Making a Difference in Health Care

Patient Safety Today

http://nnlm.gov/training/patientsafety/global.html

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Legislation Issues

Malpractice regulations Mandatory and/or voluntary reporting

– Adverse events, hospital acquired infections, etc. Patients

– Patient notification / Disclosure of events– Apologies permitted

Staffing issues Pharmaceutical laws Electronic prescription/health records

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National Legislation

National Laws – UK Medical Act 1858– National Patient Safety Agency Regulations, 2001– China Regulation on the Handling of Medical

Accidents, 2002– Act on Patient Safety in the Danish Health Care

System, 2003– US Federal Patient Safety and Quality Improvement

Act of 2005 – Patientsäkerhetslag 2010 Patient Safety Act

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Legislation: USA

Electronic Prescription and Health Records Programs– Medicare Prescription Drug, Improvement and

Modernization Act (MMA) of 2003– American Recovery & Reinvestment Act of 2009– The Patient Protection & Affordable Care Act of

2010 and Health Care & Education Reconciliation Act of 2010 (Affordable Care Act) o Health Information Technology for Economic and

Clinical Health Act (HITECH Act)

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International Commitments

Resolutions and Declarations– World Health Organization (WHO): Quality of

care: patient safety; WHA55.18, 2002

– European Commission: Patient safety - making it happen!; Luxembourg Declaration on Patient Safety, 2005

– Helsinki Declaration on Patient Safety in Anaesthesiology, 2010

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International Organizations

Agencies, Councils, Institutes– The Australian Commission on Safety and Quality in

Health Care (ACSQHC), 2000– Danish Society for Patient Safety (DSFP), 2001– UK National Patient Safety Agency (NPSA), 2002– Canadian Patient Safety Institute (CPSI), 2003– WHO World Alliance for Patient Safety, 2004– European Network for Patient Safety (EUNetPaS), 2008– Middle East Regional Network for Patient Safety Culture

(PSCMEN), 2010– Centre for Patient Safety, Saudi Arabia, 2013

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Campaigns

National – 1000 Lives plus. National Health Service (NHS)– Health/Gesundheit/Santé/Sanità/Sanadad 2020– Norwegian patient safety campaign– Sorry Works! Campaign to Educate Patients and Families

International – World Health Organization – Global Patient Safety Challenges: Clean care is safer care,

Safe surgery saves lives

– High 5s: Standardized Operating Protocols (SOPs), Assuring medication accuracy at transitions in care, Managing concentrated injectable medicines, performance of correct procedure at correct body site

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Conferences

International Patient Safety and Quality Congress Middle East, 24-27 March

2013, Abu Dhabi, UAE Patient Safety Forum 2013, 9-11 April 2013, Saudi Arabia International Forum for Quality and Patient Safety, 16-19 April

2013, London, UK Patient Safety Congress, May 8-10, 2013, New Orleans, LA, USA International Congress on Patient Safety: Best Practices for Asia,

6-7 September 2013, London, UK Patient Safety Congress, 27-29 October 2013, Abu Dhabi, UAE 6th Medication Safety Conference, 22-24 November 2013, Abu

Dhabi, UAE

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Ongoing Studies

Multiple types of studies– Medication safety; Nosocomial infection; Patient

satisfaction

– AHRQ Patient Safety Indicators, 2002

– AHRQ Patient Safety Culture surveys (Hospital, 2004, Nursing homes, medical offices, retail pharmacies)

41 countries: Spain-2008, Turkey-2009, Saudi Arabia-2009, Lebanon-2010, Iran-2012, Taiwan-2012, Egypt-2012

22 languages

– University of Texas: Safety Attitudes and Safety Climate Questionnaire, 2006

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OUR JOURNEY TOWARDS PATIENT SAFETY

Affra S. Al Shamsi, MScIM

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The Story of Patient Safety in the Region

Patient Safety in the Eastern Mediterranean Region initiatives by EMRO/WHO The first Regional Meeting on Patient Safety

The first intercountry consultation for ‘Developing a Regional Strategy

for Patient Safety in EMR countries’ was held from 27 to 30

November 2004 in Kuwait.

Patient Safety Friendly Hospital Initiative (PSFHI) PSFHI is a program that aims to instigate and encourage safe health

practices in hospitals in the Eastern Mediterranean region (EMR). It

represents a collaboration with the World Alliance for Patient Safety

(WAPS), the International Islamic Relief Organization (IIRO) and

Member States.

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Strategic Directions for Health Systems in the Gulf Region

Developing health services according to the priorities of each country

Setting unified quality systems at the level of the Gulf Region

Sustaining and integrating health care at all levels Setting and developing rules and regulations of

medical practice Setting and developing the accreditation system for

improving medical practice in the Gulf health establishments

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The Royal Hospital, Department of Quality Management 1

The Story of Patient Safety in Oman

Our definition of quality

Quality is a care that is accessible, safe, effective, patient-centred, timely, equitable, appropriate and efficient.

and as main aspect of our Goals to

Maximize patient safety and minimize patient and organization risk of adverse events

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The Royal Hospital, Department of Quality Management 2

Strategic Goals Establish and enhance a culture of

excellence and patient safety

Continuously and incrementally improve the quality of healthcare provided to patients of the Royal Hospital

Enhance patient’s experience by exceeding their expectations

Improve efficiency by optimizing the usage of facilities and resources

Patient safety

Quality Culture

Data

Customer service

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Patient safety work

Medication error

initiative

Involve all

employees

Patient Centered

Care/Culture

Team buildin

g

Training in risk

manageme

nt

Surgical safety

checklist initiative

System thinking

Surgical site

infection

initiative

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Safety Culture Involves Paradigm Shift

OLD

Who did it?

Focus on bad event

-Root Cause Analysis

Top down

Punish bad behavior

NEW

What happened?

Focus on Near Miss

-Failure Modes and Effects Analysis (FMEA)

Bottom up

Fix broken processes

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The Royal Hospital,Department of Quality Management 5

The Story of Patient Safety in Oman

One of the Critical Success Factors Availability of required resources to effectively

maximize the quality improvement initiatives at the Royal Hospital

Establish specialized staff including Patient Safety Officer, Medication Safety Officer, Risk Manger and quality specialists.

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The Royal Hospital, Infection Control Department 2

The Story of Patient Safety in Oman

Active prevention of infectious diseases outbreaks

Education and training of healthcare workers about infection prevention principles and implementation

Development and implementation of strategies and policies on infection, prevention and control

Environmental hygiene auditing of clinical areas including kitchen and laundry and following improvements actions

Monitoring compliance of Health Care Worker with hand hygiene

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Ministry of Health, Quality Assurance & Patient Safety Department

Milestones of the ProjectPhase III (2012-2013)Developing & launching national patient safety

indicatorsDeveloping national

patient safety standardsPhase II (2010-2011)Develop patient safety

training scheduleDraft patient safety

standardPhase I (2009-2010)Situational analysis

Assessment of patient safety culture

The Story of Patient Safety

in Oman

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Project Recommendations 1

Institutional Level: Standardize & computerize incident reporting system

for all healthcare institutions

Develop & standardize patient safety indicators

Establish patient safety auditing system, identifying indicators, making annual plan for the audit

Develop patient safety policies & procedures

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Project Recommendations 2

Governorate Level: Establish patient’s safety structure, including patient

safety departments & committees

Improve patient safety practice by ensuring adequate resources (personnel) & training

Strengthen patient safety environment (e.g. waste disposal & appropriate ventilation)

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Project Recommendations 3

National Level: Re-activate the National Patient Safety Committee

Develop capacity building for patient safety

Develop appropriate channel of communicating safety issues to staff as feedback

Develop Quality & Patient Safety Websites as networking for all healthcare quality professionals

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Project Conclusion

Improvement in patient safety demands a complex system-wide effort

Significant commitment & leadership support is required

Establish Prioritization Strategy: including activities that support Mission, Vision, & Value of institutions

Prepare the workforce (i.e. Capacity Building)

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Summary

We need: Librarians to be advocates in this field To take part in designing health care systems

that put safety first To apply the knowledge we already have in

patient safety and share it To remember it’s a long, on going process To coordinate between those who are doing

patient safety

http://nnlm.gov/training/patientsafety/global.html