INTRODUCTIONKURSUS ORIENTASI PEGAWAI BARUHOSPITAL PAKAR SULTANAH FATIMAHDR AIMI ZAFIRA JAAFAR
1. To understand the burden of patient safety incidents.2. To understand the basic concept of patient safety.3. To prevent patient safety incidents in clinical setting.4. To understand patient safety strategies by MOH.Learning objectives
It is estimated 1 in 10 patients is harmed while receiving hospital care50% ispreventable
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Learning objectives1. Understand the basic concept of incidentreporting and learning system.2. Understand the differences between error,violation and near miss3. Understand the role of Health CareProfessional in improving Patient Safetythrough incident reporting and learningsystem
A system of reporting patient safety incidents that happened in healthcare, investigate or review why the incident happen, learn from the incident, take appropriate action to prevent similar incident from happening and share with others
error violation Near missNon – intentional deviation from an accepted protocol or standard of care.“Tak sengaja”Intentional deviation from an accepted protocol or standard of care.Against the lawAn error that has been prevented before it occurred
error violation Near missACCIDENTALLYwrote wrong unit on medication prescriptione.g : 10mg instead of 10µgTake blood pre- and post potassium correction but send the same sample INTENTIONALLY( pre-sample ) twice and resulting in over-correctionWrong dose of medication being prescribed but DETECTED BEFORE IT IS ADMINISTERED to the patient
Don’t hide it Report it!
Damage controlPrevent worsening of situationLearning from mistakesImprove quality & safety of healthcareImprove system defect
2. respond1. report3. share
• Medication error • Wrong transfusion• Wrong Surgeries/ procedures• Patient fall • Obstetric related incidents e.g neonatal injury during birth• Adverse outcome of clinical procedure• Patient suicideANY INCIDENTS RELATED TO PATIENT SAFETY
IMMEDIATE ACTION / DAMAGE CONTROLINFORM SUPERVISORFILL IN INCIDENT REPORTING FORM (SECTION A)INCIDENT OCCURINCIDENT INVESTIGATED BY INVESTIGATION TEAM(e.g : Root Cause Analysis)ACTION TAKEN & FURTHER OCCURANCE OF INCIDENCE PREVENTEDMONITORING OF ACTION PLANSUBMIT TO QUALITY MANAGER WITHIN 48H FROM DATE OF INCIDENT
SECTION A:FILLED BY WHO IS INVOLVED / WITNESS THE INCIDENTSECTION A:FILLED BY WHO IS INVOLVED / WITNESS THE INCIDENT
ACTUAL NEAR MISSAn incident that reach the patientAn incident which did not reach the patient
Patient outcome: The impact upon a patient which is wholly or partially the severity and duration of any harm, and any treatment implications, that RESULT FROM AN INCIDENT.
Patient outcome is not symptomatic or no symptoms detected and no treatment is required e.g. Wrong dose of medication given but the patient did not suffer any harmPatient outcome is symptomatic, symptoms are mild, loss of function or harm is minimal or intermediate but short term, and no or minimal interion (e.g., extra observation, investigation, review or minor treatment) is required, increase length of stay (up to 72 hours)Patient outcome is symptomatic, requiring intervention (e.g. : additional operative procedure; additional therapeutic treatment), increase length of stay (more than 72 hours to 7 days)
Patient outcome is symptomatic, requiring life-saving intervention or major surgical/medical intervention, increase length of stay (more than 7 days), shortening life expectancy or causing major permanent or long term harm or loss of functionThe definite outcome is yet to be determined, cannot be certain during the time of reportingOn balance of probabilities, death was caused or brought forward in the short term by the incident.