-
(1)
PI
QA 2010
-
/
: :
2
-
SE , SE 45 RCA Action plan JC
SE 45 15
RCA
-
N = 5,208
Sentinel Event Statistics
-
Root Cause Analysis Framework
-
JCAHO Sentinel Event Policy
Sentinel event
Action plan
JCAHO Sentinel Event Alert : data trend (sentinel event
prevention )
9
Sentinel Event Alert
-
10
-
11
-
WHO: World Alliance for Patient Safety Patient Safety
Solution
JCAHO, JCI : WHO Collaborating centre for Patient Safety
Solution
Patient Safety Solution definition :Any system design or
intervention that has demonstrated the ability to prevent or
mitigate patient harm stemming from the process of health
care.(Good process design can prevent human errors.)
12
Patient Safety Solution
-
Selection of topics(by International Steering Committee)
Prioritize based on- potential impact- strength of evidence -
feasibility for adoption
Patient Safety Solution
-
Patient Safety Solution
-
1. Look-alike, Sound-Alike Medication Names2. Patient
Identification3. Communication During Patient Hand-Overs4.
Performance of Correct Procedure at Correct Body
Site5. Control of Concentrated Electrolyte Solutions6. Assuring
Medication Accuracy at Transitions in Care7. Avoiding Catheter and
Tubing Mis-Connections8. Single Use of Injection Devices9. Improved
Hand Hygiene to Prevent Health Care-
Associated Infection
Nine Patient Safety Solution
-
Evidence based Presented in a standard format Describe in simple
term- what to do to address the risks associated with a particular
safety problem
-
statement of problem and impact associated issues suggested
actions looking forward strength of evidence supporting the
solution applicability Opportunity for patient and family
involvement potential barriers risk for unintended consequences
created by
the solution reference and other resources
Individual Solution
-
Statement of problem and impact
: , , / ,
The United Kingdom National Patient Safety Agency(2003 11 ~ 2005
7)- 236 , near miss
United States Department of Veterans Affairs(VA) NationalCenter
for Patient Safety(2000 1 ~ 2003 3)- 100
2003 : JCAHO National Patient Safety Goal
Patient Identification
-
Suggested Actions
1.
-
- (;, )
-
2. , .
3. .
-
Looking Forward- bar coding, radiofrequency identification
Potential barriers- - -
- - - : - : -
-
1.
-
2. ,
-
3.
-
4.
-
5.
-
6.
-
7.
-
,
8.
-
Statement of problem and impact JCAHO(2005) : 88
:
Miscommunication
Unavailable or incorrect information
Lack of a standardized pre-operative process
Sentinel event alert
1998 : Lesson learned : Wrong Site Surgety
2001 : A follow-up review of wrong site surgery
2003 : JCAHO National Patient Safety Goal
Universal Protocol
Performance of Correct Procedure at Correct Body Site
-
Suggested actions
1.
.(, )
2. .
1) , , ,
2) :
3) time-out
-
Potential barriers
-
-
-
- automatic behavior during time-out process
-
-
TFT
:
: , , , , ,
, , ,
, PI
1.
-
2.
-
( , )
1)
3. ,
-
2) (1) (2)
-
3) Time out
-
4.
-
,
gauze count, time-out (pilot test)
5.
-
Communication during patient Hand-overs
Handoff :
Joint Commission (1995~2004)
65%
- 2005 70%
- 50% Handoff communication
-
Handoff communication .
-
Handoff
( , )
(repeat back, SBAR)
1. NPSG
-
Situation > () , (, , ..),
()
Background () , , ,
Assessment > ()
Recommendation >
2. - SBAR
-
)
Hi, Doctor. 000 .
, .
, .
,
. PCA pump
.
-
[SBAR ] *** . ## 000 . 5 , 10 8 (Situation). 68 , abdominal
peritoneal resection (Background). , (Assessment). nitroglycerin ,
5 (Recommendation).
(receiver)
-
Note
()
3. Site-to-site Handoff
-
4. Person-to-Person Handoff
()
(, )
.
.
.
-
5.
-
Tubing misconnection
Top 10 Health Technology Hazards
Alarm hazardsMisconnections MRI Infusion pump programming
errors
(Health Devices November 2007)
-
Liquid Misconnections (. -> , -> )
Gas misconnections gas (e.g. CO2 instead of Oxygen)
: ,
1. Misconnection
-
, , , , , , , ,, ...
[TFT ] , (, )
,
2.
-
Delays in treatment
Blood transfsion errors : preventing future occurrence
Infusion pump : preventing future adverse events
Fata falls : lessons for the future
Medical gas mix-up
Emergency electrical power system failure
-
reference
evidence-based practice
( )
modification
( )
,
, ,
, ,
,
-
.
(1) 3 4 5 6 7 8 Sentinel Event Alert 10 11 Patient Safety
Solution 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53
54 55 56 57 58 59 60
