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Patient Safety in the Ambulatory Surgery Setting

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					 National Patient Safety Foundation®




  Making Hospital Care Safe:
What Hospital Name is doing and
   how the Board can help

                                   1
  Definition of Patient Safety
Patient Safety is the prevention of healthcare
errors, and the protection of patients from harm
caused by healthcare errors.




                                                   2
Definition of Healthcare Error
An unintended healthcare outcome resulting
from a defect in the delivery of care to a patient.

The defect may be flawed professional judgment,
failure to learn from prior incidents, improper
administration of medication, a surgical mistake,
diagnosis or treatment clearly outside accepted
practice, or use of inappropriate equipment.




                                                      3
Brief History of Patient Safety
Institute of Medicine‟s Report, To Err is
Human, 1999
– 44,000 to 98,000 deaths per year in hospitals
  attributed to preventable medical errors
– Preventable injury resulting from medical
  mistakes costs the economy between
  $17 billion and $29 billion annually, of which
  half are healthcare costs


                                                   4
Brief History of Patient Safety
Contributions of IOM Report:
– Described model for patient safety improvement
– Highlighted need to identify & learn from errors
– Called for legislation to protect voluntary
  reporting systems
– Defined need to set patient safety performance
  standards
– Provided sense of scope & breadth of the problem
– Recommended implementation of safety systems
  in all healthcare organizations
                                                5
Brief History of Patient Safety
Subsequent Patient Safety Developments
– The Business Roundtable launches the
  “Leapfrog Initiative” in 2000
– Agency for Healthcare Research and Quality
  publishes Making Health Care Safer: A Critical
  Analysis of Patient Safety Practices in 2001
– JCAHO issues National Patient Safety Goals
  in 2002
– National Quality Forum releases Safe Practices
  for Better Healthcare in 2003

                                               6
Brief History of Patient Safety
Subsequent Patient Safety Developments
– The „Pay-for-Performance‟ Movement

    CMS links hospital payment rate increases
    to reporting of quality data

    CMS‟ Hospital Quality Incentive
    Demonstration with Premier, Inc.


                                                7
Brief History of Patient Safety
HealthGrades study (July 2004):
– Average of 195,000 people in U.S. died from
  potentially preventable, in-hospital medical
  errors in each of the years 2000, 2001 and
  2002.
– Associated extra costs of $6 billion per year




                                                  8
Brief History of Patient Safety
The Old View of Patient Safety
    Clinicians are supposed to be infallible
    Bad things happen only when people make
    mistakes
    People/ organizations that fail are bad
    Blame and punishment sufficiently motivate
    carefulness




                                                 9
  Brief History of Patient Safety
The New Systems Approach to Patient Safety
– Risk of failure is inherent in complex systems
– Healthcare is becoming increasingly complex
– Not all risk is foreseeable
– People are fallible -- no matter how much they try
  not to be
– Systems are fallible
– Alert, well-trained clinicians are crucial to reducing
  medical errors
– Open disclosure of unexpected outcomes and a
  blame-free environment create a patient safety-
  friendly culture                                    10
     The New Systems Approach to
            Patient Safety
Errors are mainly caused by
system failures, rather than
incompetent or careless
individuals
In complex systems,
administrators, regulators and
policymakers (blunt end) control
organizational factors that impact
practitioners operating at the
hazardous process level (sharp
end)
                                     From the NPSF Report – A Tale of Two Stories: Contrasting
                                     Views of Patient Safety. Graphic by Woods, R.I.


                                                                                           11
    The New Systems Approach to
           Patient Safety
Complex systems usually
have defenses (e.g.
                                  Triggers
technical, human,
organizational) that prevent                                    Defenses
single failures from causing
                                                                 Failures
accidents
Accidents only occur when
multiple failures align & occur
together.                            “Normal
                                     operations”



                                                                   Accident

                                   Modified from Reason, 1990
                                                                       12
 The New Systems Approach to
        Patient Safety
Open disclosure of unexpected outcomes and a
blame-free environment create a patient safety-
friendly culture.
Organizational reactions to failure that target
individual performance therefore are largely
inappropriate




                                                  13
National Patient Safety Foundation®

 Founded in 1996 by:

 – American Medical Association
 – 3M Corporation
 – CNA HealthPro
 – With support from Schering-Plough




                                       14
National Patient Safety Foundation®




 Stand Up for Patient Safety Program
 An ongoing educational and leadership
 program designed to assist health care
 organizations in advancing patient safety.


                                              15
National Patient Safety Foundation®
Stand Up Member Benefits
 – Member Resources Guide with materials for
   Administration, Board, Clinical Staff, PR/Marketing
   Department, and Patients and Families.
 – Current awareness materials/ materials for the annual
   Patient Safety Awareness Week
 – Educational videotapes for patients and staff
 – Live workshops and audio conferences
 – Opportunities to share best practices with colleagues
   and NPSF Board members



                                                      16
 The Board‟s Role in Patient Safety
    Include patient safety as an agenda item at all
    Board meetings
    Review reports about specific patient safety
    projects and results
    Support reporting of adverse events to external
    databases
    Promote open disclosure of unexpected
    outcomes and a blame-free environment
    Join the CEO in speaking to staff about safety
    Support investment in system improvements to
    reduce medical errors
Source: “What You Can Do: The Trustee, Patient Safety, and JCAHO,” Trustee (February 2003).
                                                                                              17

				
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posted:9/27/2011
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