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No one should be harmed in healthcare!

On 17 September 2020, the World Health Organization arranges World Patient Safety Day. The theme for this year is “Health Worker Safety: A Priority for Patient Safety”. They call for everyone working in healthcare to speak up for health worker safety, which we fully support! (The patient safety company, 2020).

(http://www.patientsafety.com/en/about-us/news/worldsafetyday2020?utm_source=adwords&utm_term=world patient safety day&utm_cam…)

The objectives of World Patient Safety Day 2020 are:

  1. Raise global awareness about the importance of health worker safety and its interlinkages with patient safety
  2. Engage multiple stakeholders and adopt multimodal strategies to improve the safety of health workers and patients
  3. Implement urgent and sustainable actions by all stakeholders which recognise and invest in the safety of health workers, as a priority for patient safety
  4. Provide due recognition of health workers’ dedication and hard work, particularly amid the current fight against COVID-19

It does not matter what one’s role in the multidisciplinary team is, all of us are concerned about patient safety. The patient safety company (2020) developed a blueprint which could assist personnel to consider the conditions which need to be met.

  1. Identify the risks for patients

In order to learn from incidents, it is essential that all incidents and near incidents are reported. Unfortunately, reporting an incident is still often considered an administrative burden that is difficult and redundant. When incidents are reported you get a clear overview of the root causes and the different types of incidents. With an up-to-date management system, trends can be identified that can then be used for an in-depth incident analysis. This can contribute to the improvement of care. The quality manager would be able to keep a database with root causes that occur regularly, which can be used for targeted improvement actions. New analyses will then indicate if such incidents occur less frequently. According to Snook (2019 – https//i-sight.com/resources/reporting-patient-incidents-a-best-practice-guide/) patient incident reports communicate information to facility administrators. The information contained in the reports shed light on measures that need to be taken to provide effective patient care as well as keep facilities running smoothly. These reports help administrators with risk management. Knowing that an incident has occurred can push administrators to correct factors that contributed to the incidents and this reduces the risk of similar incidents in the future. Quality control, medical facilities want to provide the best care and customer service possible. Reviewing incident reports reveals areas that could be improved.

  1. Implement and monitor improvements

Quality and safety management should be part of the quality manager’s daily activities in the organisation. With the correct tools such as incident management, complaints registration and audits are necessary, but does it assist in managing the subsequent improvement actions? Dashboards are a powerful tool for internal communication about improvements. They not only allow better understanding of the number of reports, but can also be used to share improvement actions, thus allowing departments to adopt each other’s improvement actions. The generic dashboard is based on general information gathered from reports of patient safety concerns associated with at least one of ten specific event types. The dashboard charts detail event type, report type by event type, extent of harm by event type, event type by the extent of harm, and extent of harm (Agency for Healthcare, Research and Quality: 2019).

  1. Formulate SMART goals for the improvement actions.

SMART is an acronym that stands for Specific, Measurable, Achievable, Relevant and Time-Based. Each element of the SMART framework works together to create a goal that is carefully planned, clear and trackable.

Often goals have been set which were too difficult to achieve because they were too vague, aggressive, or poorly framed. Working toward a poorly-crafted goal can feel daunting and unachievable. Creating SMART goals can help solve these problems. Whether you are setting personal or professional goals, using the SMART goal framework can establish a strong foundation for achieving success.

  1. Ensure that patients, caregivers, and management receive information about the results and the way forward.

Patient feedback is a valuable source of information and should be used to improve the quality and safety of the care we deliver, but do nurses use it to make improvements in service areas? If not, what are the barriers that are stopping us from doing so? Patient feedback is an invaluable source of information that should assist staff the implement changes that will improve quality of care and patient safety. In a recent study exploring the reasons why staff might find it difficult to use patient feedback constructively found there are a number of prerequisites to effective and lasting change. In order to obtain such changes requires a willingness to act; staff at ward level having autonomy, ownership of the problem and resources to act; and the organisation being ready and able to support change (Moore, 2018), How can we use patient feedback more effectively to improve care? Nursing Times [online]; 114: 12, 45-48).

 

  1. Transparency about medical incidents

Reporting calamities and the lessons learned from them would appear to be the next logical step after a decade of hard work on safety and learning how to anticipate medical incidents.

Only through transparency can research be conducted into what went wrong, can lessons be learned and can healthcare be enhanced. A learning network for hospitals and researchers. Research indicates that transparency regarding medical incidents does not just happen. The willingness to be open and upfront is no more than a point of departure. Transparency truly needs to be organised. The hard question is simply: “how can being open and upfront about complaints and incidents best be institutionalised?” This issue was the reason why Project OPEN was set up. OPEN kicked off in the spring of 2015 and is the learning network for hospitals and researchers, working together to generate greater insight into the way in which transparency can best be promoted. In international scientific literature, the art of being open and upfront is generally referred to by the word disclosure. This is the process by which the institution provides clarity about what happened, how it happened, what is being done for the patient involved or the family and those bereaved, and what the institution intends to improve to prevent the repetition of a similar incident in the future (The patient safety company, 2019).