PATIENT SAFETY GOALS

WORLD ALLIANCE FOR PATIENT SAFETY

Launched by WHO in October 2004 in Launched by WHO in October 2004 in response to World Health Assembly R l ti 2002 i WHO d Resolution 2002 urging WHO and member states to pay the closest possible attention to Patient Safety.

WORLD ALLIANCE FOR PATIENT SAFETY and

PATIENT SAFETY COUNCIL MALAYSIA (PSCoM)1 1 1 Cl C i S f C1. 1.1. Clean Care is Safer Care

1.2. Safe Surgery Saves Lives1.3. Tracking antimicrobial resistance

2. Patients for Patient Safety: Patient and Consumer involvement3. Research for Patient Safety4. Taxonomy – International Patient Safety Classification aims to define, harmonize and group patient safety concepts into an internationallyharmonize and group patient safety concepts into an internationally agreed classification. 5. Adverse Events Reporting 6 Solutions for Patient Safety6. Solutions for Patient Safety7. Action on Patient Safety:5S8. Technology for Patient Safety: 9. Knowledge Management9 o edge a age e t10. Eliminating Central Line-associated

bloodstream infections: 11. Education for Safer Care12. Safety Prize

WORLD ALLIANCE FOR PATIENT SAFETY

CRITERIA FOR COMPLIANCE TO MSQH HOSPITAL ACCREDITATION

CERTIFICATIONPROGRAMME AREASPROGRAMME AREASACTION AREA 1 (cont..)1. Clean Care is Safer Care

- Aseptic techniques for procedures-Practice of standard and additional precautionsh d h i-hand hygiene

-Dress code-white coat/overall,-Appropriate attire according to-Appropriate attire according to Kod Etika Pemakaian kakitangankerajaan-Surat Pekeliling KetuaP h K ih t Bil 4/1989Pengarah Kesihatan Bil.4/1989: Kod Pakaian Untuk Doktor.-no dangling handbag/name tag/tieno dangling handbag/name tag/tie while blood taking procedure

WORLD ALLIANCE FOR PATIENT SAFETY

CRITERIA FOR COMPLIANCE TO MSQH HOSPITAL ACCREDITATION

CERTIFICATION

PROGRAMME AREAS

ACTION AREA 1 (cont..)2. Safe Surgery Saves Lives

(Standard:19)CLEAN SURGERY-Hand washing -OT scrub suite/gown/cap/mask

ki / l /d-skin prep/clean/drap-Instrument disinfection and sterilizations e a o-no wound infection/breakdown

WORLD ALLIANCE FOR PATIENT SAFETY

CRITERIA FOR COMPLIANCE TO MSQH HOSPITAL ACCREDITATION

CERTIFICATION

PROGRAMME AREAS

ACTION AREA 1 (cont..)2. Safe Surgery Saves Lives

Safe Providers-Credentialed and Privileged providersInformed consent-Informed consent

-Correct patient / site-Pre and post op care-Documentation and communication-continuous training and educationVerification site- time out procedure-to be comply by surgeon/assistancePerformance measurement-outcomes- patient safe, no complication,outcomes patient safe, no complication, pt. satisfaction

WORLD ALLIANCE FOR PATIENT SAFETY

CRITERIA FOR COMPLIANCE TO MSQH HOSPITAL ACCREDITATION

CERTIFICATION

PROGRAMME AREAS

ACTION AREA 1 (cont..)2. Safe Surgery Saves Lives

Standard 9:SAFE ANAESTESIA -Patient assessment (pre, intra,

t) d t d i t fpost)- documented, signature of doctor at anesthetist note.

WORLD ALLIANCE FOR PATIENT SAFETY

CRITERIA FOR COMPLIANCE TO MSQH HOSPITAL ACCREDITATION

CERTIFICATION

PROGRAMME AREASACTION AREA 1 (cont ) Standard 5: Prevention andACTION AREA 1 (cont..)3. Tracking antimicrobial resistance

Standard 5: Prevention and control of Infection .Standard 18:Pharmacy Servicesy-Policy on Antibiotic use (based on national antibiotic guidelines)A tibi ti i t tt (l l l l )•Antibiotic resistance pattern (local levels)

•Appropriate use of Antibiotics

WORLD ALLIANCE FOR PATIENT SAFETY

CRITERIA FOR COMPLIANCE TO MSQH HOSPITAL ACCREDITATION CERTIFICATION

PROGRAMME AREAS

ACTION AREA 2Patients for Patient Safety:Patient and Consumer

Standard 6: Patient and Family Rights.

idi th t tPatient and Consumer involvement is building a patient led, global network of patients and patients

-providing processes that supports Patient and Family Rights during care.-care provided is considerate and

tf l f th ti t’ lpatients and patients organisations to champion patient safety

respectful of the patient’s personal values and spiritual beliefs/religion-care is respectful of the patient’s need for privacy especially during clinicalfor privacy especially during clinical interviews, examinations, procedures/treatments.

WORLD ALLIANCE FOR PATIENT SAFETY

CRITERIA FOR COMPLIANCE TO MSQH HOSPITAL ACCREDITATION CERTIFICATIONPROGRAMME AREAS

ACTION AREA 2Patients for Patient Safety:

Standard 6: Patient and Family Rights. (cont..)

Patient and Consumer involvement

-the patient’s right to respectful and compassionate care at the end of life.-informs patients and families about pits grievance mechanism to receive and act on complaints, conflicts of difference of opinion and about care and the patient’s right to participate in these process.-patients and families are informed as to what tests, procedures and treatments that require consent and how they can give consent.

WORLD ALLIANCE FOR PATIENT SAFETY

CRITERIA FOR COMPLIANCE TO MSQH HOSPITAL ACCREDITATION CERTIFICATION

PROGRAMME AREAS

ACTION AREA 3Research for patient safety

Standard 6: Patient and Family Rights. (cont..)

li i d d d f-policies , procedures and code of ethics for the selection and participation of the patient in clinical research investigation or clinicalresearch, investigation or clinical trials.-Medical ethic committee

WORLD ALLIANCE FOR PATIENT SAFETY

CRITERIA FOR COMPLIANCE TO MSQH HOSPITAL ACCREDITATION

CERTIFICATION

PROGRAMME AREAS

ACTION AREA 5Adverse Events Reporting –incident reporting

Standards 1-24 (except 6),-Portal UMMC-

incident reporting(http://ezform.ppum.icare.net)Log in using single sign on.I id t ti li &-Incident reporting policy &

procedure-manual kualiti-Responsibility of all staff to p yreport any incident related to staff /visitor/patient

WORLD ALLIANCE FOR PATIENT SAFETY

CRITERIA FOR COMPLIANCE TO MSQH HOSPITAL ACCREDITATION

CERTIFICATION

PROGRAMME AREASACTION AREA 6 Standard 1: GovernanceACTION AREA 6Solutions for Patient Safety: are interventions and actions that prevent patient safety

Standard 1: Governance, Leadership, Direction1.5.1.3. There is a Risk Management S i h I id R ithat prevent patient safety

problems recurring and thus reduce risk to patients.

System with Incident Reporting mechanism that addresses but is not limited to the following patient safety solutions such as:

1.Look-Alike,Sound-Alike medications2.Patient Identification3Hand-Off(Handover) Communication4.Wrong site, Wrong patient surgery

solutions such as:

1.Look-Alike,Sound-Alike medications2.Patient Identification3Hand-Off(Handover) Communicationg , g p g y

5.Concentrated electrolyte Solutions6.Continuity of Medication7.Catheter and Tube Misconnections8.Needle reuse and Unsafe Injections9 Hospital Acquired Infection

3Hand Off(Handover) Communication4.Wrong site, Wrong patient surgery5.Concentrated electrolyte Solutions6.Continuity of Medication7.Catheter and Tube Misconnections8 N dl d U f I j ti9.Hospital Acquired Infection 8.Needle reuse and Unsafe Injections9.Hospital Acquired Infection

WORLD ALLIANCE FOR PATIENT SAFETY

CRITERIA FOR COMPLIANCE TO MSQH HOSPITAL ACCREDITATION

CERTIFICATIONPROGRAMME AREASACTION AREA 7 -Statistic of incidentHigh 5s : will spread best practice for change in organizational, team and clinical practices to improve patient safety

-Surgical safety checklist compliancepatient safety.

1.Prevention of patient care hand-over errors

p-Hand hygiene compliance audit/statistic

2.Prevention of wrong site/wrong procedure/wrong person surgical error3.Preverntion of continuity of medication errors4 P ti f hi h t ti d4.Prevention of high concentration drug errors5.Promotion of effective hand hygiene practices

• During 2008, the Alliance will work • Technology for Patient 

Safety• Area  8• Electronic patient records, 

with Imperial College London, to• review global activities on the state 

of technology and patient safety.F d i itt ill b

Safety

p ,automated prescribing systems, simulation training and fail safe mechanisms in

• Four advisory committees will be established with distinct technical

• areas of responsibility, including:• • Information technology andand fail safe mechanisms in 

diagnostic tools, such as computerized radiographs, 

ll d

• • Information technology and knowledge management in safety

• programmes;• • Introducing new technology safely;can all prevent error and 

reduce harm.

• Introducing new technology safely;• • Technology in use – monitoring 

device and drug safety;• • Training technology – simulation, g gy ,

avatars and the future of safety

• Knowledge management:  • UMMC WebsiteArea 9

• The goal of the Alliance is• to achieve enhanced

• Research Publication

to achieve enhanced capabilities in disseminating useful knowledge around theknowledge around the world. A key new programme will be a service to provide regular service to provide regularupdates of key

• information related to patient safety worldwidepatient safety worldwide.

WORLD ALLIANCE FOR PATIENT SAFETY

CRITERIA FOR COMPLIANCE TO MSQH HOSPITAL ACCREDITATION

CERTIFICATIONPROGRAMME AREASACTION AREA 10Eliminating Central Line-

Standard 13: Critical care servicesEliminating Central Line

associated bloodstream infections: The Alliance will ensure that the results of the

services-Central line insertion only performed by privileged staff

work in the State of Michigan, USA, to eliminate central line-associated

-work process shall comply with set standards (Aseptic technique) -facilities are expected to conduct studies

bloodstream infections is replicated in other settings, this could change the lives of tens of thousands of

pin this area as part of quality improvement initiatives

of tens of thousands of patients worldwide, especially on intensive care patientspatients.

MALAYSIAN PATIENT SAFETY GOALSGOALS

1. Clinical Governance 2. Clean Care is Safer Care3. Safe surgery saves lives 4. Tackling antimicrobial resistance g5. Patient identification 6. Safety of blood and blood product7 Medication safety 7. Medication safety 8. Clinical communication – implementing a critical test and critical value

program9 P ti t f ll 9. Patient fall 10. Pressure Ulcer 11. CRBSI 12. Ventilator Associated Pneumonia13. Patient Safety Incident Reporting & Learning System