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Using Guidelines to Assure Clinical Quality and Patient Safety

Using Guidelines to Assure Clinical Quality and Patient Safety

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Using Guidelines to Assure Clinical Quality and Patient Safety

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  1. Using Guidelinesto AssureClinical Quality and Patient Safety Dr. Evita Fernandez HOSPITAL Hyderabad, INDIA www.fernandezhospital.com

  2. Patient safety has always been a prime concern of the clinician

  3. Hospital Admissions 1 in 10 : Adverse event 1 in 300 : Death

  4. Harm to an Individual 1 in 1,000,000 : Air travel 1 in 300 : Healthcare

  5. Why Use Guidelines ? 1. Standardizes care 2. Improves quality of care 3. Improves patient safety 4. Cost effective 5. Facilitates audits

  6. 1 Standardize Medical Care • 12 Consultants - 40 other clinicians • Nursing staff comfortable • Coordinated teamwork • Patient comfort • Institutionalizes care

  7. 2 Improve Quality of Care • Evidence based practice • Algorithm / protocols

  8. WHO Partogram • Overall improvement • Differentiates normal / abnormal progress • Identifies women requiring intervention

  9. “Its use in all labour wards is recommended” Lancet, 1994

  10. All women should have support throughout labour and birth. Hodnett ED, Gates S, Hofmeyr GJ, Sakala C. Continuous support for women during childbirth. Cochrane Database of Systematic Reviews 2007

  11. Research Findings The need for analgesics Rate of Oxytocin Instrumental deliveries Caesarean sections 5 min APGAR Score of < 7

  12. Continuous support in labour increased the chance of a spontaneous vaginal birth, had no harm, and women were more satisfied.

  13. Improve Quality of Care • Protocols

  14. Protocols

  15. 3 Improves Patient Safety

  16. Clinical Risk Management

  17. Fernandez Hospital CRM Committee

  18. Reporting Form

  19. Incident Evaluation Form

  20. The CRM Box in Labour Ward

  21. Not focusing on ‘who was the person’ …

  22. The key question is not who blundered but how and why the defenses failed

  23. Oxytocin Infusion Regime

  24. Aim at the System not the Individual Standardize processes and equipment

  25. TERBUTALINE FOR HYPERSTIMULATION More than 5 contractions in 10 minutes with FHR changes • Stop syntocinon infusion. Start plain RL drip. • Observe CTG over next 15 minutes. • Vaginal examination to determine the progress. • Draw the contents of the entire ampoule into the syringe provided in the kit • Use the volume side of the syringe to determine the dose. • Inject 0.5 ml subcutaneously. • Continue CTG monitoring • If no change repeat dose (the remainder of drug in the syringe) after 15 min. • If no change in CTG pattern over the next 15 min despite second dose •  for C. Section.

  26. Learning from Mistakes • Human error seen as a consequence not as a course of failure • The best people can often make the worst mistake • Errors usually fall into a recurrent pattern

  27. High Risk Management PlanSheet

  28. Checklist for Correct Patient / Site / Surgery

  29. Monthly Meets • Perinatal Mortality Meet • CTG Meet • CRM Interaction • Anesthesia interaction • Neonatologist interaction

  30. 4 Cost Effective

  31. Enemas during labour (review) Reveiz L, Gaitán HG, Cuervo LG, Cochrane Database of Systematic Reviews 2007, updated in 2010

  32. Variables Evaluated • Neonatal infections • 1. Any infection • 2. Umbilical infection • 3. Ophthalmic infection • 4. Skin infections • 5. Respiratory tract infections • 6. Intestinal infections • 7. Meningitis • 8. Sepsis • 9. Need for systemic antibiotics • Puerperal infections 1. Episiotomy dehiscence 2. Urinary tract infection 3. Pelvic Infections 4. Vulvovaginitis 5. Endometritis 6. Myometritis 7. Vulvovaginitis 8. Other puerperal infections 9. Need for systemic antibiotics

  33. These findings speak against the routine use of enemas during labour; therefore, such practice should be discouraged.

  34. Active versus expectant management for women in the third stage of labour (Review) Begley CM, Gyte GML, Murphy DJ, Devane D, McDonald SJ, McGuire W. Cochrane Database of Systematic Reviews 2010, Issue 7. Art. No.: CD007412. DOI: 10.1002/14651858.CD007412.pub2.

  35. Recommendations on active management of the third stage of labour • Active management of the third stage • Use of oxytocin • Dose: 10 IU by intramuscular injection

  36. Active management of third stage reduced the risk of haemorrhage greater than 1000 ml in an unselected population

  37. 5 Facilitates an Audit

  38. Obstetric Anal Sphincter Injury(OASI) The Obstetrician & Gynecologist, 2003 1% of all vaginal deliveries Anal incontinence Recognized sphincter disruption 0.6 – 9% Occult injury : 36% after vaginal delivery

  39. Audit on Vaginal DeliveriesAugust – September 2007 HOSPITAL

  40. Audit on Vaginal DeliveriesAugust – September 2007 HOSPITAL

  41. Protocol and Documentation

  42. Follow up

  43. Changes in Practice • Training of Doctors • Perineal repair workshop • Protocols, Follow up • Clinical attachment with Dr. Abdul Sultan • Perineal Repair Clinic

  44. Monitoring Health Care with Maternity Dashboard

  45. Concept of a Car Dashboard Current status of fuel, speed, temperature, battery, seat belts and so on

  46. Maternity Dashboard • Clinical activity • Workforce • Clinical outcome • Risk incidents / complaints / patient satisfaction

  47. Determining the Traffic Lights • Green – within desired limits • Amber – alert zone • Red – urgent action

  48. Clinical Activity Indicators