Improved Patient Care and Safety
|
|
- Barry Patterson
- 5 years ago
- Views:
Transcription
1 Improved Patient Care and Safety David Fitzgerald, CCP, LP Division of Cardiovascular Perfusion College of Health Professions Medical University of South Carolina ARS Question #1 In my department/unit, we are actively doing things to improve patient safety Strongly agree Agree Neither Disagree Strongly disagree ARS Question #2 When an event is reported, it feels like the person is being written up, not the problem Strongly agree Agree Neither Disagree Strongly disagree 1
2 ARS Question #3 My supervisor/manager overlooks patient safety problems that happen over and over Strongly agree Agree Neither Disagree Strongly disagree ARS Question #4 Staff will freely speak up if they see something that may negatively affect patient care Always Most of the time Sometimes Rarely Never ARS Question #5 When a mistake is made, but is caught and corrected before affecting the patient, how often is this reported? Always Most of the time Sometimes Rarely Never 2
3 Patient Safety Application of safety science methods toward the goal of achieving a trustworthy system of health care delivery 1 An attribute of health care systems that minimizes the incidence and impact of adverse events and maximizes recovery from such events 1 Patient safety is freedom from healthcare associated, preventable harm 2 1- Emanuel L et al Patient Safety World Health Organization s World Alliance for Patient Safety Surgical Unit-based Safety Program (SUSP) Surgical Site Infection control in Kenya and Uganda WHO Safe Childbirth Checklist 130 million births 303,000 mothers, 5.3 million children die WHO Guidelines Safe Surgery Surgical Safety Checklist Pulse Oximetry Project Patient Safety in Robotic Surgery: SAFROS Project Global initiative for Emergency and Essential Surgical Care WHO: 10 Facts on Patient Safety 1. Patient safety is a serious global public health issue 2. One in 10 patients may be harmed while in the hospital (developing nations) 3. Hospital infections affect 14 out of every 100 patients admitted 4. Most people lack access to appropriate medical devices 5. Unsafe injections decreased by 88% from 2000 to Delivery of safe surgery requires a teamwork approach 7. About 20-40% of all health spending is wasted due to poorquality care 8. A poor safety record for health care 9. Patient and community engagement and empowerment are key 10. Hospital partnerships can play a critical role 3
4 Purpose: Chart 5-1. Composite-Level Average Percent Positive Response 2014 Database Hospitals Comparison Assessment and Learning Supplemental Information Trending 42 Items that measure 12 composites of pt. safety Communication openness Feedback and communication about error Frequency of events reported Handoffs and transitions Management support for patient safety Non-punitive response to error Organizational learning- continuous improvement Overall perceptions of safety Staffing Supervisor expectations and actions promoting safety Teamwork across/within units Assessing the Culture of Safety in Cardiovascular Perfusion: Attitudes and Perceptions Chad Lawson, Megan Predella, Allison Rowden, Jamie Goldstein, Joseph J. Sistino, David C. Fitzgerald Division of Cardiovascular Perfusion College of Health Professions Medical University of South Carolina Survey broadcasted through invitation (Perflist, Perfmail and LinkedIn) 37 closed, Likert-scaled questions based on AHRQ Hospital Survey on Patient Safety Culture >75% agree or strongly agree Overall work unit grade of patient safety Culture of Safety Highest Scoring Categories 4
5 Culture of Safety Lowest Scoring Categories Joint Commission- 5 Principles of a Learning Organization Team learning Shared visions and goals A shared mental model Individual commitment to lifelong learning Systems thinking Must have a fair and just safety culture, a strong reporting system, and a commitment to put data to work by driving improvement. How to Promote Patient Safety Limiting Blame Fallacy: Well-trained and conscientious practitioners do not make mistakes Systems Thinking Standardization and simplification Transparency and Learning Sharing information about medical errors 1- Emanuel L et al. Available at: 5
6 Patient name/procedure Age/Allergies Stage of the procedure Status of temperature History Circuit Lab values and targets Anticoagulation Medications Pump settings Other conditions or concerns Fluid status Final thoughts surgical approach, cannulation, backup plan, target flows medications, adverse reactions, associated risks preoperative, perioperative, postoperative, surgical status target temperatures, current temperatures, rewarming rate symptoms, risk factors, diagnosis, prior procedures, preoperative medications oxygenator, tubing size and coating, cardioplegia, shunts, hemoconcentrator, accessories hematocrit, blood gasses, electrolytes, enzymes, targets status, targets, heparin use, alternative anticoagulants, blood components vasoconstrictors, vasodilators, cardioplegia, electrolytes, antiarrhythmics, colloids FiO2, sweep, blood flow, vacuum, RPMs, timers, shunts jehovah s witness, sickle cell anemia, pregnancy, sepsis, DIC I/Os, crystalloid use, ultrafiltrate amount and rate, urine 3/17/2016 How to Promote Patient Safety Culture and Professionalism Collective mindfulness - High-Reliability Organizations Search for and report unsafe conditions before they pose a substantial risk and when they re easy to fix Accountability for Delivering Effective, Safe Care Joint Commission- 20,000 centers accredit/certify Commitment to continuous learning / Published literature Health Care as an Industry Partnerships Human factors engineering in health care How to Promote Patient Safety Rethinking Risk Quality improvement Risk management Emphasizing Teamwork Relationships between coworkers which can lead to failure, including both individual errors and inherent weaknesses within a system. Reason s model likens this to slices of Swiss cheese, with the holes in the cheese representing potential weaknesses. If a hazard arises, it can progress through a hole in the first slice; that is, a weakness in the first stage of the process will allow it to go unchecked. But ideally, the hazard will encounter a solid section of cheese in a subsequent slice, and progress no further; i.e. one of the subsequent stages of the process will identify the hazard and prevent it developing. Figure 1: Patient Safety Swiss Cheese Model 30 However, if a system is set up in such a way that holes in the cheese can become aligned across all slices, then a hazard could develop unchecked, and eventual failure of the system is inevitable. I PASS THE Therefore, CLAMP OFF in Reason s model, maximising safety requires more slices, and smaller and fewer holes; i.e. more defence stages across a model, and fewer and better-identified weaknesses Patient Handoff Tool at for Perfusionists each stage, minimising the aligned-weakness outcome. 31 I Isolation precautions contact, droplet, airborne The Three Bucket model P A Reason s three bucket model 32 S aims to help clinicians take an appropriate approach to S considering their surrounding and limitations, so as T to estimate Transfusion the degree blood type, of targets, risk product use, present, availability and from a number of perspectives. H E Equipment condition mechanical concerns or issues The model C advises staff to consider three areas in which L risks may be present Self, Context A and Task and in the model, illustrates these M as three P separate buckets. At any one time, each O bucket will be filled with a mixture of Good Stuff F and Bad Stuff ; and the overall risk of error F in a task will be in line with the total amount of Bad Stuff present across all three buckets. Figure 2: Reasons Three Bucket Model 33 The NPSA have produced examples of factors which may be present in the three buckets 34 e.g. in the Self bucket, knowledge, skill, expertise, as well as their current capacity. If workload, fatigue and stress levels all increase, the Self bucket will contain more Bad Stuff, and the risk of error rises. All buckets are then considered. An example of this is given by McKimm & Forrest 35 : if a clinician were to insert a cannula to a compliant patient with large veins at the start of a day shift, they would not likely foresee any issues. But if the patient were uncooperative, and an intravenous drug user with poor veins; it were the middle of the night; and the clinician were tired, stressed and hungry, then ideally the clinician should stop and consider their three buckets as being full, and so reconsider the task before deciding how best to proceed. Royal College of General Practitioners- Implications of General Practice Workload Joint Commission Standard LD The hospital has an organization-wide, integrated patient safety program This standard describes a safety program that integrates safety priorities into all processes, functions, and services within the hospital, including patient care, support, and contract services. It addresses the responsibility of leaders to establish a hospital-wide safety program; to proactively explore potential system failures; to analyze and take action on problems that have occurred; and to encourage the reporting of adverse events and near misses, both internally and externally. The hospital s culture of safety and quality supports the safety program. At least every 18 months, the hospital selects one high risk process and conducts a proactive risk assessment. At least once a year, the hospital provides governance with written reports on all actions taken to improve safety, both proactively and in response to actual occurrences 6
7 Identifying Risks Incident reports Near-misses Environmental tours Issues reported by Patient Safety Officer Observations by staff members Publications New regulatory issues Joint Commission Sentinel Events Product Recalls Audits, inspections Industry Standards and Guidelines Simulation exercises Time-outs, briefings, debriefings Failure Mode & Effect Analysis (FMEA) Summary 7
Hospital Survey on Patient Safety Culture: Debrief and Action Planning
Hospital Survey on Patient Safety Culture: Debrief and Action Planning August 7, 2018 A partnership of the Healthcare Association of New York State and the Greater New York Hospital Association 1 Three
More informationStatewide Patient Safety Culture: North Carolina HSOPS and Medical Office SOPS
Statewide Patient Safety Culture: North Carolina HSOPS and Medical Office SOPS What is safety culture? The safety culture of an organization is the product of individual and group values, attitudes, perceptions,
More informationAn Overview of the AHRQ Hospital Survey on Patient Safety Culture TM (SOPS TM ) and Value and Efficiency Supplemental Item Set
An Overview of the AHRQ Hospital Survey on Patient Safety Culture TM (SOPS TM ) and Value and Efficiency Supplemental Item Set Using the SOPS Toolkit for Patient Safety Improvement Theresa Famolaro, MPS,
More informationComposite Results and Comparative Statistics Report
Patient Safety Culture Survey of Staff in Acute Hospitals Report April 2015 Page 1 Table of Contents Executive Summary 3 1.0 Purpose and Use of this Report 8 2.0 Introduction 8 3.0 Survey Administration
More informationA Study to Assess Patient Safety Culture amongst a Category of Hospital Staff of a Teaching Hospital
IOSR Journal of Dental and Medical Sciences (IOSR-JDMS) e-issn: 2279-0853, p-issn: 2279-0861.Volume 13, Issue 3 Ver. IV. (Mar. 2014), PP 16-22 A Study to Assess Patient Safety Culture amongst a Category
More informationHSOPS Analysis and Interpretation. Using The Pa,ent Safety Group (PSG)
HSOPS Analysis and Interpretation Using The Pa,ent Safety Group (PSG) Objectives Describe post-survey activities Explain how to generate reports from PSG Identify HSOPS interpretation strategies Results,
More informationReview for Required Monitors
Review for Required Monitors The Joint Commission Hospital Accreditation Manual, 2009 Medicare Conditions of Participation, Hospitals Update: February 2009 Indicator / Monitor Restraint, Medical (non-specific
More informationHealthStream Ambulatory Regulatory Course Descriptions
This course covers three related aspects of medical care. All three are critical for the safety of patients. Avoiding Errors: Communication, Identification, and Verification These three critical issues
More informationMeasurability of Patient Safety
Measurability of Patient Safety Marsha Fleischer IMPO Conference, November 17, 2016 External requirements in Germany lead to a higher need for safety and risk management, among others arising from the:
More informationCognitive Level Certified Professional in Patient Safety Detailed Content Outline Recall. Total. Application Analysis 1.
Cognitive Level Certified Professional in Patient Safety Detailed Content Outline Recall Application Analysis Total 1. CULTURE 2 12 4 18 A. Assessment of Patient Safety Culture 1. Identify work settings
More informationFacilitating Change in the Patient Safety Culture of the Clinical Learning Environment
Facilitating Change in the Patient Safety Culture of the Clinical Learning Environment Andrew R. Buchert, MD Dept. of Pediatrics Gregory M. Bump, MD Dept. of Medicine Associate Medical Directors for GME
More informationPreventing Medical Errors
Presents Preventing Medical Errors Contact Hours: 2 First Published: March 31, 2017 This Course Expires on: March 31, 2019 Course Objectives Upon completion of this course, the nurse will be able to: 1.
More informationSURGEONS ATTITUDES TO TEAMWORK AND SAFETY
SURGEONS ATTITUDES TO TEAMWORK AND SAFETY Steven Yule 1, Rhona Flin 1, Simon Paterson-Brown 2 & Nikki Maran 3 1 Industrial Psychology Research Centre, University of Aberdeen, Aberdeen, Scotland, UK Departments
More informationTo Err is Human To Delay is Deadly Ten years later, a million lives lost, billions of dollars wasted
1999 Institute of Medicine study estimated that as many as 98,000 people die in any given year from medical errors that occur in hospitals. To Err is Human To Delay is Deadly Ten years later, a million
More informationReviewing Methods Used in Patient Safety Research: Advantages and Disadvantages. This SPSRN work is funded by
Reviewing Methods Used in Patient Safety Research: Advantages and Disadvantages Dr Jeanette Jackson (j.jackson@abdn.ac.uk) This SPSRN work is funded by Introduction Effective management of patient safety
More informationNexus of Patient Safety and Worker Safety
Nexus of Patient Safety and Worker Safety Jeffrey Brady, MD, MPH & James Battles, PhD Agency for Healthcare Research and Quality October 25, 2012 Diagnosing the Safety Problem is One Challenge The fundamental
More informationECRI Patient Safety Organization HFACS and Healthcare
October 15, 2015 ECRI Patient Safety Organization HFACS and Healthcare Thomas W. Diller, MD, MMM VP System Chief Medical Officer CHRISTUS Health Learning Objectives Understand the human factors errors
More informationMeasure what you treasure: Safety culture mixed methods assessment in healthcare
BUSINESS ASSURANCE Measure what you treasure: Safety culture mixed methods assessment in healthcare DNV GL Healthcare Presenter: Tita A. Listyowardojo 1 SAFER, SMARTER, GREENER Declaration of interest
More informationPatient Safety Assessment in Slovak Hospitals
1236 Patient Safety Assessment in Slovak Hospitals Veronika Mikušová 1, Viera Rusnáková 2, Katarína Naďová 3, Jana Boroňová 1,4, Melánie Beťková 4 1 Faculty of Health Care and Social Work, Trnava University,
More informationPatient Safety Case Study. Clara K. Terral. Angelo State University
Running Head: PATIENT SAFTEY CASE STUDY Patient Safety Case Study Clara K. Terral Angelo State University PATIENT SAFTEY CASE STUDY 2 The case study that stood out most to me was Case 18, which is Not
More informationPROCESS FOR HANDLING ELASTOMERIC PAIN RELIEF BALLS (ON-Q PAINBUSTER AND OTHERS)
PROCESS FOR HANDLING ELASTOMERIC PAIN RELIEF BALLS (ON-Q PAINBUSTER AND OTHERS) REQUIRES SAFETY IMPROVEMENTS From the July 16, 2009 issue Problem: In our May 21, 2009, newsletter we noted an association
More informationIntra-operative Cell Salvage. Competency Assessment Workbook. Trainee: Hospital: Trainer/Supervisor: Date Commenced: Date Completed:
Intra-operative Cell Salvage Competency Assessment Workbook Trainee: Hospital: Trainer/Supervisor: Commenced: Completed: Contents Introduction 1-2 Record of Assessors 4 Confirmation of Required Pre-assessment
More informationQuality Improvement and Patient Safety (QPS) Ratchada Prakongsai Senior Manager
Quality Improvement and Patient Safety (QPS) Ratchada Prakongsai Senior Manager Overview 2 Comprehensive approach to quality improvement and patient safety that impacts all aspects of the facility s operation.
More informationNational Health Regulatory Authority Kingdom of Bahrain
National Health Regulatory Authority Kingdom of Bahrain THE NHRA GUIDANCE ON SERIOUS ADVERSE EVENT MANAGEMENT AND REPORTING THE PURPOSE OF THIS DOCUMENT IS TO OUTLINE SERIOUS ADVERSE EVENTS THAT SHOULD
More informationUnit Based Culture of Safety and Learning. Owensboro Health March, 2017
Unit Based Culture of Safety and Learning Owensboro Health March, 2017 Owensboro Health 477 Bed Regional Hospital 32 Bed ICU 30 Transitional Care Beds Level III Trauma Center Level III NICU Largest employer
More information2017 Good Catch Program: Blueprint Companion Guide
2017 Good Catch Program: Blueprint Companion Guide EXECUTIVE SUMMARY The following document provides guidance to accompany the recommended strategies listed within the Blueprint for Success, a comprehensive
More informationImproving Nursing Home Patient Safety in Maine: A Review of the AHRQ Patient Safety Culture survey Implementation Process
University of Southern Maine USM Digital Commons Muskie School Capstones Student Scholarship 5-1-2012 Improving Nursing Home Patient Safety in Maine: A Review of the AHRQ Patient Safety Culture survey
More information9/9/2016. How Respiratory Therapist Enhance Patient Safety. Introduction. Raise your hand. Tawana Shaffer CPHRM, MBA, BSc, CRT
How Respiratory Therapist Enhance Patient Safety Tawana Shaffer CPHRM, MBA, BSc, CRT Introduction Raise your hand 1 How do you define Patient Safety? What is Patient Safety? Communication Care Falls Outcomes
More informationPatient Safety Course Descriptions
Adverse Events Antibiotic Resistance This course will teach you how to deal with adverse events at your facility. You will learn: What incidents are, and how to respond to them. What sentinel events are,
More informationPatient Safety Overview Muhammad H. Islam, MBBS, MS, MCH Director of Patient Safety & Patient Safety Officer SUNY Downstate Medical Center, UHB
Patient Safety Overview Muhammad H. Islam, MBBS, MS, MCH Director of Patient Safety & Patient Safety Officer SUNY Downstate Medical Center, UHB www.downstate.edu/patientsafety Definitions Patient Safety
More informationEffective Date: January 9, 2017
Effective Date: January 9, 2017 Overview: The safety and quality of care, treatment, and services depend on many factors, including the following: - A culture that fosters safety as a priority for everyone
More informationASCA Regulatory Training Series Course Descriptions
This course will help you: Improve drug safety in your ambulatory surgery center (ASC) Comply with accreditation standards related to drug safety Learn the common causes of drug errors Learn methods Improve
More informationHospital Survey on Patient Safety Culture: 2007 Comparative Database Report
Hospital Survey on Patient Safety Culture: 2007 Comparative Database eport Prepared for: Agency for Healthcare esearch and Quality (AHQ) U.S. Department of Health and Human Services (HHS) 540 Gaither oad
More informationNational Patient Safety Agency Root Cause Analysis (RCA) Investigation
National Patient Safety Agency Root Cause Analysis (RCA) Investigation Margaret O Donovan Assistant Director for Acute Services Types of failure Active failures - slips, lapses, fumbles, mistakes, procedural
More informationThe Importance of Transfusion Error Surveillance This is step #1 in error management. Jeannie Callum, BA, MD, FRCPC, CTBS
The Importance of Transfusion Error Surveillance This is step #1 in error management Jeannie Callum, BA, MD, FRCPC, CTBS 6051 Clinical Errors 9083 Laboratory Errors 15134 Errors over 6 years I don t want
More informationStandards for Laboratory Accreditation
Standards for Laboratory Accreditation 2017 Edition cap.org 2017 College of American Pathologists. All rights reserved. [ T y p e t h e c o m p a n y a d d r e s s ] CAP Laboratory Accreditation Program
More informationJourney to an Effective Safety Culture Part I of III Exploring the Role of Culture in Safety Outcomes. Embracing Patient Safety Culture
White Paper Journey to an Effective Safety Culture Part I of III Exploring the Role of Culture in Safety Outcomes Embracing Patient Safety Culture What is the Purpose of this Series? The purpose of this
More informationText-based Document. The Culture of Incident Reporting Among Filipino Nurses. de Guzman, Barbara Michelle. Downloaded 28-Apr :54:41
The Henderson Repository is a free resource of the Honor Society of Nursing, Sigma Theta Tau International. It is dedicated to the dissemination of nursing research, researchrelated, and evidence-based
More informationWHO PATIENT SAFETY PROGRAMME
WHO PATIENT SAFETY PROGRAMME Carmen Audera WHO Patient SAFETY Meeting the Challenges Faced by Emerging Countries in the Provision of Quality Primary Health Care Cape Town A 23 year old women in her first
More informationThe Human Factor: Applying Safety Science in Health Care
The Human Factor: Applying Safety Science in Health Care Sarah Henrickson Parker, PhD Director of Education and Academic Affairs, Research Scientist National Center for Human Factors Engineering in Healthcare
More informationSandra Trotter, MBA, MPHA, CPHQ PATIENT SAFETY PROGRAM LUCILE PACKARD CHILDREN S HOSPITAL STANFORD UNIVERSITY MEDICAL CENTER
Sandra Trotter, MBA, MPHA, CPHQ PATIENT SAFETY PROGRAM LUCILE PACKARD CHILDREN S HOSPITAL STANFORD UNIVERSITY MEDICAL CENTER LUCILE PACKARD CHILDRENS HOSPITAL STANFORD UNIVERSITY MEDICAL CENTER PALO ALTO,
More informationLeadership and Culture: Building Highly Reliable Systems of Care
Learning Objectives Leadership and Culture: Building Highly Reliable Systems of Care Michael Batchelor, CEO Baptist Easley Hospital Easley, South Carolina Discuss recent developments in health systems
More informationTowards Quality Care for Patients. National Core Standards for Health Establishments in South Africa Abridged version
Towards Quality Care for Patients National Core Standards for Health Establishments in South Africa Abridged version National Department of Health 2011 National Core Standards for Health Establishments
More informationTable of Contents. TeamSTEPPS Framework and Competencies Key Principles. Team Structure Multi-Team System For Patient Care
Table of Contents TeamSTEPPS Framework and Competencies Key Principles Team Structure Multi-Team System For Patient Care Leadership Effective Team Leaders Team Events Brief Checklist Debrief Checklist
More informationDecember 20, Thursday. 7 am. 12 pm. 20 Thursday. December 2012 SuMo TuWe Th Fr Sa 1. January 2013 SuMo TuWe Th Fr Sa
December 20, 2012 Thursday December 2012 SuMo TuWe Th Fr Sa 1 2 3 4 5 6 7 8 9101112131415 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 January 2013 SuMo TuWe Th Fr Sa 1 2 3 4 5 6 7 8 9 10 11 12 13 14
More informationPatient Safety in Resource Poor Settings
Patient Safety in Resource Poor Settings Global Opportunities (MIT April 8, 2011) Pedro Delgado, Executive Director Institute for Healthcare Improvement www.ihi.org 1 Safe, Timely, Effective, Efficient,
More informationBest Practice Model Determination: Oxygenator Selection for Cardiopulmonary Bypass. Mark Henderson, CPC, CCP,
Best Practice Model Determination: Oxygenator Selection for Cardiopulmonary Bypass. Mark Henderson, CPC, CCP, 1 Abstract In recognizing the uniqueness of perfusion practice, building a best practice model
More informationRevolutionizing Patient Safety through Organizational Certification Anne Arundel Medical Center
Revolutionizing Patient Safety through Organizational Certification Anne Arundel Medical Center 1 Anne Arundel Medical Center 1 Learning Objectives Established the Patient Safety Officer (PSO) as the focal
More informationPatient Safety Overview
Patient Safety Overview Muhammad H. Islam, MBBS, MS, MCH, LSSBB Director of Patient Safety & Patient Safety Officer SUNY Downstate Medical Center, UHB www.downstate.edu/patientsafety Definitions Patient
More informationIBBM PBMS Review Course The Job, Quality, and Data
JECT 2017 PBMS Review Course IBBM PBMS Review Course The Job, Quality, and Data Jeff Riley MHPE, CCP Portland OR October 21, 2017 1 1996 ABCA-Sponsored Job Analysis 1996 demographics for PMBT Rating scales
More informationEuroELSO GUIDELINES FOR TRAINING & CONTINUING EDUCATION OF ECMO PHYSICIANS
EuroELSO GUIDELINES FOR TRAINING & CONTINUING EDUCATION OF ECMO PHYSICIANS PURPOSE The "EuroELSO Guidelines for Training & Continuing Education of ECMO Physicians" is a document developed by the Extracorporeal
More informationChoi, Ji-an Keum, Kyeong-lim Choi, Seon-yeong Kim, Myung-Ja
Development of an Instrument to Measure Knowledge, Skills and Attitude for Patient Safety among Nursing Officers & Civilian Nurses of Military Hospitals Choi, Ji-an Keum, Kyeong-lim Choi, Seon-yeong Kim,
More informationSusan Moffatt-Bruce, MD, PhD Chief Quality and Patient Safety Officer Associate Professor of Surgery The Ohio State University s Wexner Medical Center
Engaging the team: Steps to Reduce Complications Susan Moffatt-Bruce, MD, PhD Chief Quality and Patient Safety Officer Associate Professor of Surgery The Ohio State University s Wexner Medical Center Safety
More informationAdministrative Policies and Procedures
Administrative Policies and Procedures Originating Venue: Environment of Care Policy No.: EC 2007 Title: Environment of Care Management Program Cross Reference: EC 2001 Date Issued: 04/14 Authority Environmental
More informationPatient Safety. If you have any questions, contact: Sheila Henssler Performance Improvement/Patient Safety Coordinator Updated:
Patient Safety If you have any questions, contact: Sheila Henssler Performance Improvement/Patient Safety Coordinator 615-7018 Updated: 2013-05-03 Learning Objectives In this presentation, you will learn:
More information2. Unlicensed assistive personnel: any personnel to whom nursing tasks are delegated and who work in settings with structured nursing organizations.
XVIII. A. General Information: The judgments that you make in about coordinating and facilitating client care situations have to be based on knowledge. You MUST know your content, and then you can move
More informationIMPORTANCE OF IMPROVING INTERPERSONAL COMMUNICATION SKILLS OF MEDICAL PERSONNEL IN MINIMIZING MEDICAL LIABILITY CLAIMS PIOTR DANILUK, MD
Polskie Towarzystwo Medycyny Ubezpieczeniowej IMPORTANCE OF IMPROVING INTERPERSONAL COMMUNICATION SKILLS OF MEDICAL PERSONNEL IN MINIMIZING MEDICAL LIABILITY CLAIMS PIOTR DANILUK, MD Warsaw, 23.09.2016
More informationSpecialized Nursing Postgraduate Diploma, Faculty of Nursing, University of Iceland, Reykjavik, Iceland
Specialized Nursing Postgraduate Diploma, Faculty of Nursing, University of Iceland, Reykjavik, Iceland Program director: Thorunn Sch. Eliasdottir, CRNA, PhD Specialized Nursing Postgraduate Diploma Faculty
More informationTowards Quality Care for Patients. Fast Track to Quality The Six Most Critical Areas for Patient-Centered Care
Towards Quality Care for Patients Fast Track to Quality The Six Most Critical Areas for Patient-Centered Care National Department of Health 2011 National Core Standards for Health Establishments in South
More informationPatient Safety Culture in the Radiologic Sciences
Slide 1 Patient Safety Culture in the Radiologic Sciences Jeff Legg Virginia Commonwealth University Laura Aaron Northwestern State University of Louisiana Melanie Dempsey Virginia Commonwealth University
More information12.01 Safety Management Plan UWHC Administrative Policies
Page 1 of 7 12.01 Safety Management Plan Category: UWHC Administrative Policy Policy Number: 12.01 Effective Date: October 8, 2013 Version: Revision Section: Environmental Safety (Hospital Administrative)
More informationManitoba Transfusion Best Practice Resource Manual Appendix 17 Guidelines for Perioperative Autologous Blood Collection and Administration
Guidelines for Perioperative Autologous Blood Collection and Administration Purpose These guidelines intend to inform health care providers about the principles of Perioperative Autologous Blood Collection
More informationPatient Safety is Everyone s Responsibility Tammy Brock, MSN RN CPHRM
Patient Safety is Everyone s Responsibility Tammy Brock, MSN RN CPHRM Objectives Know TJC 2016 National Patient Safety Goals Discuss human factors on patient safety What is your role in patient safety?
More informationAssessment of patient safety culture in a rural tertiary health care hospital of Central India
International Journal of Community Medicine and Public Health Goyal RC et al. Int J Community Med Public Health. 2018 Jul;5(7):2791-2796 http://www.ijcmph.com pissn 2394-6032 eissn 2394-6040 Original Research
More informationExemplary Professional Practice: Accountability, Competence and Autonomy
Exemplary Professional Practice: Accountability, Competence and Autonomy EP16 Nurse autonomy is supported and promoted through the organization s governance structure for shared decision-making. EP16b:
More informationRisk Assessment Form HS 9 (1)
s Full Name: Date of Birth: NHS Number 1. The fully implanted port system Sitimplant is not regularly used in the community and nursing staff may be unfamiliar with the recommended care of this system
More informationMeasuring Patient Safety Culture Manual, Part I: Getting Started & Planning Your Survey Process
The Armstrong Institute for Patient Safety and Quality Measuring Patient Safety Culture Manual, Part I: Getting Started & Planning Your Survey Process This manual has been adapted from the publically available
More informationMHA Patient Safety Organization
MHA Patient Safety Organization Membership Benefits 2014 Copyright ECRI Institute PSO MHA PSO does more than analyze reported events and near misses. They provide members with tools and resources to help
More informationLetitia Cameron, MD Aniel Rao, MD Michael Hill, MD
Presented by: Suchita Pancholi, MD Letitia Cameron, MD Aniel Rao, MD Michael Hill, MD I. Introductions II. III. IV. Marshmallow Challenge Why Teach Patient Safety? Barriers to Teaching Patient Safety V.
More informationEligibility Introduction Practice Ethics and Patient Rights and Responsibilities (RI)... 6
Table of Contents Eligibility... 2 Introduction... 3 Practice Ethics and Patient Rights and Responsibilities (RI)... 6 Provision of Care, Treatment, and Services (PC)... 8 Medication Management (MM)...
More informationMidwest Alliance for Patient Safety Patient Safety Organization Getting Started with a PSO. An Illinois Hospital Association Company
Midwest Alliance for Patient Safety Patient Safety Organization Getting Started with a PSO An Illinois Hospital Association Company Today s Roadmap Objectives: 1. Explain the PSQIA and PSO Basics 2. Learn
More informationCAMH February 2005 Update HIGHLIGHTS
CAMH February 2005 Update HIGHLIGHTS STANDARD UP 1. How to Use Manual Multiple changes to scoring, category changes and Measure of Success (MOS) designation removed 2. Accreditation Policies & Procedures
More informationADVANCE DIRECTIVE FOR HEALTH CARE
ADVANCE DIRECTIVE FOR HEALTH CARE This document includes a list of definitions and the two types of Advance Directives (together called a Combined Directive). Some people choose to fill out only one portion.
More informationACCOUNTABILITY: OBJECTIVES: RELATION TO MISSION: RELATION TO OPERATION: POLICY: Chief Nursing Officer
Our Lady of Lourdes Health Care Services, Inc. and Affiliates including Our Lady of Lourdes Medical Center Lourdes Medical Center of Burlington County Administrative and General Policy Page number: 1 of
More informationDesigning for Safety
2014 FGI Guidelines Update Series FGI Guidelines Update #1 July 11, 2013 Designing for Safety Ellen Taylor, AIA, MBA, EDAC In 2010 one of the topics introduced to the Guidelines for Design and Construction
More informationYoder-Wise: Leading and Managing in Nursing, 5th Edition
Yoder-Wise: Leading and Managing in Nursing, 5th Edition Chapter 02: Patient Safety Test Bank MULTIPLE CHOICE 1. In an effort to control costs and maximize revenues, the Rehabilitation Unit at Cross Hospital
More informationSepsis The Silent Killer in the NHS
Sepsis The Silent Killer in the NHS Kate Beaumont, Trustee, UK Sepsis Trust Nurse Director The Learning Clinic Director QGi Ltd Former Head of Patient Safety and lead for deterioration, National Patient
More informationClick to edit Master title. style. Click to edit Master title. style. style 8/3/ Are You on Track?
Are You on Track? Diagnostic Test Results, Consults and Referrals Click to edit Master subtitle EXPLORE Conference August 9, 2018 8/3/2018 1 EXPLORE August 9, 2018 Today s speaker is Brenda Wehrle, BS,
More informationImproving Hospital Performance Through Clinical Integration
white paper Improving Hospital Performance Through Clinical Integration Rohit Uppal, MD President of Acute Hospital Medicine, TeamHealth In the typical hospital, most clinical service lines operate as
More informationat OU Medicine Leadership Development Institute August 6, 2010
Effective Patient Handovers at OU Medicine Leadership Development Institute August 6, 2010 Quality and Patient Safety Realize OU Medicine s position with respect to a culture of safety and quality. Improve
More informationThe Health Quality & Safety Commission. Research Report. Surgical Culture Safety Survey. Prepared for Health Quality & Safety Commission
RESEARCH REPORT DECEMBER 2015 The Health Quality & Safety Commission Surgical Culture Safety Survey Research Report Prepared for Health Quality & Safety Commission Prepared by Ltd. 1 1: Executive Summary...
More information2018 OPTIONS FOR INDIVIDUAL MEASURES: REGISTRY ONLY. MEASURE TYPE: Process
Quality ID #427: Post-Anesthetic Transfer of Care: Use of Checklist or Protocol for Direct Transfer of Care from Procedure Room to Intensive Care Unit (ICU) National Quality Strategy Domain: Communication
More informationUNIVERSITY OF MISSISSIPPI MEDICAL CENTER PATIENT SAFETY PLAN
UNIVERSITY OF MISSISSIPPI MEDICAL CENTER PATIENT SAFETY PLAN 2014 1 PATIENT SAFETY PLAN 2014 PROGRAM GOALS The goal of the Patient Safety Program at University of Mississippi Medical Center (UMMC) is to
More informationPerioperative management of the higher risk surgical patient with an acute surgical abdomen undergoing emergency surgery
CLINICAL GUIDELINE Perioperative management of the higher risk surgical patient with an acute surgical abdomen undergoing emergency surgery CG10214-2 For use in (clinical areas): For use by (staff groups):
More informationPatient & Family Guide. Blood Transfusion. Aussi disponible en français : La transfusion sanguine (FF )
Patient & Family Guide 2017 Blood Transfusion Aussi disponible en français : La transfusion sanguine (FF85-1811) www.nshealth.ca Blood Transfusion You have been given this pamphlet because you or your
More informationSelf-Assessment and Cross-Referencing for internationally trained magnetic resonance technologists
Self-Assessment and Cross-Referencing for internationally trained magnetic resonance technologists Name: Date: This self-assessment tool is meant to assist you in identifying how your previous program
More informationThe Transfusion Medicine diplomate will respect the rights of the individual and family and must
Competency Portfolio for the Diploma in Transfusion Medicine Guide for AFC-Diploma Committees/Working Groups, Educators 2012 VERSION 1.0 This portfolio applies to those who begin training on or after July
More informationInsertion of a ventriculo-peritoneal or ventriculo-atrial shunt
Department of Neurosurgery Insertion of a ventriculo-peritoneal or ventriculo-atrial shunt Information for patients Shunt surgery This leaflet explains what to expect when you are in hospital and during
More informationCommission on Accreditation of Allied Health Education Programs
Standards and Guidelines for the Accreditation of Educational Programs in Perfusion Essentials/Standards initially adopted in 1980; revised in 1989, 1994, 2000, 2005, and 20-- by the: American Academy
More informationWhy Iron? Iron is the Most prevalent micronutrient deficiency in the world (WHO 1968)
Why Iron? Iron is the Most prevalent micronutrient deficiency in the world (WHO 1968) Iron deficiency anaemia is a Major reason for blood being transfused Iron deficiency without anaemia is 3 times as
More informationHCAHPS, HSOPS, HACs and HIQRP Connecting the Dots
HCAHPS, HSOPS, HACs and HIQRP Connecting the Dots Sharon Burnett, R.N., BSN, MBA Vice President of Clinical and Regulatory Affairs Missouri Hospital Association Objectives Discuss how the results of the
More informationFrontline Improvement Using Defect Analysis March 9, 2012 R Resar, MD; N Romanoff, MD, MPH; A Majka, MD; J Kautz, MD; D Kashiwagi, MD; K Luther, RN
Frontline Improvement Using Defect Analysis March 9, 2012 R Resar, MD; N Romanoff, MD, MPH; A Majka, MD; J Kautz, MD; D Kashiwagi, MD; K Luther, RN Introduction More than a decade ago, the Institute of
More informationRoot Cause Analysis: The NSW Health Incident Management System
Root Cause Analysis: The NSW Health Incident Management System SARAH MICHAEL, RN, GradDipQHCM PAUL DOUGLAS, MB, BS, DRACOG, MHA, FRACMA With a background in intensive care, Sarah is a Principal Analyst
More informationADMINISTRATIVE POLICY & PROCEDURE PATIENT SAFETY PLAN
PAGE #: 1 of 6 CROSS REFERENCES: Administrative Policy PI-01: Administrative Policy PI-03: Administrative Policy RI-20: Administrative Policy EC-25: Sentinel Event Risk Management Plan Guidelines for Disclosure
More informationIntern training term assessment form
Australian Medical Council Limited Intern training term assessment form Intern details Intern name AHPRA registration no. This form is being completed for Mid-term Intern self-assessment End of term Term
More informationStandards for Forensic Drug Testing Accreditation
Standards for Forensic Drug Testing Accreditation 2013 Edition cap.org Forensic Drug Testing Accreditation Program Standards for Accreditation 2013 Edition Preamble Forensic drug testing is a laboratory
More informationTHE AMERICAN BOARD OF PATHOLOGY PATIENT SAFETY COURSE APPLICATION
THE AMERICAN BOARD OF PATHOLOGY PATIENT SAFETY COURSE APPLICATION Requirements: Component I Patient Safety Self-Assessment Program Programs must meet the following criteria to be an ABP approved Patient
More informationThese Things (Don t Have to) Happen Patient Safety Tami Minnier Chief Quality Officer Friday, April 5, 2013
These Things (Don t Have to) Happen Patient Safety 2013 Tami Minnier Chief Quality Officer Friday, April 5, 2013 Agenda Review the current state of healthcare Define and understand the concept of reliability
More informationCONSENT FORM UROLOGICAL SURGERY
CONSENT FORM for UROLOGICAL SURGERY (Designed in compliance with consent form 1) PATIENT AGREEMENT TO INVESTIGATION OR TREATMENT Patient Details or pre-printed label Patient s NHS Number or Hospital number
More informationThe Joint Commission Medication Management Update for 2010
Learning Objectives The Joint Commission Medication Management Update for 2010 U.S. Army Medical Command Fort Sam Houston, TX Describe most recent changes in The Joint Commission (TJC) Accreditation Program
More information