National Patient Safety National Patient Safety Goals Goals Summits and Summits and Patient Safety Solutions Patient Safety Solutions Peter B. Angood MD FRCS(C) FACS FCCM Peter B. Angood MD FRCS(C) FACS FCCM VP & Chief Patient Safety Officer VP & Chief Patient Safety Officer The Joint Commission The Joint Commission
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National Patient Safety Goals Summits and Patient Safety Solutions Peter B. Angood MD FRCS(C) FACS FCCM VP & Chief Patient Safety Officer The Joint Commission.
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National Patient Safety GoalsNational Patient Safety GoalsSummits andSummits and
Patient Safety SolutionsPatient Safety Solutions
Peter B. Angood MD FRCS(C) FACS FCCMPeter B. Angood MD FRCS(C) FACS FCCMVP & Chief Patient Safety OfficerVP & Chief Patient Safety Officer
Requirements that define performance expectations with respect to structure, process, and outcomes that must be substantially in place in an organization to enhance the safety and quality for patient care
Performance Expectations – the moving targetPerformance Expectations – the moving target
• Established in January 1996 with the following goals:To have a positive impact in improving careTo focus attention on underlying causes and risk
reductionTo increase the general knowledge about sentinel
events, their causes and preventionTo maintain public confidence in the accreditation
process
Type of Sentinel Event # %
Wrong-site surgery 625 13.0%
Suicide 596 12.4%
Op/post-op complication 568 11.8%
Medication error 446 9.3%
Delay in treatment 360 7.5%
Patient fall 281 5.8%
Assault/rape/homicide 177 3.7%
Patient death/injury in restraints 176 3.7%
Perinatal death/loss of function 143 3.0%
Unintended retention of foreign body** 141 2.9%
Transfusion error 113 2.3%
Infection-related event 100 2.1%
Medical equipment-related 82 1.7%
Anesthesia-related event 81 1.7%
Patient elopement 76 1.6%
Fire 72 1.5%
Maternal death 70 1.5%
Ventilator death/injury 50 1.0%
Abduction 28 0.6%
Utility systems-related event 24 0.5%
Infant discharge to wrong family 7 0.1%
Other less frequent types 601 12.5%
4817 total4817 total
Sentinel Events Reviewed*:
Total & Self-reported
0
100
200
300
400
500
600
700
800
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
# of non-self-reported events# of self- reportedevents
*This graph represents all RCAs reviewed and accepted in a particular calendar year.
**Unintended retention of a foreign object was added to the definition of reviewable events June 2005. This data represents events reviewed since that date, not 1995-2007.
*This graph represents all RCAs reviewed and accepted in a particular calendar year.
**Unintended retention of a foreign object was added to the definition of reviewable events June 2005. This data represents events reviewed since that date, not 1995-2007.
• Assess data from the Sentinel Event Database• Advise on future topics for Sentinel Event Alert• Reach consensus on candidate NPSGs• Assess practicality and cost of implementing each of
identified evidence-based NPSG recommendations• Assess comparability of alternatives to NPSG
requirements that are implemented by individual organizations
• One NEW requirement under Goal #3:3E—Management of anticoagulant therapy
• One NEW goal:Goal #16—Rapid response to changes in patient
condition [Hospitals & critical access hospitals]• One-year phase-in period for 3E and 16A• Retire requirement 3B (see MM.2.20, EP #10)• Compliance with WHO Hand Hygiene Guidelines will
The organization selects a suitable method that enables health care staff members to directly request additional assistance from a specially trained individual(s) when patient’s condition appears to be worsening
Goal #16: Improve recognition and response to changes in a patient’s condition
- Universal Protocol is sound but does not go far enough
- U.P. should be more prescriptive- U.P. should address “upstream” factors- Employ technology, where possible- Emphasize applicability to anesthesia procedures
and non-OR settingsDiscussion of “zero tolerance” & “campaign” strategy
• Sept. 25, 2007 - 85 organizations invited• NPSG 8 is important but needs clarification
• Accuracy & reliability of the list vs reconciliation• Next Provider issues• Minimal-Use scenarios• Inpatient & Outpatient• Focus on systems & processes• Focus on leadership and inter-professional teams• Patient engagement and education
• Follow-up on Critical Test Results • Patient Falls • Healthcare Associated Infections – Central Lines• Pressure Ulcers• Response to the Deteriorating Patient• Patient and Family Involvement• Apology and Disclosure• Look-alike Sound-alike Medication Packaging
• To achieve significant, sustained, and measurable reduction in the occurrence of 5 patient safety problems over 5 years in at least 7 countries and build an international, collaborative learning network that fosters the sharing of knowledge and experience in implementing innovative, standardized, safety operating protocols.