University of Santo Tomas

Faculty of Medicine and Surgery

Department of Preventive, Family, & Community Medicine

KEY INFORMANT INTERVIEW SUMMARY

Patient Safety Protocols

Facilitator:

Dr. Anna Karenina V. Causapin

Student Authors:

Villanueva, Anna Patricia

Villareal, Giselle Mae C.

Villaroman, Angelo D.

Virtudazo, Marian S.

Viñas, Patricia Anne M.

Wenceslao, Bryce Tristan N.

Wepee, Ralph Ryan C.

Yabot, Julian Andrei M.

Yadao, Latoya Lae B.

Yahot, Kemuel Dave N.

D6-Group 1

2D-Med
September 24, 2018
 TABLE OF CONTENTS

CHAPTER 1: Introduction……………………………………………………………….….........1
Background………………………………………………………………..………1
The Institution……………………………………………………………..………2
CHAPTER 2: Potential Weaknesses and Risks for Harm/Adverse Events………………….........3
Lack of Space………………………………………………………………..…….3
Potential for Infection……………………………………………………….…….4
Staff and Patient Safety……………………………………………………………5
Patient’s Records………………………………………………………………….5
CHAPTER 3: Prevention of Adverse Events……………………………………………………..6
On Diagnostic and/or Surgical Procedures…………………………………….….6
On Medication Procedures/Prescription…………………………………………..6
On Space and Accommodation …………………………………………………..7
On Hygiene……………………………………………………………………….8
On Hazard Control……………………………………………………………….10
On Data and Records…………………………………………………………….10
CHAPTER 4: Assessment of Information Given……………………………………………….11
CHAPTER 5: Conclusion and Recommendations……………………………………………...13
Conclusion……………………………………………………………………….13
Recommendations………………………………………………………………..13
Citations………………………………………………………………………………………….14
 Key Informant Interview on Patient Safety Protocols

CHAPTER 1: Introduction

Background

Patient safety, as defined by the World Health Organization, is the absence of preventable harm

to a patient during the process of healthcare and the reduction of risk of unnecessary harm

associated with healthcare to an acceptable minimum. Studies published in multiple countries

show that a significant number of patients are harmed during the process of healthcare, resulting

to increased hospitalization, permanent injury, or even death. While patient safety is a global

issue, countries that have low to middle incomes and have fewer resources are more prone to

poor patient outcomes induced by unsafe medical practice. (Jha, AK., Larizgoitia, I., & Audera-

Lopez, C. et.al. 2013). Data regarding the frequency, severity, and types of unsafe care coming

from low-income countries from Southeast Asia are limited; knowledge about a particular

countries’ culture, political, and social setting is required in order to develop appropriate data

collection and intervention strategies for formulation of health policies and improve outcomes

for patients (World Health Organization. 2004).

Harrison et.al. (2015) state in their study that addressing quality and safety challenges in

Southeast Asia requires clinicians and researchers to understand the characteristics of unsafe care

and the context in which the care is delivered. This include whether the type of unsafe care

occurs in rural, metropolitan, district, or city hospitals.

This report provides a summary of the results from a key informant interview conducted to the

patient safety officer of the Villanueva Eye Clinic. The purpose of the survey is to identify the

potential weakness in the workplace that put patients at risk for harm/adverse events, and the

1
 Key Informant Interview on Patient Safety Protocols

possible solutions or intervention that have been proposed or currently implemented to act as

defense to prevent the adverse events to the patients in the clinic.

The Institution

Figure 1 & 2. Exterior of the clinic (left) and interior of the clinic, waiting area (right)

The Villanueva Eye Clinic is run by an ophthalmologist and optometrist team. With a one liner

ID “ Your Vision is Our Mission”, it offers eye care (refraction, optical services, diseases and eye

surgery) in a one stop manner. The clinic is located in middle of the city. It houses a large

display area for eyeglasses frames, two examination/consultation room with complete

ophthalmic and optometric instruments, a laboratory to process optical frames and lenses, and a

wide waiting area with a reception desk. This also has four (4) comfort rooms for the

convenience of everyone. The clinic is not an ambulatory surgery clinic, therefore surgeries

(minor, major and laser) are done at a nearby hospital. The clinic has six (6) staff members (three

(3) secretaries, two (2) assistants, one (1) technician), one (1) optometrist, and one (1)

ophthalmologist.

2
 Key Informant Interview on Patient Safety Protocols

CHAPTER 2: Potential Weaknesses and Risks for Harm/Adverse Events

Lack of Space

In the year 1996 when the clinic was just starting, the health institution had some potential

weaknesses that are found within their workplace. Initially the lack of appropriate space to

accommodate all the patients as well as the equipments of the clinic was their main concern.

There was limited space in the 30 square meters clinic that there is only one room for the

treatment of eye diseases as well as the examination room for optometry.

The design of the facility has an impact on human performance, especially on the health and

safety of patients and employees. This could either elicit a latent condition (conditions conducive

to error) or minimize adverse effects. Patients in the study preferred an environment that offered

quality and comfortable personal space. They also felt safer when there’s a sense of well being

and normalcy (presence of television, being able to walk around, homely environment). There

were less aggression levels in patients and fewer patients who left against medical advice. The

table below shows the factors to consider (Reiling, et. al., April 2008) :

Patient-Centeredness ● using variable-acuity rooms and single-bed rooms

● ensuring sufficient space to accommodate family
members
● enabling access to health care information
● having clearly marked signs to navigate the
hospital

Safety ● applying the design and improving the availability

of assistive devices to avert patient falls
● using ventilation and filtration systems to control
and prevent the spread of infections
● using surfaces that can be easily decontaminated
● facilitating hand washing with the availability of
sinks and alcohol hand rubs

3
 Key Informant Interview on Patient Safety Protocols

● preventing patient and provider injury

● addressing the sensitivities associated with the
interdependencies of care, including work spaces
and work processes

Effectiveness ● use of lighting to enable visual performance

● use of natural lighting
● controlling the effects of noise

Efficiency ● standardizing room layout, location of supplies and

medical equipment
● minimizing potential safety threats and improving
patient satisfaction by minimizing patient transfers
with variable-acuity rooms

Timeliness ● ensuring rapid response to patient needs

● eliminating inefficiencies in the processes of care
delivery
● facilitating the clinical work of nurses

Equity ● ensuring the size, layout, and functions of the

structure meet the diverse care needs of patients

Potential for Infection

The limited working area in the clinic may pose possible adverse event in the form of an

infection to those patients who just needs an eyeglasses since patients with contagious diseases

are also examined in the same room. The sterility also during that time at the clinic was not yet

advanced because there is only one sink wherein the clinic equipments and utensils of the staffs

are washed. In addition, the advent of autoclave was also not common at that time, that’s why

surgical instruments were not fully sterilized for they were only soaked in cidex.

According to CDC: Guidelines for Environmental Infection Control in Healthcare Facilities

(2003), number and types of microorganisms are influenced by the number of people, the amount

4
 Key Informant Interview on Patient Safety Protocols

of activity, moisture, material capable of supporting growth, rate at which organisms suspended

in the air and the type of surface and orientation. Non-critical medical equipments like

stethoscopes, equipment knobs require low to intermediate level disinfection. 60-90% of ethyl

alcohol or isopropyl alcohol can be used to disinfect these. In the 2008 CDC Guideline for

Disinfection and Sterilization in Healthcare Facilities, surgical instruments should be presoaked

or rinsed. It was also mentioned that automated method of cleaning was more efficient than

manual cleaning (friction or fluidics method). Neutral or near neutral pH detergent solution is

commonly used to provide best material profile and good soil removal on instruments. Enzyme

added detergent solutions are compatible with both metal and non-metal instruments.

Staff and Patient Safety

There was only one bathroom back then for all the patients and the staffs of the clinic which may

pose possible harm to the staffs of the clinic as well as other patients who doesn’t have diseases.

Infections may become widespread at that time because any patients can enter the clinic’s

treatment room in street clothes.

Patient’s Records

During the first few years of the clinic, records of the patients are not yet computerized which

means that their medical records can possibly be lost and eventually can be access by anyone.

Also, a non-computerized data may not be an accurate and up-to-date due to incomplete

information about the patient. Lastly, non-computerized records may not enable quick accessing

for follow-up check up of the patients, and for worst case scenarios may lead down to identity

mistake for patients with same names.

5
 Key Informant Interview on Patient Safety Protocols

CHAPTER 3: Prevention of Adverse Events

On Diagnostic and/or Surgical Procedures

Instruments such as slit lamp, smart autorefractor, spot autorefractor, optical biometer,

keratomer, LED Snellen’s Chart are checked and regularly. Majority are up to date and can self

calibrate. Technicians from the instrument’s company are requested as needed. Manual

refraction kits are still available but the smart autorefractor does most of the work up. The

physician prepared powerpoints with photos about diseases to allow patients to have a better

understanding on what their diagnosis is. If it is a surgical procedure, the physician gives the

patient a printed instruction (printed in dialect and in English) of what the patient must do to

have the hospital process the procedure. This instruction is repeated by the reception desk to

make sure the patient understands the procedure. Follow ups are done as instructed. Rosdahl et.

al. (2014) concluded that most ophthalmology patients surveyed in their study preferred

personalized education interventions, such as one-on-one education sessions, and materials

(printed and electronic) recommended by their provider.

For pupil dilation procedures, the physician marks the patient above the eyebrow with a plaster

tape as to which eye should be dilated. This prevents dilation of the wrong eye.

On Medication Procedures/Prescription

The physician and the optometrist double checks with the patient and makes sure that they have

received the correct clipboard with the patient data from the reception. The physician prescribes

the patient medications available in any drugstore. He demonstrates how to apply the medication,

such as applying ointments or instilling eye drops. Feng et. al. (2016) inferred that their study

6
 Key Informant Interview on Patient Safety Protocols

participants demonstrated an immediate significant improvement after exposure to an

instructional video on proper eyedrop administration technique and an illustrated educational

handout.

The optometrist prescribes the proper grade and briefs the reception desk and the technician

about the prescription and the availability of the lenses. The optometrist and technician also

consults with the patient if their chosen eyeglass is in the right shape for their reading lenses or

such. When the eyeglasses has been cut and process, the optometrist counsels the patient on how

to use it. Patients have the right to select their frames and lenses or choose a different optical to

have their eyeglasses done.

On Space and Accommodation

Figure 3 & 4. Interior of the clinic, a 30-seater waiting area (left) and eyeglasses display

area (right).

7
 Key Informant Interview on Patient Safety Protocols

The clinic’s space improved from 30 square meters to 200 square meters. The capacity of the

waiting area has been expanded, from a 9-seater to a 30-seater. As a result, patients are able to

wait in comfort while waiting for their turn. There has also been proper division among the areas

of the clinic. The waiting area has been separated from the eyeglasses display area. There are

separate examination rooms for patients having different concerns to prevent contamination. One

examination room is for patients with optometric problems and another examination for those

with disease and surgical problems. The clinic has also been installed with four (4) comfort

rooms and one (1) employees’ lounge. Fire exits are available,fire extinguishers and emergency

lights are strategically located in the clinic.

On hygiene

Figure 5 & 6. Separate comfort rooms for male and female (left) and an interior of a

comfort room(right).

At the end of the clinic hours, both examination room as well as waiting areas are cleaned and

mopped with a chemical disinfectant, Lysol. The tabletops are also wiped with Lysol. Wiemken

8
 Key Informant Interview on Patient Safety Protocols

et. al. (2014) conclude that using ready-to-use cleaning and disinfection wipes significantly

increases healthcare providers’ compliance with cleaning and disinfection practices which may

lead to lowering environmental bioburden, hence decreasing the risk of transmission of

healthcare-associated pathogens. According to CDC (Centers for Disease Control and

Prevention), disinfecting the environmental surfaces is necessary in reducing the risk of

healthcare-associated infections. Since they carry less risk of disease transmission than medical

instruments and devices, environmental surfaces could be disinfected in less rigorous ways.

Hand contact serves a very common ground in microorganism transfer which is why hand

hygiene is very important. Sinks are installed in the examination rooms, comfort rooms, as well

as employees’ lounge with liquid soap and disposable paper towels. The World Health

Organization (WHO)’s annual global campaign of “SAVE LIVES: Clean Your Hands”

reinforces the “Five (5) Moments for Hand Hygiene” approach in promoting patient safety,

preventing sepsis in healthcare, and reducing cases of healthcare-associated infections. Patient

handling has also been improved. Isopropyl alcohol sprays (70%) were provided for the staff to

use before and after handling the patients. An example would be whenever they would dilate the

patient’s pupils for examination. The use of an alcohol-based hand rub is one of the keystones in

improving hand hygiene practice. Alcohol kills vegetative forms of bacteria and fungi, however,

9
 Key Informant Interview on Patient Safety Protocols

Figure 7 & 8. Examination area equipped with sink and an isopropyl alcohol sprays (70%).

it has no action on spores or viruses. The best effects of alcohol may attained by the use of

concentrations of 50 and 70%. (Harrington, 1903).

On hazard control

The clinic employs safety precautions with regards to any adverse event it might cause to the

patients. For example, the optical laboratory is located at the back of the clinic away from the

examination rooms and waiting area. Major and minor surgeries are exclusively done and

scheduled in the nearby hospital since the hospital has available equipment and room. Also,

patients 45 years and above are required to secure a cardiopulmonary clearance from their

internists.

On data and records

The clinic’s records are computerized. As such, it strictly follows the Data Privacy Act. Steps

done to ensure patient privacy are as follows: (1) Nobody can get a medical certificate unless the

patient himself/herself asks for it, (2) a valid ID must be provided, (3) each computer is protected

by a data privacy officer who is the only one who can open each computer.

10
 Key Informant Interview on Patient Safety Protocols

CHAPTER 4: Assessment of Information Given

Identified Patient Culture of Safety? High Risk?

Safety Issues

Workplace

Area/Space Improved capacity (200m2). No.

Equipment/Devices Up to date and accurate. No.

Cleanliness Clinic is maintained on a regular basis No mention of proper

using disinfectants. Cleaning is biohazard disposal.
observed through daily monitoring
checklists.

Human Resource

Fatigue Adequate working hours. Employee-related (sick,

lack of sleep, etc.)

Adequacy Adequate number of employees and No.

staffs relative to clinic size.

Safety

Staff Safety Follows safety protocols. Human error-related.

Patient Safety Follows safety protocols. No.

Records and Data

Privacy Follows the Data Privacy Act Human factor (data

manager)

Health Care Associated

Infection (HCAI)

Sterility of Medical Equipment and devices are sterilized No.

Equipment/Devices using approved chemicals before and

11
 Key Informant Interview on Patient Safety Protocols

after a procedure; and are maintained

regularly.

Errors

Diagnostics Makes sure diagnostic procedure is No.

accurate; Double checks everything.

Medication Prescriptions are well-written and Patient-related error.

explained thoroughly to the patients.

Surgical Not applicable

Transition and Hand-offs Referral details are accurately and Possible

completely provided miscommunication.

The table above is based on the interviewee’s answers regarding the patient safety questions. The

data collected are then assessed using existing knowledge on patient safety and are identified if

the clinic has truly followed the culture of safety, or still has high risk for causing harm and

adverse effect to the patients.

By looking at the summarized table, most of the patient safety issues are evaded by the clinic. To

consider, only a few concerns have been identified to be high risk like on biohazard waste

management which was not mentioned, human-related mistakes which are almost always

unforeseen causes of error, harm, or adverse effect, and possible handoff error in surgery patient

referrals.

Hence, with the assessment, the Villanueva Eye Clinic is considered to have followed the ideal

culture of safety.

12
 Key Informant Interview on Patient Safety Protocols

CHAPTER 5: Conclusion and Recommendations

Conclusion

In conclusion, The Villanueva Eye Clinic is found to be a well-managed and a well-maintained

primary eye clinic following most of the patient safety ideals. Indeed, patient safety or the

culture of safety has a vital part in maintaining order, quality and excellence in healthcare by

providing guiding principles towards patient’s best intentions.

Recommendations

Human error is the major risk factor in patient safety protocol. Therefore, clinic personnel must

undergo training and seminar on a quarterly basis to educate them with basic knowledge and

skills to assure high quality performance and improve inadequacies.

13
 Key Informant Interview on Patient Safety Protocols

Citations:

CDC. (2003). Guidelines for Environemental Infection Control in Health-Care Facilities.

Retrieved from: https://www.cdc.gov/infectioncontrol/guidelines/environmental/

background/services.html

CDC. (2008). Guidelines for Disinfection and Sterilization in Healthcare Facilities.

Retrieved from https://www.cdc.gov/infectioncontrol/guidelines/disinfection/

cleaning.html.

Feng, A., O’Neill, J., et. al. (2016). Success of patient training in improving proficiency of

eyedrop administration among various ophthalmic patient populations. Clin

Ophthalmol, 10: 1505–1511. doi: 10.2147/OPTH.S108979

Jha AK, Larizgoitia I, Audera-Lopez C, et al. (2013). The global burden of unsafe medical

care: analytic modelling of observational studies. BMJ Qual Saf Published Online

First: 18 September 2013. doi: 10.1136/bmjqs-2012-00174

Harrington C, Walker H. (1903). The germicidal action of alcohol. Boston Medical and

Surgical Journal, 148:548–552. doi: 10.1056/NEJM190305211482102

Harrison, R., Cohen, AWS., & Walton, M. (2015). Patient safety and quality of care in

developing countries in Southeast Asia: a systematic literature review. International

Journal for Quality in Health Care, Volume 27, Issue 4, 1 August 2015, Pages 240–

254. https://academic.oup.com/intqhc/article/27/4/240/2357347

Reiling, J., et al. (2008). Patient Safety and Quality: An Evidence-Based Handbook for

Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US).

14
 Key Informant Interview on Patient Safety Protocols

Rosdahl, J.A., Swamy, L., et. al. (2014). Patient education preferences in ophthalmic care.

Patient Prefer Adherence, 8, 565–574. doi: 10.2147/PPA.S61505

Wiemken, T.L., Curran, D.R., et al. (2014). The value of ready-to-use disinfectant wipes:

Compliance, employee time, and costs. American Journal of Infection Control,

Volume 42, Pages 329-330. http://dx.doi.org/10.1016/j.ajic.2013.09.031

World Health Organization. (2004). World Alliance for Patient Safety: Forward Programme

2005. http://www.who.int/patientsafety/en/brochure_final.pdf

World Health Organization. (2009). WHO Guidelines on Hand Hygiene in Health Care. First

Global Patient Safety Challenge. Clean Care is Safer Care. Available from:

http://apps.who.int/iris/bitstream/handle/10665/44102/9789241597906_eng.pdf;jsessi

onid=EAA548DDF49673085B316A0338C5D11C?sequence=1

15