Chester Clinic

 

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THE CENTRAL HOSPITAL,
COLOMBO, SRI LANKA
PREPARED BY:
NAME: DR. ANIL PERERA,
SIGNATURE:
DESIGNATION: CONSULTANT
ANESTHETIST & GROUP HEAD
ANESTHESIA
REVIEWED BY:
NAME: DR. RUWAN SENATILLEKE
SIGNATURE:
DESIGNATION: CHAIRPERSON,
ASIRI HOSPITALS POLICY REVIEW
COMMITTEE

APPROVED BY:
NAME: DR. MANJULA
SIGNATURE:
KARUNARATNE
DESIGNATION: DEPUTY CHIEF
EXECUTIVE OFFICE
JCI ACCREDITATION CHAPTER: QUALITY & PATIENT
REVISION NO: 0
STANDARDS FOR
DATE OF REVISION: NA
HOSPITALS – 5TH
DOCUMENT TITLE:
REPORTING, ANALYSIS AND
SECTION III: HEALTH ACTING ON PATIENT SAFETY
ISSUE NO: 1
EVENTS INCLUDING NEAR MISS TO DATE OF ISSUE: 15 DECEMBER
MANAGEMENT
REDUCE PATIENT HARM.
STANDARDS
DOCUMENT IDENTIFICATION NO:
NUMBER OF PAGES: 8
CHL/HP/QPS 05

STANDARDS REFRENCE:

QPS 09
CHL/HP/QPS 05 Page 1 of 8


A. PURPOSE

 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. B. DEFINITIONS
Events – 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.
Adverse Event- 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). CHL/HP/QPS 05 Page 2 of 8


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)
Sentinel 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. C. RESPONSIBILITY

 GQC  QAD  Medical Director & Department / Services Area Heads D. SCOPE

All staff

E. RELATED JCI STANDARDS
QPS.9. The organization uses a defined process for the identification and analysis of near-miss

F. POLICY

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. CHL/HP/QPS 05 Page 3 of 8


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 G. PROCEDURE(S)
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 process variations  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. CHL/HP/QPS 05 Page 4 of 8


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 Wrong documentation 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 CHL/HP/QPS 05 Page 5 of 8


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. 2. 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 Preventive 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. CHL/HP/QPS 05 Page 6 of 8



H. IMPLEMENTATION

QA Department
I. REFERENCES

JCI ACCREDITATION STANDARDS FOR HOSPITALS – 5TH EDITION (EFFECTIVE 1ST APRIL 2014)
J. POLICY CROSSLINKAGES

Nil
K. ATTACHMENTS

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. CHL/HP/QPS 05 Page 7 of 8


 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. CHL/HP/QPS 05 Page 8 of 8

Source: http://asiri.info/intranet/images/sampledata/mypdf/jci/ash/CHL/QPS/CHL-HP-QPS%205%20Reporting,%20analysis%20and%20acting%20on%20patient%20safety%20events.pdf