1. PATIENT SAFETY
INITIATIVE OVERVIEW
DR LEE OI WAH
MD(UKM), CMIA

2. Patient Safety Definition
• Healthcare
organizations
including hospitals
were founded to give
care to those who
need it and to keep
patients safe.
• It is generally agreed
upon that the
definition of patient
safety is…

3. What is Patient Safety?
 The absence of the potential for patient
harm
 Involves all Employees/Contract workers, All
job descriptions
 Involves all Departments
 Time frame: 24/7

4. A model of patient safety
1. Those who work in health care.
2. Those who receive health care or have
a stake in its availability.
3. The infrastructure of systems for
therapeutic interventions (health-care
delivery processes).
4. The methods for feedback and
continuous improvement.

5. Methods: CQI on
info, hardware,
plant, policy
Systems for therapeutic
action designed to
Recipients of care
preempt/rescue from failure
Preparation on:
illness
understanding, Workers: teams
accessing care trained to preempt /
systems, rescue from /
advocacy manage failure
Methods: CQI
on: competence
communication,
A patient safety model of health care Emmanuel et al 2008
teamwork

6. Avoidable confusion is everywhere…

7. Health care is increasingly
complex
Gaba

8. Traps in health care?
• look-alike and sound-alike
pharmaceuticals
• equipment design
○ e.g. infusion pumps

9. Removing error traps
• a primary function of an incident
reporting system is to identify
recurring problem areas - known as
“error traps” (Reason)
• identifying and removing these traps
is one of the main functions of error
management
Error traps

10. What is being done to make healthcare
organizations safe for patients?
• Joint Commission on Accreditation for
Healthcare Organizations (JCAHO) first
established patient safety goals in 2002.
• Each year those goals are re-evaluated
and revisions are published.
• When healthcare organizations are
accredited, they are given report cards and
graded on their compliance with meeting
the goals.

11. National Safety Goals
• Improve the accuracy of patient
identification.
• Improve the effectiveness of
communication among caregivers.
• Improve the safety of using medications.

12. National Safety Goals
• Reduce the risk of healthcare associated
infections.
• Accurately and completely reconcile
medications across the continuum of
care.
• Reduce the risk of patient harm resulting
from falls.

13. PATIENT SAFETY INITIATIVE
OF HOSPITAL CHANGKAT
MELINTANG

14.  Clean care is safer care
 Communication policy
 Patient identification
 Medication safety
 Notification of critical lab
results
 Safe blood transfusion
 Patient fall
 Incident reporting and
management

15.  Medical Officers
 Paramedics
 Pharmacists
 PPKs
 Allied health
professionals
 HSS
WHO SHOULD KNOW?

16.  Reduce medical error
 Improve patient safety
 Requirement for
Accreditation
 Protect from litigation
 Patient’s right
WHY???

17. What else is being done to promote
patient safety?
• Committees to
investigate all aspects
of patient safety.
• Employee training on
proper lifting and
transfer techniques
which benefit both
employees and
patients.

18. What else is being done to promote
patient safety?
• Policies for safe disposal
of contaminated articles
and sharps
– Syringes
– Needles
– Blades

19. What else is being done to promote
patient safety?
• Frequent Fire and Disaster drills
• Inspection and maintenance of all
equipment…
– Hospital beds
– Patient Lifting equipment
– Gas containers
– Infusion pumps
– Monitoring equipment

20. What can employees do to promote
patient safety?
• Report any potentially dangerous patient
situation to your supervisor.
• Know about and participate in performance
improvement processes in your
department or unit.
• Take your annual mandatory training
seriously; it will help you to identify safety
issues.

21. What can employees do to promote
patient safety?
• Don’t take “shortcuts”.
• Use check lists.
• Ask co-workers to complete double
checks.

22. Conclusion
Be an advocate for our patients.
Patient safety
is