THE CENTRAL HOSPITAL,
COLOMBO, SRI LANKA
NAME: DR. ANIL PERERA,
ANESTHETIST & GROUP HEAD
NAME: DR. RUWAN SENATILLEKE
ASIRI HOSPITALS POLICY REVIEW
NAME: DR. MANJULA
DESIGNATION: DEPUTY CHIEF
JCI ACCREDITATION CHAPTER: QUALITY & PATIENT
REVISION NO: 0
DATE OF REVISION: NA
HOSPITALS – 5TH
REPORTING, ANALYSIS AND
SECTION III: HEALTH ACTING ON PATIENT SAFETY
ISSUE NO: 1
EVENTS INCLUDING NEAR MISS TO DATE OF ISSUE: 15 DECEMBER
REDUCE PATIENT HARM.
DOCUMENT IDENTIFICATION NO:
NUMBER OF PAGES: 8
To ensure prompt assessment and response to all undesirable incidents resulting in injury
to Patients, employees, or visitors. To accurately document threats or actions of violence, inappropriate sexual behavior, fires and environmental emergencies. To accurately document incidents of property damage.
To accurately document events and to identify staff response to the events.
To identify contributing factors/conditions that led to the incident and to identify steps
taken to prevent the recurrence of a similar incident.
To provide accurate, timely information for an ongoing incident report database.
– Any unusual or unexpected occurrence that results in injury or injury to patients,
staff, or visitors. Threats or actions of violence, inappropriate sexual behavior, fires and environmental emergencies. Any event that results in damage or potential damage to or loss of hospital property, patient property or specified employee property.
An injury related to medical management, in contrast to complications of
disease. Medical management includes all aspects of care, including diagnosis and treatment, failure to diagnose or treat, and the systems and equipment used to deliver care.Adverse events may be preventable or non-preventable.
Near Miss and No Harm-
These terms are often used synonymously. However, some
authors draw a distinction between these two phrases.
A Near Miss
is defined when an error is realized just in the nick of the time and abortive
action is instituted to cut short its translation.
In the No Harm
scenario the error is not recognized and the deed is done but fortunately
for the health care professional, the expected adverse event does not occur.
The distinction between the two is important and is best exemplified by reaction to
administered drugs in allergic patients. A prophylactic injection of Cephalosporin may be stopped in time because its suddenly transpires that the patient is known to be allergic to penicillin (Near Miss).
If this vital piece of information is overlooked and the Cephalosporin is administered, the
patient may fortunately not develop an anaphylactic reaction (No Harm Event)
A relatively infrequent, unexpected incident, related to system or process
deficiencies, which leads to death or major and enduring loss of function for a recipient of health care services.
Major and enduring loss of function refers to sensory, motor, physiological or psychological
impairment not present at the time services were sought or begun. The impairment lasts for a minimum period of two weeks and is not related to an underlying condition.
GQC QAD Medical Director & Department / Services Area Heads
E. RELATED JCI STANDARDS
The organization uses a defined process for the identification and analysis of near-miss
1. Asiri Hospitals will improve patient safety by establishing the culture that promotes patient
safety incident reporting in a non-punitive environment, and implementing corrective action plans where necessary in order to reduce risk to patients, visitors, and staff.
2. The hospitals has defined a near miss, types of events to be reported, established the
process of reporting events including near misses and ensures the data is analysed to reduce such events and prevent near-miss events in future
PROMOTION OF CULTURE OF PATIENT SAFETY
1. Asiri group of hospitals will create a culture of patient safety
by encouraging all staff to
report all known patient harm incidents so that causes that lead to harm can be identified and analyzed to prevent recurrences of similar adverse events.
Asiri hospitals will have a non-punitive, blame free approach when patient harm is
Asiri hospitals will encourage all staff to report near miss events, unsafe conditions and
Asiri hospitals will encourage reporting of non-compliance of policies and procedures and
safeguard staff from abuse or disciplinary action.
2. All staff will be educated on Asiri hospitals philosophy in relation to patient safety
No employee, staff member, volunteer, or contract service member will be subject to
disciplinary action or blame for reporting non-intentional or non-malicious patient harm incidents.
Employees will be subject to disciplinary action and/or employment termination for failure
to report known adverse incidents or occurrences.
Any harm resulting from staff under influence of alcohol, substance abuse or acts of patient
abuse or a purposefully unsafe acts ( knew act was unsafe , but did it anyway) will be considered blameworthy and will not be considered under patient safety system bur as a criminal issue.
GUIDELINES ON REPORTING OF EVENTS AND NEAR MISS 1. Following undesirable events shall be reported as soon as the occurrence of these events
comes in to notice.
b. Medication error c. Improper blood transfusion d. Restraint related injury e. Any other injury within the hospital f. Patient burns g. Absconded patient h. Diagnostic errors (Like wrong test, mismatch of reports etc.) i. Violation of patient's rights j. Missing medical record k. Damage / loss to hospital's building 2. Employees who witness or are aware of an incident are responsible for filling an Incident
Reporting format at the earliest.
3. An Incident Report shall be filled anytime, regardless of severity of incidence to any
patients, employees or visitors. An Incident Report must be completed within a particular time.
4. Damage or loss of hospital property. When possible, a photograph of the damaged
property shall be taken by security and given to the Safety Officer.
5. Following details shall be provided in case of occurrence of an undesirable event a) Patient details – (name / UHID number) b) Date of occurrence c) Time d) Department / Area e) Reported by f) Category
ii. Medication error
iii. Improper blood transfusion iv. Restraint related injury
v. Or any other injury
vi. Patient burns
vii. Absconded patient
viii. Diagnostic errors (Like wrong test, mismatch of reports etc.)
ix.Violation of patient's rights
x.Missing medical record
xi.Loss / damage to hospital building
g) Details of Accident / Incidence h) Severity of the event
Near miss Adverse event Sentinel event
i) Immediate Action taken / to be taken j) Corrective and Preventive action taken
6. When completing an Incident Report that involves an injury (or property damage) to a
patient or employee resulting from another patient, the UHID number of the patient who caused the injury must be provided in the "Details of Incident" portion of the report.
7. The actual incident report shall not be noted in the patient's case file. 8. Safety Committee shall monitor and evaluate data generated by the reporting process as
part of the Hospital's performance improvement activities.
PROCESS FOR REPORTING AND ANALYZING EVENTS & NEAR MISS
1. An Incident Report must be completed anytime a patient, employee or visitor has
undergone through any of the incidences listed above regardless of severity. An employee who witnesses an incident must complete the Incident Report. If the event is unobserved, the employee who first becomes aware of it must complete an incident report.
Nurses must assess the injury and administer first-aid as necessary. Injured Employees can
be referred to the casualty during normal working hours. Nurse Supervisors must be notified of all incidents before the end of the injured employee's Shift.
3. Nurse Supervisors/Immediate Supervisors must take steps to ensure all injury reports
submitted to them by employees are acted upon appropriately.
4. The filled format shall be sent to QA Department. 5. The QAD Executive with the role of Safety Officer shall review all Incident Reports and will
assign severity rating and injury type.
6. All cases shall be discussed in Safety Committee for analysis and Corrective Actions
7. The record of same shall be maintained. 8. A monthly statistics shall be calculated by the Safety Committee for occurrence of such
events, which shall be presented to hospital authorities.
JCI ACCREDITATION STANDARDS FOR HOSPITALS – 5TH EDITION (EFFECTIVE 1ST APRIL 2014)
J. POLICY CROSSLINKAGES
1. Asiri group "Reporting to improve patient safety" philosophy
2. Incident Report Format
ATTACHMENT -1 Philosophy of handling health care delivery related patient safety events
It is the philosophy of Asiri Hospital group that
Health care delivery related adverse events are inevitable despite the best efforts of
conscientious professionals and institution of systems to prevent them.
Adverse events are not necessarily viewed as incompetence or misconduct on behalf of the
practitioners involved. We consider that practitioners do their best to provide safe patient care. We acknowledge that systems – related issues account for the majority of adverse events.
All healthcare practitioners have an obligation to report adverse events as a means to
improve our healthcare delivery systems and to provide a safe environment for patient care by making it difficult for similar events to occur in the future.
Prompt and thorough reporting of adverse events in good faith by practitioners or staff will
not result in disciplinary action by the hospital against the individual involved.
It is the right of the patient and the obligation of Asiri Group of Hospitals and its employees
and staff, to disclose clinically relevant adverse events to the patient in a prompt, clear and honest manner.
NOVEL RETINOID ESTER IN COMBINATION WITH SALICYLIC ACID FOR THE TREATMENT OF ACNE PRIMARY AUTHOR: Zoe Draelos MD CO-AUTHORS: Joseph Lewis BS; Laura McHugh MS; Arthur Pellegrino BS; Lavinia Popescu MS, MBA combining the RC induced normalization of cellular differentiation, AHA induced exfoliation in hydrophilic Retinoids (RC), alpha hydroxy acids (AHA), and salicylic acid (SA) have therapeutic benefit in acne treatment
SK is happy to present the Annual Report for the year 2010. The report endeavors to communicate to the readers the tasks accomplished by the organization over the defined period, the challenges met and Aalso the emerging issues it had to deal with. Needless to say it would not have been possible to achieve many of the goals without the assistance provided by different sections of people. Planning, Monitoring and Evaluation unit of ASK prepared the report by collecting and compiling information from different programmes. All the staff including the Executive Director and members went through the draft and commented upon it. ASK