9/9/2016. How Respiratory Therapist Enhance Patient Safety. Introduction. Raise your hand. Tawana Shaffer CPHRM, MBA, BSc, CRT

Transcription

1 How Respiratory Therapist Enhance Patient Safety Tawana Shaffer CPHRM, MBA, BSc, CRT Introduction Raise your hand 1

2 How do you define Patient Safety? What is Patient Safety? Communication Care Falls Outcomes Quality Accurate Appropriate Timely Trust Medications Definition Patient Safety? AHRQ A discipline in the health care sector that applies safety science methods toward the goal of achieving a trustworthy system of health care delivery. Patient safety is also an attribute of health care systems; it minimizes the incidence and impact of, and maximizes recovery from, adverse events. NQF The prevention and mitigation of harm caused by errors of omission or commission that are associated with healthcare, and involving the establishment of operational systems and processes that minimize the likelihood of errors and maximize the likelihood of intercepting them when they occur AHRQ - NQF - 2

3 Why is Patient Safety important? In 2000, there are approximately 98,000 preventable deaths every year In 2008, medical errors cost the United States $19.5 billion We are dealing with someone s life! Page, Ann. Keeping Patients Safe: Transforming the Work Environment of Nurses. Washington, DC: National Academies, J Health Care Finance Fall;39(1): What is a medical error? Institute of Medicine (IOM) failure of the planned action to be completed as intended or using a wrong plan of action to achieve a goal. Any unintended deviation from standard of care or generally accepted performance standard that may or may not cause harm IOM, 1999; Raju, Suresh, & Higgins, 2011 Types of Errors Diagnostic Error or delay in diagnosis, failure to obtain necessary tests, or failure to act on results Treatment Error in performance, administering, administering medications, inappropriate care, or failure to rescue Preventive Failure to provide prophylactic treatment, inadequate monitoring or followup of treatment Other Failure of communication, equipment failures, or IT failures "To Err Is Human: Building a Safer Health System 1st Edition." To Err Is Human: Building a Safer Health System: Committee on Quality of Health Care in America, Institute of Medicine, Linda T. Kohn, Janet M. Corrigan, Molla S. Donaldson: 3

4 Why do healthcare errors occur? Healthcare is very complex Human Factors Communication Factors Human Resource Factors Equipment Factors Environmental Factors Technology Factors Culture of Safety True Stories Ventilator errors linked to 115 deaths Over oxygenation of COPD/Emphysema patients Failure to recognize patients with undiagnosed sleep apnea Liz Kowalczyk. Ventilator errors are linked to 119 deaths: Warnings are often ignored, missed by overtaxed caregivers. Globe Staff December 11, 2011 How can RTs help prevent errors? Perform respiratory care timely and accurately Document your care timely and accurately Communicate with your peers as well as nursing, physicians, patients and families Don t be afraid to respectfully speak up if you feel there is inadequate order for the patient Comply with the standard of care and your policies/procedures* Learn about the medications you provide and equipment you use *Be cautious of policies/procedures, as they are not always up to date and reference best practices! 4

5 National Patient Safety Goals Identify patients correctly Improve staff communication Use medicines safely Use alarms safely Prevent infection Identify patient safety risks Prevent mistakes in surgery Patient Identifiers Always check 2 patient identifiers when you are providing: Care Treatment Services Communication Communicate effectively with the team of caregivers for your patients Provide critical information pertaining to your patient Change in condition Critical results of diagnostic tests Handoff report Shift to Shift Department to Department 5

6 Medication Safety Label procedural medications if drawn up in a syringe and administered at a later time Discuss the medication and dose given when provided Discuss medication safety with your patient when necessary Report look alike-sound alike medications Alarm Fatigue Alarm limits/parameters Default settings Designate who can change limits/parameters Audibility of alarms Timely response Spratt, Greg. Three Steps to Reduce Alarm Fatigue and Improve Patient Safety. AARC Times, August Infection Prevention WASH YOUR HANDS to prevent the spread of infectious diseases Follow your policies/guidelines - signage Wear your Personal Protective Equipment (PPE) 6

7 Identify Patient Safety Risks Communicate unsafe situations with nursing and physicians Any particular threats of harm to self or others should be escalated up the chain of command If you participate in an invasive procedure or surgical procedure, participate in the time out process Error Reducing Techniques Stop Think Act Review (STAR) Have a questioning attitude Validate and verify Trust your intuition Fundamentals of Safety Standardize your work Error Reducing Techniques Communicate Effectively SBAR Read back Repeat back Clarify Accountability Just Culture 7

8 Changing & Sustaining a Culture of Safety Be accountable, but don t blame or shame staff when events occur. Consider Just Culture Report near miss events as well as harm events Examine the contributing factors and root causes of the events Share lessons learned from events* Participate in Failure Modes and Effects Analysis (FMEA) in your department and Root Cause Analysis (RCA) *In the state of Kentucky, it is important to either participate in a Patient Safety Organization to protect your event information and analysis and work with your Risk/Legal team to know how best to share lessons learned from events Key Takeaways Respiratory Therapist and other healthcare workers can enhance patient safety Be an advocate for your patients Keep safety top of mind Questions 8

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