June O Shea Pharmacy Manager St.Vincent s University Hospital Paul Tighe Deputy Pharmacy Manager Mater Private Hospital T E j.oshea@st-vincents.ie T (01) E ptighe@materprivate.ie