Student Dissertation

Agency : Patient Safety Goals; CARE Process Re- engineering; NPSG Goals; Three Tier Process; Root Cause Analysis

Objective : • To analyze the awareness about patient safety amongst nursing staff. • To develop a training module on patient safety goals. • Providing training on patient safety goals, its requirement, need and necessity. • To demonstrate bed side training on history taking. Documentation and reporting. • To develop a questionare to evaluate the effectiveness on understanding and its practical implication. • To provide recommendations for improving patient safety needs. • To suggest top management on the improvement points related to patient safety observation and implementation

Background : Patient Safety Goals implementation is one of the key components of care process re-engineering. The prevention and mitigation of harm caused by errors of omission or commission that are associated with healthcare and involving the establishment of operational systems and processes that minimize the likelihood of intercepting them when they occur is the agenda behind the study. The study was conducted in respect to the following goals: National patient safety goals published, which are part of JCI and WHO Requirements are: • Accuracy of patient Identification • Medication safety • Health care associated infections • Reduce Falls / Sentinel Events • Incidence of pressure ulcers • Risk Assessments • Communication of critical results / Tissue damage events • Protocol for preventing Wrong site, Wrong Procedure; Wrong person surgery

Methodology : The whole process of driving and implementing patient safety goals was divided into three tier process: • Tier 1: Patient Safety Team- To facilitate, educate and train all Nursing Incharges and Staff Nurses • Tier 2: Nursing Incharges- To train the staff nurses and give them bed side training to identify the parameters. • Tire 3: Identification of parameters, their documentation and reporting

Findings : • Awareness and understanding about the patient safety parameters like Haematoma, Thrombophlebitis, New Onset of Fever, Anaemia, Re-intubation, Hperkalemia, Hypokalemia, Hyponatremia, Hpernatremia etc. amongst the staff. • Implementation in form of recording of these parameters in Inpatients in InHospital Patient Safety and Data Collection Sheet. • Improvement in Recording of relevant parameters from Februrary’15- April’15

Recommendations : • Continuous Assessing, Training, Monitoring and Mentoring by the patient safety team to the Nursing Incharges and staff on patient safety parameters. • Atleast once in a week revision of training sessions. • Making concept of importance of patient safety clear to all concerned is of utmost importance. • Analysis and assessing Nursing Staff on the importance and implementation of patient safety goals. • Root cause analysis of occurrence of event in patients and necessary preventive and corrective actions taken for the same • More involvement of RMO’S for better monitoring of events