Академический Документы
Профессиональный Документы
Культура Документы
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Group Members
Lim Keng Li 10A558E Liu Weihua 10A561H Nur Shida Zainal Abidin 10A569A Xu Shuhui 10A580R Hussni Bin Satiman 10A361G Li Jie 10A364W Santhiya Sammugam 10A369Y
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Objective
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Introduction Risk management Problems identify Root cause analysis Strategies Key performance index Conclusion
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RISK MANAGEMENT
Making an assessment of what can possibly go wrong, developing a plan to manage these risks, acting on the plan, harnessing the efforts of the team and 4/29/12 then recognizing improvements
It is simply not acceptable for patients to be harmed by the same health care system that is supposed to offer healing & comfort
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Mr. Siva aged 75 years old is scheduled for elective haemorrhoidectomy and sigmoidoscopy the next morning. Senior Staff Nurse (SSN) Ong was required to serve tab lorazepam 10mg to him at 2200 hours on the night before the operation as premedication. Mr. Siva informed SSN Ong that he would take the medication later as he was not sleeping 4/29/12 yet. SSN Ong left the medication on the
At 0600 hours the next morning, SSN Ong instructed Enrolled Nurse (EN) Siti to administer fleet enema to Mr. Siva. EN Siti had a hard time waking Mr. Siva to administer the fleet enema as he was sleeping really soundly but EN Siti was able to administer the fleet enema to him eventually. As Mr. Siva was still sleeping after the fleet enema, EN Siti put up the bed rails and left 4/29/12 the cubicle.
At 0630 hours, Senior Staff Nurse (SSN) Ong was informed by EN Siti that Mr. Siva had a fall. On investigation, Mr. Siva was seen lying face down on the floor, bleeding from his forehead. He was quickly assisted back to his bed. A physical examination was done by SSN Ong and revealed that Mr. Siva had sustained a 2cm cut at his right forehead.
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According to Mr. Siva he claimed that he wanted to go to the toilet after the fleet enema and decided to climb over the bed rail. He felt giddy and fell on his way to the toilet. Mr. Siva was seen by the ward doctor and his surgeon who confirmed that he required toilet and suture to his forehead instead of haemorrhoidectomy and sigmoidoscopy as this elective operation may be cancelled due to his head injury. Mr. Siva informed SSN Ong that he had taken the
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Not well orientated on how to use bed rail Dosage for Lorazepam is a very high dose Left medication on patients locker follow up on consumption of
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No explanation regarding purpose of medication Patient was not monitored after given sedation Did not seek approval before administration of fleet enema was not informed that he may need to go to the toilet after the
Patient 4/29/12
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Clearly defined objectives for communication Identification of work flows and perspectives need to be taken into account during the risk management process Development of communication strategies to be used during the risk management process Processes to be used to measure and evaluate the effectiveness of the organization's communication programs.
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Fishbone
Pt refused listen to staff
Patient
Staff never explains the precaution of med
Staff
No knowledge about the effect of sedative Assume pt already knows Time limited Assume Dr always right No habit of doing that No monitor pt after heavy dose of sedative
Pt climbed up from cot side Pt confused Pt went to toilet without telling staff Pt took medicine at wrong time Pt did not bother staff Not familiar of cot side bed
Staff has no knowledge about it Staff never checks the dosage with Dr before serve
Pt forgot to take
Fall
Not familiar/compliance with the hospital policy* Long service Time limited No proper training Faulty on the cot side bed Lack of maintenance Lack of proper assessment
No immediate action Time limited Risky environment Time limited No habit of doing that
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Policy
Environment
Revision of hospital policies Change Champions Educational Sessions Carrying out the policies (Reminders & Identification Systems Audit & Feedback
Identific ation
Interven tion
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Identification
Recommendations by
Evidenced-based studies MOH guidelines other hospitals guidelines Incidents Reports, error rates learning from experiences, root cause analysis
Incidences
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Identification
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Identification
Change Champions
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Multi-disciplinary team Oversee the planning Implementation of interventions to promote safety Senior staffs to encourage nurses to comply to strategies.
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Intervention
Educational Sessions
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Importance of Fall Prevention, administering Fall Risk and medication errors preventions
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Intervention
Mandatory Fall Risk Assessment Tool Assessing and reassessing patient and modifying as appropriate Reminders Strategies
Wrist tag Fall risk identifiers at bed 4/29/12Side effects highlighted with drug package
Internal & external ward audits Incidences Report (Medication errors & Falls)
Reporting (internal and external) Measuring/monitoring error rates
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F C all hecklis t
Complete falls risk assessment Document falls risk rating and strategies Educate patients, families and staff Call buzzer, walking aids and belongings in reach Bed low, brakes on Reduce clutter Well-fitted, non-slip footwear
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RESULTS
Brakes locked on - All bed brakes were locked Buzzer within reach - all patients could reach their buzzer Chair appropriate height. I.e. patient can sit on chair with feet resting on the floor
Twelve patients had chairs at their bedside. All chairs were of an appropriate height
Patient requires assistance to mobilize. Walking aid not within reach Four patients with a mobility aid were noted to require assistance to mobilize None of these patients were able to reach their walking aid
Key performance index of fall mangement % to meet % of staff who has received fall management education 100% % of high risk patients with risk assessment form 100% % of high risk patients with action plan 100% % of high risk patients being audited weekly (depending on the number of identified patients) Num of patients who had a fall Immediate intervention provided to patient who had a fall List the interventions provided: EHOR reported 4/29/12 Yes/No
References
Bates, D. W., Leape, L. L., Cullen, D. J., Laird, N., Petersen, L. A., Teich, J. M., Burdick, E., Hickey, M., Kleefield, S., Shea, B., Vliet, M. V. & Seger, D. L. (1998). Effect of computerized physician order entry and a team intervention on prevention of serious medication errors. JAMA [Online serial], 280(15), 1311-1316. Available: h http://www.safetyleaders.org/SafePracticeArticles/effect_of_cpoe_an d_a_team_intervention.pdf (2011, March 23) v Center for Health Care Strategies. (2007). Care Management Definition and Framework. America: New Jersey. v Crowther, A. (2004). Nurse managers: A guide to practice. Melbourne: Ausmed Publications Pty Ltd. v Department of Health Government of Western Australia. (2009). Clinical Risk Management Guidelines for the Western Australian Health System Series No.8 [Online serial]. Available: h http://www.safetyandquality.health.wa.gov.au/docs/clinical_risk_man/ Clinical_risk_man_guidelines_wa.pdf (2011, March 23)
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References
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Koh S.L.S., Hafizah N., Lee J.Y., Loo Y.L., Muthu R., (2009) Impact of a fall prevention programme in acute hospital settings in Singapore. Singapore Med J, 50(4), 425-432. Kuhn A. M., Youngberg B. J. (2002). The need for risk management to evolve to assure a culture of safety. Qual Saf Health Care, 15(11), 158162. Stuart E., Kirstine K., Martin P. (2002). Improving Patient Safety: Insights from American, Australian and British Healthcare. United Kingdom: Department of Health.
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