??????- Seven Steps

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??????- Seven Steps

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3
??????-1

• ?????(National Health Service)
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• 2002??????28? ???????Strategic health authority?

???? NPSA
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??????-2

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• Primary Care Trust(PCT)???
• 300?PCT(????????????NHS Direct?NHS walk-in
  center)
• PCT??75?????
• GP??
• Waiting list
• ????

???? NPSA
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??????-3

• ??????
• Acute trust????????????
• Foundation Trust ??????,??????????????
• Mental Health trust?????????????
• Ambulance Trust?????,???????????

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Patient Safety A global issue
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Notification to NRLS
Others 1 ambulance service 2 community general
dental service 3 community optometry / optician 4
community pharmacy 5 general practice Learning
disabilities
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Cost of unsafe care

• ??10( 900,000) ????????
• ????????10???
• ?????8.5?
• ?400???????????
• ??????450??????????
• ???????????10???
• ???????????????.?290??????

???? NPSA
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• National Patient Safety Agency (NPSA)

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??NPSA

• 2001???,?400???,???2500??
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Seven Steps

• Build a safety culture that is open and fair
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• Lead and support your staff in patient safety
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• Integrate your risk management activity
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• Promote reporting
• ?????

???? NPSA
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Seven Steps

• Involve patients and the public
• ????????????????
• Learn and share safety lessons
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• Implement solutions to prevent harm
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???? NPSA
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Risky Jobs
Step-1
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Who gets the blame?
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patients
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Step-1??????

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Step-1??????

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• ???????????????, ???????
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???? NPSA
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????????
Generative
???? NPSA
Proactive
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Calculative
?????????
Reactive
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Pathological
?????????
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Step-1??????-??

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Step-2
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Step-2?????????

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Step-2?????????

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Step-2 ?????????

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Team working and patient mortality
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Step-3
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Step-3??????

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???? NPSA
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Step-3??????

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Identifying Areas of Risk

• Retrospective learn lessons
• Accidents and incidents,
• Root Cause Analysis
• Prospective anticipate issues
• Reporting systems, near misses, reported hazards
• Prospective Risk Assessments, (proactive hazard
  assessment)

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??????

• ????( Terminate )
• ?????????
• ????( Treat )
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• ????(Tolerate)
• ??????,??????,?????
• ????(Transfer)
• ??????????

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What is Risk Assessment?
???? NPSA
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• ???????

???? NPSA
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Incident Decision Tree
Start Here
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Step 4Promote reporting

• National reporting and learning system (NRLS)
• Reporting via
• local risk management systems
• E-form on NHS net
• E-form on www
• Anonymous (names of patients and staff)
• Confidential (names of organisations)

???? NPSA
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Step 4
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???? NPSA
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Step 4Promote reporting

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Step 4Promote reporting

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• ??????(eForm) ,???? ??????????

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Step 4Promote reporting

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The reporting gap?
Occurrence
Incident occurrence
10.0
(Per C.Vincent et al)
Reporting Gap ?
5.0
Reporting rate
(NRLS)
0
time
???? NPSA
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Step 5
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Step 5??????

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???? NPSA
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Step 5??????

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Step 5??????

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Step 5??????

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Step 6
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Step 6 ???????

• ??6000?RCA????
• ??E-learning ??
• ????
• ????RCA??
• ??????

• Root Cause Analysis Programme

???? NPSA
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Step 6 ???????

• ??
• ????????RCA??
• ??? RCA??
• RCA????????????????????
• ??
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• ??????????

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Fishbone Diagram
Fishbone Diagram
Individual (staff) Factors
Team Factors
Task Factors
Patient Factors
No guidance on site marking
Inexperienced SHO marked site, Unaware of correct
procedure
No check of procedure within multi-disciplinary
team
Pt helpfully removed and replaced TED to show mark
Site Marking not visible
Patients admitted too late for Cons ward round
Delay in pts admission
Concern around meeting cancelled operation targets
Lack of formal local orientation training prog
for junior Drs
Ward busy
Institutional Context Factors
Organisational Management Factors
Work Environmental Factors
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Fishbone Diagram
Fishbone Diagram
Individual (staff) Factors
Team Factors
Task Factors
Patient Factors
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Ward busy
Institutional Context Factors
Organisational Management Factors
Work Environmental Factors
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Step 7
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Step 7????????????

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Telling people to be more careful doesn,t work
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Step 7????????????

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???? NPSA
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What would you do? JFK International terminal
mens restrooms

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• ?????????mark site
• ??????

Source Wall Street Journal, used by John Grout,
NPSA Seminar, 17 January 2003
???? NPSA
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• d) etch the image of a fly on the porcelain !

Source Wall Street Journal as used by John
Grout, NPSA Seminar 17 January 2003
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Which dial turns on the burner?
Stove A
Stove B
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Crash Call Survey27 different
numbers used in Hospitals across England.
Crash Call Number No ()
2222 76 Hospitals (34)
222 36 Hospitals (18)
25 other numbers are used in the remaining hospitals 112 Hospitals (48)
???? NPSA
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• NPSA Patient Safety Alert 1
• Preventing Accidental Overdose with Intravenous
  Potassium
• NPSA Patient Safety Alert 2
• Standardisation of Cardiac Arrest Tel Numbers

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Mark OP Site

• or X ?
• Both or one side ?
• Wrong side marked ?
• Other Marks ?

• Visit www.npsa.nhs.uk/newsletter/newsline.asp to
  subscribe to updates on safety solutions

???? NPSA
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The cleanyourhands campaign
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Understanding the problem

• Is it a patient safety issue?
• UK 5000 deaths
• UK 1bn
• UK 300,000 patients per year
• Hand hygiene can probably reduce 9-50

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??????????

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• ??????,??????????,?????????? ????

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????

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• ????RCA????
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• ????TPR????
• ????RCA????
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Safer health care More informed views Better
understanding of risks Growth in skills and
knowledge
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Thank you for listening