Annual Learning Package Patient Safety & Incident Reporting

Transcription

1 Annual Learning Package Patient Safety & Incident Reporting 2013 Safety Core Curriculum

2 Patient Safety Patient Safety, defined as the reduction and mitigation of unsafe acts within the health care system, as well as through the use of best practices shown to lead to optimal patient outcomes, is a critical aspect of quality health care. Who is responsible for patient safety at Stevenson Memorial Hospital (SMH)? Each & every one of us at SMH is responsible for patient safety. Patient safety is in our hands. The following 6 safety competency domains provide a framework of abilities that are shared by all health care professionals and hospital staff. 1. Contribute to a Culture of Patient Safety A commitment to applying core patient safety knowledge, skills and attitudes to everyday work. 2. Work in teams for Patient Safety Working within interprofessional teams to optimize both patient safety and quality of care. 3. Communicate Effectively for Patient Safety Promoting patient safety through effective health care communication. 4. Manage Safety Risks Anticipating, recognizing and managing situations that place patients at risk. 5. Optimize Human and Environmental Factors Managing the relationship between individual and environmental characteristics in order to optimize patient safety. 6. Recognize, Respond to and Disclose Adverse Events Recognizing the occurrence of an adverse event or close call and responding effectively to mitigate harm to the patient, ensure disclosure, and prevent recurrence. Quality Indicators The following are examples of healthcare quality indicators that are monitored to provide measurement of patient quality and safety within a healthcare organization: Patient satisfaction Infection rates Medication incident rates Patient fall rates Wait times Readmission rates Hospital Standardized Mortality Rate (HSMR ) Page 2 of 6

3 Accreditation Canada has identified six Patient Safety Areas and 36 Required Organizational Practices (ROPs): All of these Required Practices need to be a focus at all times and not just prior to an accreditation survey. Incident Reporting All adverse events and non-person/near misses occurring to inpatients, outpatients, visitors, staff and volunteers are to be reported using the Safe Point Incident Reporting System found on all SMH computers (on-line software program). The factual details of actual incidents involving patients will also be documented in the health record. The person witnessing/discovering the incident will complete the Incident Report in SafePoint. Please ensure that you enter the data required and as many facts as possible. Incident reports are reviewed by the managers/clinical coordinators and follow up occurs as necessary. Investigation is key in finding out the cause of events and addressing factors to prevent reoccurrence. Page 3 of 6

4 Welcome to Stevenson Memorial Hospital's Incident Reporting System The purpose of incident reporting is to: Collect factual information in relation to the occurrence of incidents or near misses in the hospital Collect data for a workplace injury to aid completion of the WSIB report Provide a systematic means to record incidents, document the results of investigations and note how, when and what corrective action will be taken Help to ensure the provision of prompt medical treatment Assist in the determination of the causative factors related to the incident Systematically collect factual data for statistical records Guide the investigator in conducting an effective investigation The use of data helps us to focus on the processes or systems that we work within which will give us opportunities to make improvements and ultimately improve safety. REPORT AN INCIDENT OR NEAR MISS The data is compiled and trends are identified. This forms the basis for process improvement using a systems approach. Page 4 of 6

5 Terms Defined Adverse Event: results in unintended harm to the patient, and is related to care and/or services provided to the patient rather than to the patient s underlying medical condition. Good Catch: A good catch (also known as a close call or near miss) is an event or situation that could have resulted in an accident, injury or illness, but did not reach the patient; either by chance or through a timely intervention. If the flaws in the processes within which we work that contributed to the near miss are not corrected, the same conditions will continue to exist that allowed it to happen. We will have a much better success at improving safety if we focus on improving our processes and not on creating the perfect practitioner because we know that human error is an expected part of the systems in which we work. This is called the Systems Approach to Error. Sentinel Event: A serious undesirable and unexpected outcome that involves actual or potential loss of life, limb or function, or has a significant potential to adversely affect public perception and confidence. Reporting of incidents has traditionally been considered to be a valuable source of information to identify risks in a hospital setting and to serve as a platform for quality improvement. At Stevenson Memorial Hospital we also encourage and endorse the strategy of reporting near misses (or good catches) in order to identify systemic issues and proactively bring about changes that will improve the safety of our staff, patients and visitors. We know that this approach will prove to be successful and valuable in maintaining a culture of safety. Reporting of Sentinel Events Some sentinel events are reported externally to the Coroner s Office All Sentinel Events and Recommendations are reported to Senior Administration Sentinel Event Investigations conducted by the Quality of Care Committee provide recommendations only to appropriate stakeholders as legislated by Quality of Care Information Protection Act (QCIPA). Accreditation requires the hospital to report Sentinel Events in the documentation for the accreditors There are important policies to keep in mind when encountering an incident involving a patient or visitor. 1. Sentinel Event Policy Administration & Human Resources Policy and Procedure Manual # S Disclosure Administration & Human Resources Policy and Procedure Manual # D40 Page 5 of 6

6 1. A good catch is: ANNUAL LEARNING REVIEW TEST Please record your answers on the ANSWER SHEET provided a) An incident where a standard of care has not been met b) An incident that leads to a patient losing a major loss of function c) An incident that causes moderate harm to a patient d) An event or situation that could have resulted in injury, but by chance has not 2. Incident reports are completed by the person witnessing/discovering the incident or near miss. a) True b) False 3. Which of the following in place at SMH to ensure patient safety? a) Patient Identification using 2 identifiers b) Infection Control practices & hand washing c) Falls Reduction program d) Medication Reconciliation Program (checking medication profile at Admission & Discharge) e) All of the above 4. An Adverse Event results in unintended harm to the patient, and is related to care and/or services provided to the patient rather than to the patient s underlying medical condition. a) True b) False 5. Disclosure of information regarding a critical or sentinel event is the responsibility of the: a) Most Responsible Physician (MRP) b) Any staff member c) The MRP and a member of the SMH Management team d) The nurse caring for the patient 2012 Patient Safety & Patient / Visitor Incidents Workbook Page 6 of 6