actep2014: patient safety & risk management
DESCRIPTION
Patient safety and risk management in ED - อ.นพ.อารักษ์ วิบุลผลประเสริฐTRANSCRIPT
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Patient safety & Risk management in Emergency Room ARRUG WIBULPOLPRASERT, M.D.
EMERGENCY MEDICINE DEPARTMENT
RAMATHIBODI HOSPITAL, MAHIDOL
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Outline Patient safety & Risk management
Patient safety ◦SIMPLE ◦Patient safety in Emergency Room ◦Research & Education
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ระบบงานส าคญของ รพ.
ความเสยง ความปลอดภย คณภาพ การก ากบดแลวชาชพ สงแวดลอมในการดแลผปวย การปองกนการตดเชอ ระบบเวชระเบยน ระบบจดการดานยา การตรวจทดสอบ การเฝาระวงโรคและภยสขภาพ การท างานกบชมชน กระบวนการดแลผปวย
การเขาถงและเขารบบรการ การประเมนผปวย การวางแผน การดแลผปวย การใหขอมลและเสรมพลง การดแลตอเนอง
ดานการดแลผปวย ดานการมงเนนผรบผลงาน ดานการเงน ดานทรพยากรบคคล ดานประสทธผลของกระบวนการ ดานการน า ดานการสรางเสรมสขภาพ
ตอนท IV
ตอนท III
ตอนท II
ตอนท I
การน า
การวางแผน กลยทธ
การมงเนนผปวย และสทธผปวย
การวด วเคราะห และจดการความร
การจดการ กระบวนการ
การมงเนน ทรพยากรบคคล
ผลการ ด าเนนงาน
กระบวนการดแลผปวย Patient Safety & Risk management
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II – 1.2 ระบบบรหารความเสยง ความปลอดภย และคณภาพ (Risk, Safety, and Quality Management System)
1
ประสาน ระบบทเกยวของกบการ
บรหารความเสยง และระบบสารสนเทศ
คนหาและจดล าดบความส าคญของ
ความเสยง
ก าหนดมาตรการปองกน, สอสาร,
สรางความตระหนก
ระบบรายงานอบตการณ รายงาน วเคราะห ใชประโยชน
ประเมน ประสทธผล ปรบปรง
วเคราะหสาเหต
แกปญหา
ก าหนดกลม/วตถประสงค ก าหนด KPI ใชวธการทหลากหลาย
ก. ระบบบรหารความเสยงและความปลอดภย
ข. คณภาพการดแลผ ปวย 2 3 4
1
2
3 4
6
5
ทบทวนการดแลผปวย พฒนาคณภาพการดแล ส าหรบกลมเปาหมาย
Risk management team
PCT
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Patient Safety Goals - SIMPLE S: Safe Surgery
I: Infection Control
M: Medication Safety
P: Patient Care Processes
L: line, Tube & Catheter
E: Emergency Response
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S : Safe Surgery? In ER? Critical procedures
Intubation - RSI
Cricothyroidotomy
Pericardiocenthesis
Tube thoracostomy
DPL
Central-line catheter
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Safe Surgery? In ER? Common Procedures
Thoracenthesis
Abdominal paracenthesis
Arthrocentesis
Dislocation & fractures
Suprapubic cystostomy
Wound dressing & suture
Nail removal
Nasal packing
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ED Concern
Safe Procedures in ER S1 – SSI Prevention
S2 – Safe Anesthesia
S3 – Safe Surgical Team S3.1 – Correct procedure at correct body site S3.2 – Surgical Safety Checklist
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S2 – Safe anesthesia 1. Anesthesiologist - knowledge
2. Anesthesia complications
3. Complication preventions 3.1 Specific complications 3.2 Systematic prevention
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S2 – Safe anesthesia 3.2 Systematic prevention
Personnel
High-risk patient
Inform-consent
Team communication
Patient, type and site identification
Pre-anesthesia evaluation
Equipment
Environment
Continuous monitoring
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S2 – Safe anesthesia 1. Anesthesiologist - knowledge
2. Anesthesia complications
3. Complication preventions 3.1 Specific complications 3.2 Systematic prevention
4. Unexpected event
5. Anesthesia standard
ED Procedures
RSI ICD
Central Venous Access Wound Management
Bone & Joint Reduction
Procedural Sedation and Anesthesia – PSA in ED
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S3 – Safe Surgical Team 3.1 Correct Procedure at
Correct body site
- Verification
- Mark site
3.2 Surgical Safety Checklist
WHO Guideline for Safe surgery
Before anesthesia
Before skin incision
Before leaving operating room
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I : Infection Control I1 – Hand Hygiene / Clean hand
I2 – Prevention of Healthcare Associated Infection I 2.1 CAUTI prevention I 2.2 VAP prevention I 2.3 Central line infection prevention
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Infection Control I1 – Hand Hygiene / Clean hand
Alcohol-based handrubs
อางลางมอ
Guidelines on Hand Hygiene
Organization culture
Monitoring system
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Infection Control I2.1 – CAUTI Prevention
Indication for urinary catheter
Aseptic technique
“CIC for UA, U/C”
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Infection Control I2.2 – Ventilator associated pneumonia (VAP) Prevention
Hand hygiene
Alternative PPV – NIPPV
“minimize intubation time”
Decrease ICU LOS, hospital LOS, cost
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Infection Control I2.3 – Central line infection Prevention
Protocol : • Checklist • Nurse assistant during procedure • Proper equipment cart
Hand hygiene (again?)
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Infection Control I2.3 – Central line infection Prevention (cont.)
Maximal barrier precautions :
หมวก, mask, กาวน, glove, คลมผา sterile ตงแตศรษะ-เทา
Chlorhexidine 2% in 70% ispropyl alcolhol ATLEAST 30 sec before procedure
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Infection Control I2.3 – Central line infection Prevention (cont.)
Proper site : avoid femoral catheter
Catheter care protocol
Evaluation
Fast vs Proper How long patient can wait?
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M: Medication Safety M 1 – Safe from ADE
M 1.1 Control concentrated electrolyte solutions Managing concentrated injectable medicines
M 1.2 Improve safety of High-Alert Drug
M 2 – Safe from medication error M 2.1 Look-Alike Sound-Alike (LASA)
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M: Medication Safety M 3 – Medication Reconciliation / Assuring medication accuracy at transition in Care
M 4 – Blood safety
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M: Medication Safety M 1.1 Control concentrated electrolytes solutions Managing concentrated injectable medicines ◦KCL, 3% NaCl, 50%MgSO4, Calcium gluconate ◦Heparin, Morphine, Fentanyl ◦RSI drugs ◦Cardiovascular drugs
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M: Medication Safety M 1.1 Basics approaches - Protocol construction - Do not use ratio or % in protocol/label use weight/volume - Ready-to-administer or ready-to-use - Prepared by pharmacist - Follow high-alert drug protocol
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M: Medication Safety M 1.2 Improve safety of High-Alert Drug Prevention of ADE
- Create – preprint order forms, protocols, guidelines - Minimized dose/concentration variation - Warning signs Monitor ADE Minimize ADE – Protocols, Antidote/reversal agent
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M: Medication Safety M 2.1 Look-Alike Sound-Alike medication names (LASA) •Concern •Search & re-evaluation •Specific strategy •Avoid phone order, trade name
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M: Medication Safety M 3 – Medication Reconciliation / Assuring medication accuracy at transition in Care ◦Medical reconciliation ◦ED concern ◦Drug interaction ◦Drug overdose (repeated visit) ◦Drug allergy / ADR
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M: Medication Safety M 4 – Blood safety
“Blood transfusion safety”
ED Concern ◦ - Emergency cross match ◦ - Patient identification ◦ - Blood transfusion reaction
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P : Patient Care Process P 1 – Patient identification
P 2 – Communication ◦ Effective communication ◦ During handovers ◦ Critical test results ◦ Abbreviations, acronyms,
symbols, dose
P 3 – Proper diagnosis
P 4 – Preventing commons complications ◦Pressure ulcers ◦Patient falls
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P : Patient Care Process P 1 – Patient identification
2 factors identification: Name + Age/date of birth Standardize identification tools Identical name/surname/age
Name + mother name Specimen identification Data record duplication
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P : Patient Care Process P 2 – Communication
P 2.1 Effective communication – SBAR P 2.2 Communication during handover : Shift change, Admit, Refer to other department/hospital - Standard guideline for handover : SBAR, vital information - Ensure information transfer to next healthcare provider
Situation Background Assessment Recommendation
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P : Patient Care Process P 2 – Communication
P 2.3 Communicating critical test results Critical lab/radiology result 1. Standard critical report procedure
- ผรบผดชอบ รบผล ตดตามผล - ผรบผดชอบส ารอง - Critical cut point - Duration - Report method - Hospital policy
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P : Patient Care Process P 2 – Communication
P 2.3 Communicating critical test results 2. Reliable system design
- Ordering doctor & contact info. - Adequate clinical information for interpretation esp. radiology - Monitoring system
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P : Patient Care Process P 3 – Proper diagnosis
Major problems 1. Delay diagnosis in life threatening, surgical & trauma emergencies 2. Delay cancer diagnosis 3. Cognitive failure – ใชดลยพนจผดพลาด
“Risk management”
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P : Patient Care Process P 4 – Preventing common complications
4.1 Pressure sore : in ED? 4.2 Falls : high risk patient – Elderly, confusion, drunk
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L : Line, Tube & Catheter CRITICAL LINE & TUBE ◦Endotracheal tube ◦Tracheostomy tube ◦Central line ◦ ICD ◦High alert IV drugs
COMMON LINE & TUBE ◦Foley’s catheter ◦NG tube placement ◦ IV fluid
Avoiding catheter and tubing Miss-connection
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E : Emergency Response ◦Cardiac arrest ◦Respiratory failure ◦Stroke ◦ACS ◦Sepsis ◦Multiple trauma
◦Mass casualty incident ◦Epidemic ◦Disaster
The area that WE are the BEST
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Other safety issue in ED 1. Critical/unstable patient ◦During transfer ◦During non-monitor area eg. CT scan
◦Equipment ◦Monitoring ◦Working instruction / Quality procedures
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Other safety issue in ED 2. Communicable disease ◦Air-bourn : TB, Measles, Chicken pox, Herpes zoster ◦Epidemic / pandemic : SARS, Ebola ◦Bioterrorism : Plague, Ebola, Small pox, Anthrax
Patient Safety Staff Safety +
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Other safety issue in ED 3. Challenge in ED patient safety ◦ED overcrowding ◦ED LOS ◦Workload & Cost
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Future on patient safety
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WHO Patient Safety Curriculum Guide for Medical Schools
Topics
1. What is patient safety
2. What is human factors
3. Systems & complexity on Pt. care
4. Being an effective team player
5. Understanding & learning from errors
6. Understanding & managing clinical risk
7. Quality improvement methods
8. Engaging with patients & carers
9. Minimizing infection through improved IC
10. Patient safety & invasive procedures
11. Improving medication safety
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II – 1.2 ระบบบรหารความเสยง ความปลอดภย และคณภาพ (Risk, Safety, and Quality Management System)
1
ประสาน ระบบทเกยวของกบการ
บรหารความเสยง และระบบสารสนเทศ
คนหาและจดล าดบความส าคญของ
ความเสยง
ก าหนดมาตรการปองกน, สอสาร,
สรางความตระหนก
ระบบรายงานอบตการณ รายงาน วเคราะห ใชประโยชน
ประเมน ประสทธผล ปรบปรง
วเคราะหสาเหต
แกปญหา
ก าหนดกลม/วตถประสงค ก าหนด KPI ใชวธการทหลากหลาย
ก. ระบบบรหารความเสยงและความปลอดภย
ข. คณภาพการดแลผ ปวย 2 3 4
1
2
3 4
6
5
ทบทวนการดแลผปวย พฒนาคณภาพการดแล ส าหรบกลมเปาหมาย
Risk management team
PCT
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Risk management Team
Patient Care Team
Patient safety & Risk management
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Q & A
คดถง ER …. คดถง รามาธบด