Patient Safety Program

Medical University Hospital Authority

PURPOSE

The purpose of the Patient Safety Program at the Medical University of South Carolina is to improve healthcare safety and reduce risk to patients, visitors and staff through an environment that encourages:

• Collaboration and coordination with various safety agents/committees and/or task groups (i.e., Environment of Care, Patient Safety and OSHA);
• Recognition and reporting of risks to patient safety and medical/health errors;
• Review of reported risks to identify underlying causes and system changes needed to reduce the likelihood of recurrence;
• The initiation of actions to reduce these risks;
• The internal reporting of what has been found and the actions taken;
• A focus on processes and systems;
• A minimization of individual blame or retribution for involvement in a medical/healthcare error;
• Prospective analysis of selected healthcare services before an adverse event occurs to identify system redesign that will reduce the likelihood of error;
• Organizational learning about medical/health errors;
• Support of the sharing of that knowledge to effect behavioral changes in the organization.

As healthcare, and therefore the maintenance and improvement of healthcare safety, is a coordinated and collaborative effort, the approach to optimal healthcare safety involves multiple departments and disciplines in establishing the plans, processes and mechanisms that comprise healthcare safety at MUHA. The safety program developed by the multidisciplinary Patient Safety Committee and approved by the Quality Council, Medical Executive Committee and the Board of Trustees outlines the components of the organizational Patient Safety Program.

SCOPE OF ACTIVITIES

The scope of the Patient Safety Program includes an ongoing assessment, using internal and external knowledge and experience, to prevent error occurrence, maintain and improve healthcare safety. Healthcare safety occurrence information from aggregated data reports and individual incident occurrence reports will be reviewed by the Patient Safety Committee to prioritize organizational safety activity efforts. These reports include but are not limited to:

• Occurrence reports
• Medication errors
• Adverse drug reactions
• Transfusion reactions
• Sentinel events
• Near misses
• Patient falls, accidents and other injuries
• Hazardous environmental conditions will be referred to the Environment of Care Committee

• Patient Rights
• Assessment of Patients
• Care of Patients
• Patient/Family Education
• Continuum of Care
• Leadership
• Improving Organizational Performance
• Management of Information
• Management of Human Resources
• Management of the Environment of Care
• Surveillance, Prevention, and Control of Infection

1. The Quality Council is responsible for the oversight of the Patient Safety Program. The administrative responsibility may be delegated to the Director of Quality, Risk Manager or Patient Safety Manager.
2. All departments within the organization (patient care and non-patient care departments) are responsible to report healthcare safety occurrences and potential occurrences. Occurrence information will be aggregated and presented to the Patient Safety Committee for additional analysis and recommendations. This analysis and aggregated occurrences will be presented to the Quality Council on a quarterly basis.
3. Through review of internal data reports and reports from external sources (including, but not limited to JCAHO sentinel event alerts, ORYX and Core Measure performance data, occurrence reporting information from state and federal sources and current literature), the Patient Safety Committee will select at least one high-risk safety process for proactive risk assessment annually. Failure Mode and Effects Analysis methodology will be used to perform the proactive risk assessment with Root Cause Analysis methodology identifying the reason(s) for variation.
4. All newly designed and redesigned services, processes, functions (to include physical construction projects) will integrate patient safety priorities into the planning and implementation of the project
5. Coordination of reporting mechanisms to ensure that all components of the healthcare organization are integrated into and participate in the organization-wide patient safety program.
6. Membership of the Patient Safety Committee consists of representation from the following departmental and functional areas:

· Infection Control · Risk Management (co-chair)
· Environment of Care/Safety & Security · Product Evaluation
· Customer Satisfaction · Director of Quality (co-chair)
· Director of Strategic Planning · Health Information Management
· Ambulatory Care Services · Institute of Psychiatry
· Clinical Services · Department of Pharmacy
· University Risk Management · Charleston Memorial Hospital
· JCAHO Administrative Coordinator · Dietary
· Patient Safety Manager
 
5. An effective Patient Safety Program cannot exist without optimal reporting of medical/healthcare errors and occurrences. Therefore, all employees are expected to report suspected and/or actual medical/healthcare errors or occurrences in a timely manner. Once reported, the organization’s focus will be on improving processes and/or systems as well as education and counseling staff as appropriate.
6. The Patient Safety Program includes an annual survey of patients, their families, and staff (including medical staff) opinions, needs and perceptions of risks to patients and requests suggestions for improving patient safety.
7. Patients, and when appropriate, their families are informed about the outcomes of care, including unanticipated outcomes, or when the outcomes differ significantly from the anticipated outcomes. When a healthcare error leads to injury, the patient/family will receive a truthful and compassionate explanation about the error and the remedies available to the patient. They should be informed that the factors involved in the injury are investigated so that steps can be taken to reduce the likelihood of similar injury to other patients.
8. Staff will educate patients and their families about their role in helping to facilitate the safe delivery of care.
9. The Patient Safety Program includes consideration, at least annually, of data obtained from the organizational Information Management Needs Assessment, which includes information regarding barriers to effective communication among caregivers.
10. Staff will receive education and training during their initial orientation process and on an ongoing basis regarding job-related aspects of patient safety, including the need and method to report medical/healthcare errors. And, because the optimal provision of healthcare is provided in an interdisciplinary manner, staff will be educated and trained on the provision of an interdisciplinary approach to patient care.
11. Medical/healthcare errors and occurrences, including sentinel events, will be reported internally and externally, per hospital policy and through the channels established by this plan. External reporting will be performed in accordance with all state, federal and regulatory body rules, laws and requirements.
12. An annual patient safety report will be forwarded to the Board of Trustees on the occurrence of medical healthcare errors and actions taken to improve patient safety, both in response to actual and potential occurrences.

• suicide of a patient in a setting where the patient receives around-the-clock care
• infant abduction or discharge to the wrong family
• rape, as defined by SC law
• hemolytic transfusion reaction involving administration of blood or blood products having major blood group incompatibilities
• surgery on the wrong patient or wrong body part, regardless of the procedure