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برنامج إدارة المخاطر وسلامة المرضى

ملتقى الجودة وسلامة المرضى
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  #1  
قديم 08-26-2012, 09:37 AM
الصورة الرمزية الكفاح
 


الكفاح will become famous soon enoughالكفاح will become famous soon enough


برنامج إدارة المخاطر وسلامة المرضى 1277300891.gif


محتويات برنامج إدارة المخاطر وسلامة المرضى يفضل ان يحتوي دليل اجراءات العمل على 30 موضوع هي كالتالي


30 Priority Focus Areas
Priority Focus Area is a system, or structure that significantly impacts the quality & safety of care.
1Policies & Procedures
1- كتابة السياسات والإجراءات لكل نقطة سوف يتم ذكرها

2Staff awareness
2- نشر الوعي بين العاملين

3Implementation
3-تطبيق السياسات والإجراءات

برنامج إدارة المخاطر وسلامة المرضى
التعرف على هوية المريض بطريقتين
1. Patient Identification - IPSG 1
الأوامر الهاتفية والتبليغ عن النتائج المفزعة والحرجة
2. Critical Value: Telephone Order IPSG
الأدوية عالية الخطورة والمحاليل عالية التركيز
3. High R isk Medication-Concentrated
Electrolytes - IPSG
التأكد من تأشير مكان العملية
4. Verification Process / Time Out - IPSG
مكافحة العدوى ( نظافة غسل اليدين )
5. Infection Control-Hand Hygiene / IPSG5
منع السقوط
6. Prevention of Patient Fall - IPSG 6
معالجة الألم
7. Pain Management
ممارسة تقييد المرضى
8. Restraint Practice
فحص عربة الإنعاش القلبي الرئوي وجهاز الصدامات
9. Crash Cart Inventory / Checklist
منع خطف الأطفال
10. Prevention of Child Abduction
الاختصارات الممنوعة
11. The Use of Prohibited Abbreviations
الأخطاء الدوائية
12. Médication Errors
إدارة الأدوية والاستشارة الدوائية
13. Medication Management Médication Réconciliation
التعرف على هوية المواليد
14. Infant Identification
التسدير ( تخدير المرضى الواعيين بالمسكنات )
15. Conscious Sedation Practice
فريق الإنعاش القلبي الرئوي
16. Code Blue Team
فريق الاستجابة السريعة
17. Rapid Response Team
سياسة استخدام الدم ومنتجاته
18. The Use of Blood & Blood Products Comm.
سياسة الإقرار بالعلم
19. Informed Consents Documentations
التحليل الجذري للأسباب والتبليغ عن والحوادث الخافرة (الجسيمة )
20. Root Cause Analysis/Sentential Events Screening
سياسة لجنة الجودة الشاملة
21. Quality Management Committee
سياسة لجنة الاعتماد والتميز الطبي
22. Medical Credentialing & Privileging Committee
سياسة لجنة المراضة والوفيات
23. Hospital Mortality and Morbidity Comm.
سياسة لجنة مراجعة السجلات الطبية
24. Medical Record Review Committee
سياسة مراجعة الاستخدام الأمثل للموارد
25. Utilization Review committee
لجنة الصيدليات والعلاجيات
26. Pharmacy & Therapeutics Committee
سياسة غرف العمليات
27.
Operating Room Committee
سياسة مراجعة الأنسجة المرضية
28. Tissue Review Committee
التبليغ عن الممارسة الإشعاعية والسلامة بالأشعة
29. Radiology Reporting Practice/ Radiology Safety
سياسة الوخز الابري
30. Needle stick Injury
المواد الخطرة ومكافحة السوائل البيولوجية المنسكبة
30. Hazardous Material / Spillage Control
السلامة من الحريق / خطة الأخلاء / مخارج الحريق / خطة الكوارث
30. Fire Safety / Fire Alarms / Fire Exits / Disaster Plan

الترجمة اجتهادات شخصية اذا كان بها خطأ امل ابلاغي
شارك
مشاركة في فيسبوك مشاركة في تويترمشاركة في قوقل بلص
medical2000, drsayed, wallooda و 2 آخرون معجبون بهذا.


من مواضيعي : الكفاح
التعديل الأخير تم بواسطة الكفاح ; 08-26-2012 الساعة 09:47 AM.
رد مع اقتباس
  رقم المشاركة : [ 2 ]
قديم 08-26-2012, 10:59 AM
صحي نشط
 

medical2000 will become famous soon enough
افتراضي رد: برنامج إدارة المخاطر وسلامة المرضى

جهد رائع و موفق
اتمنى من العاملين في ادارة المخاطر عمل
خطتهم وبرامجهم التدريبيه بناء على العناصر
المذكوره والتاكد من وضع سياسه لكل عنصر
والمام العاملين فيها وعمل مونيتورنق لها

الكفاح مبدعه كعادتك
وفقك الباري للخير
من مواضيع : medical2000
medical2000 غير متواجد حالياً   رد مع اقتباس
  رقم المشاركة : [ 3 ]
قديم 08-26-2012, 11:01 AM
مشرفة ملتقى النفحات الإيمانية

الصورة الرمزية المكينزي
 

المكينزي has a spectacular aura aboutالمكينزي has a spectacular aura about
افتراضي رد: برنامج إدارة المخاطر وسلامة المرضى

بسم الله الرحمن الرحيم
اللهم صل على محمد وعلى آله وصحبه أجمعين

السلام عليكم ورحمة الله وبركاته

أسعد الله صباحك ومساك بكل خير
جزاك الله خير

داخل الأصداف يوجد اللؤلؤ، وفي داخلكم وجدت الأنسان وأجمل القيم . وإن كانت هنالك أشياء جميلة في حياتي ، فمن المؤكد معرفتي بكم هي
واحدة من هذه الأشياء. فليحفظ الله الود بيننا ويجعل الجنة دارنا ♥

بارك الله بك
ودمت بحفظ الرحمن
من مواضيع : المكينزي
المكينزي غير متواجد حالياً   رد مع اقتباس
  رقم المشاركة : [ 4 ]
قديم 08-26-2012, 09:50 PM
افتراضي رد: برنامج إدارة المخاطر وسلامة المرضى

اقتباس
  المشاركة الأصلية كتبت بواسطة medical2000
جهد رائع و موفق
اتمنى من العاملين في ادارة المخاطر عمل
خطتهم وبرامجهم التدريبيه بناء على العناصر
المذكوره والتاكد من وضع سياسه لكل عنصر
والمام العاملين فيها وعمل مونيتورنق لها

الكفاح مبدعه كعادتك
وفقك الباري للخير


الله يسلمك ويعافيك
شكرا على هذا الاطراء
اسعدني مرورك العطر
كل الشكر والتقدير لشخصكم الكريم
من مواضيع : الكفاح
الكفاح غير متواجد حالياً   رد مع اقتباس
  رقم المشاركة : [ 5 ]
قديم 08-26-2012, 09:53 PM
افتراضي رد: برنامج إدارة المخاطر وسلامة المرضى

اقتباس
  المشاركة الأصلية كتبت بواسطة المكينزي
بسم الله الرحمن الرحيم
اللهم صل على محمد وعلى آله وصحبه أجمعين

السلام عليكم ورحمة الله وبركاته

أسعد الله صباحك ومساك بكل خير
جزاك الله خير

داخل الأصداف يوجد اللؤلؤ، وفي داخلكم وجدت الأنسان وأجمل القيم . وإن كانت هنالك أشياء جميلة في حياتي ، فمن المؤكد معرفتي بكم هي
واحدة من هذه الأشياء. فليحفظ الله الود بيننا ويجعل الجنة دارنا ♥

بارك الله بك
ودمت بحفظ الرحمن


عليكم السلام ورحمة الله وبركاته
الله يسلمك ويعافيك
الله يجزاك خير على العبارات الجميلة
اسعدني مرورك العطر
كل الشكر والتقدير لكِ اخيتي
من مواضيع : الكفاح
الكفاح غير متواجد حالياً   رد مع اقتباس
  رقم المشاركة : [ 6 ]
قديم 08-27-2012, 01:22 PM
افتراضي رد: برنامج إدارة المخاطر وسلامة المرضى

Details of the Priority Focus Areas


Patient Identification - IPSG 1
- Availability of Patient Identification Policy clearly defines the
hospital process that requires (2) patient identifiers whenever
taking blood samples or administering medications or blood
products or prior to surgery or performing procedure.
-Availability of Procedure used for staff education
- The staff are
aware of the policy.
-The two patient identifiers-patient full name and medical record
number is implemented in Emergency Room before taking blood samples or administering medications or blood products or prior to performing procedure.
-The two patient identifiers-patient full name and medical record
number is implemented in Emergency Room for all blood samples before sending to Laboratory

Critical Value: Telephone Order - IPSG 2

Availability of Multidisciplinary policy and procedure on telephone and verbal orders

Availability of Policy that clearly defines urgency/emergency

situation for accepting verbal orders “code” and time frame for order authentication

-Availability of Policy that defines proper procedure for receiving

and documenting verbal orders

-Availability of Policy that clearly defines restriction on drugs that

may be ordered verbally.

-Availability of policy that “panic” findings on laboratory tests are

reported immediately to the specialty requesting the examination.
-Availability of policy that “panic” findings on X-ray films are

reported immediately to the specialty requesting the examination.

-Availability of Policy that clearly defines non-medical staff who

may accept a verbal order.

-Staff (pharmacy and/or nurse) clearly understands how to handle

verbal orders.

-Availability of panic values Log book in Radiology & Laboratory.

-Availability of Medical Record documentation for verbal and Telephone order Authentication


High R isk Medication- Concentrated Electrolytes - IPSG 3

Availability of Written policy/ guidelines for handling high-risk medications (including the definition of high r isk medication and a defined global list).

-Availability of list of Medication that have a higher likelihood of causing injury if they are misused.

-Availability of list of high r isk medication that have high volume use.

-Availability of Standard drug concentrations of all intravenous drips in the hospital.

-Staff are aware of the policy.

-Concentrated intravenous potassium, magnesium and hypertonic saline are not allowed as floor stock except as part of the crash cart medication as per Saudi Heart recommendation.

Verification Process/Time Out - IPSG 4

Availability of Verification Process/Time Out Policy (A process to mark the operative site in a standardized method and symbol with permanent ink by the person performing the operation and/or procedure. [For organs, mark on the Body Diagram form in the appropriate area (left or right).

-Availability of Nursing preoperative checklist to assess if the patient is ready for surgery including the site of surgery and its preparation and whether it is marked or not.

-The policy is fully implemented in surgical unit and the Operating Room.

-The patient is accepted into the OR only after the site of surgery and its preparation and whether it is marked or not is checked



Infection Control-Hand Hygiene - IPSG 5

-Availability of Infection control policy.

-Availability of Steps to teach patients, nurses, physicians how to perform proper hand washing.

-Availability of hand washing Monitoring process.

-The staff are aware of the policy.

-Availability of sink with hot and cold water under pressure, liquid soup, and paper towels in patient rooms, nursing station in the working area or the entrances of isolation room & burn unit



Prevention of Patient Fall - IPSG 6

-Availability of Fall Prevention policy (The Fall Prevention Policy clearly defines the hospital process for Prevention of Fall that include an initial and ongoing nursing evaluation in areas (medication, poor vision, sudden mental
status, improper shoe fit, too much furniture the room, spills on the floor, poor hydration, uneven floor).
-Availability of Functional assessment to handle daily activity such as transferring, ambulating and bathing and Environmental fall risk assessment.
-Availability of Periodic assessment of patient for potential risk of falling.
-Availability of fall incident report following any patient fall.
-Availability of a process to educate patient & relatives about the risk of falling & how to minimize this risk.
-Availability of steps taking by the hospital to reduce risk of fall.
-The staff are aware of the policy.


Pain Management

-Availability of policy & procedure that guide optimal pain management to all patient and manage pain as the sixth vital sign.

-Availability of pain assessment form and medical record documentation.

-Availability of hospital process for providing education to the patients and staff about pain management.

-Availability of documented actions by the staff to relieve the pain.

-Staff are aware of the policy.

Patient Restraint

-Availability of a policy & procedure that guide the care of restrained patient.

-Availability of measures that reduce the risk of restraint and guard the safety of the process.

-Availability of restraint assessment and reassessment forms.

-The staff are aware of the policy.

Conscious Sedation Practice

Availability of written policy on conscious sedation approved by the head of anesthesia, the nurse manager, and the appropriate department heads.

-Availability of list of all conscious sedation privileged physicians.

-Availability of list of all conscious sedation privileged sites.

-Availability of continuous monitoring of patient level of consciousness, vital signs, oxygen saturation and skin color and this is documented by the physician and nurse during conscious sedation.

-Availability of full documentation of conscious sedation by physician including the status of the patient post procedure and includes vital signs, level of consciousness, and ECG findings.

-Availability of nursing documentations regarding the status of the patient post procedure and includes vital signs, level of consciousness, and ECG Findings.

-Availability of physician discharge order or transfers the patient back to the unit with follow up instructions for the nurses (vital signs, oxygen saturation, etc).

-Availability of evidence that a competency test is conducted to concerned staff knowledge.

-Availability of one physician close to the patient when given conscious sedation.

-Availability of one registered nurse who is certified with BCLS and preferably ACLS is at the patient side constantly and continuously monitors the patient when given conscious sedation.

The Use of Blood & Blood Products

-Availability of hospital policy/guidelines for the safe, efficacious, consistent and effective management and monitoring of anticoagulant therapy in adult and pediatrics population.

-Availability of Policy for Deep venous thrombosis (DVT) prophylaxis.

-Availability of process that guide the standard use of Coumadin.

-Availability of process that guide the use & availability of Negative Blood Group.

-Availability of a process to monitors the Blood Bank’s performance and reviews all the procedures used for collecting, testing, and storing blood and blood products.

-Availability of a process for reporting blood utilization and blood product wastage.

-Availability of a process to monitors that patient is only accepted in the OR when the requisition for blood is verified to ensure blood is reserved in the blood bank, if needed.

Rapid Response Team

-Availability of Rapid Response Policy indicating its membership and the

responsibilities of Rapid Response Team.

-Availability of Criteria/Guidelines for Initiating the Rapid Response Team.

-Availability of a process to measures the effectiveness/improvement of the Rapid Response Team.

-Availability of a process to educate staff when and how to activate the call of Rapid Response Team



Code Blue Team

-Availability of policy and procedure that regulates the actions of the CPR Team Members of the committee should include an anesthetist, cardiologist, nurse in addition to other specialties.

-Availability of documentations that the committee adopts the recommendations of the Saudi Heart Association or the American Heart Association.

-Availability of detailed protocol outlines the duties and responsibilities of each member of the CPR team and the staff who first discover the code.

-Availability of documentations to show that all codes are discussed in the CPR committee and the summary of these discussions is sent to the Medical Director and the Quality Management Director.

-Availability of document to show that the committee discus how effective is Codes.

Informed Consents

Availability of Informed Consents Policy, informed consent is obtained after the patient in research protocol& the consent is signed by the patient, guardian, or next of kin if the patient is unable to sign and kept in the patient medical record.
-The hospital has a general consent form that provides authorization the physician educates the patient regarding the risk, benefits and alternatives of the surgery, blood transfusion, outpatient procedure, sedation/analgesia, high risk procedure, and photography of patient or involving for general treatment and a policy to govern its use and completion.
-Nurses know the process of informed consent and assure that signed informed consent is available prior to the above situations.


Crash Cart Inventory/Checklist

Availability of written multidisciplinary policy on standardization of crash cart medication contents according to Saudi/American Heart recommendations.
-Availability of written multidisciplinary policy and procedure of restocking of crash cart medications and equipment.
-Availability of documentations of the monthly inspection of crash cart medications by pharmacy Staff are aware of the policy.
-Availability of documentation to specifies the permanent allocation of carts in the strategic areas of hospital (Check Crash Cart in 4 different High Risk Patient areas).


Approved/Prohibited Abbreviations

Availability of an approved hospital-wide policy on the Approved/Prohibited Abbreviations.

-Availability of a simplified alternative abbreviations list.

-Availability of printed prohibited abbreviation list that is placed in patient charts.

-Availability of pocket-sized cards with the “do not use” list to all staff.

-Availability of documented regular reminders to staff regarding the

Prohibited Abbreviations.

-Availability of documents to show prohibited abbreviations are deleted from preprinted order sheets and other forms.

-Availability of evidence that work with software vendors is carried out
to ensure changes are made to be consistent with the list.

-Availability of evidence that Pharmacy must not accept any order

containing prohibited abbreviation.

-Availability of evidence that a competency test is conducted to test

staff knowledge.

-Availability of log book for evidence that all staff sign a statement that

he or she has received the list and agrees not to use the abbreviations.

-Availability of evidence to promote a “do-not-use abbreviation of the

month” policy Staff are aware of the policy.

Medical Credentialing & Privileging Committee

Availability of Medical credentialing and privileging committee terms of reference.

-Availability of a criteria for appointments & delineated clinical privileges.

-Availability of a process to determine the qualification requirement for every type of medical staff considered for hire.

-Availability of documentation that the standards are applied for every candidate hired temporary, permanent or as locum..

-Availability of documentation that the clinical privileges standard for all staff to be reviewed, updated every 2 years or as needed.

-Availability of documentation that the performance & clinical competence of staff members are revised annually with evidence to act on the recommendations for reappointments , renewal or changes in clinical privileges.


Hospital Mortality and Morbidity Committee

The hospital has a mortality and morbidity committee that is chaired by the medical director or his designee.

-Availability of documentation that a review is carried out for any death that occurred outside expected care outcome within 24 hours of admission.

-Availability of documentation that a review is carried out for any Sentinel events, death due to suicide, accidental overdose and for multiple injuries.

-Availability of documentation that a review is carried out for any death related to inappropriate use of clinical privileges.

-Availability of documentation that a review is carried out for any case if recovery is outside expectations such as; hospital stay longer than expected

-Availability of documentation that a review is carried out for any ICU stay longer than expected.

-Availability of documentation that a review is carried out for any Iatrogenic induced illness.

Quality Management Committee

Availability of Quality Management committee Terms of reference that reflect its membership and functions (Medical Director, Nursing Director, and Quality Management Director, Medical Record Director / leader dept heads).
-Minutes - Quality Management committee “from last one year".
-Availability of documentation that the Quality Management
committee approves, initiates, receive reports on QM projects and
approve hospital wide teams.
-Availability of documentation that the QM committee review &
approve quality program.
-Availability of documentation that the QM committee monitor
& revise Quality improvement educational activities for QI knowledge.
-Availability of documentation that the QM committee facilitate the implementation of the QM plan.
-Availability of documentation that the QM committee promotes
multidisciplinary approach of problem solving processes.

Quality Management Committee 2

-Availability of documentation that the QM committee review reports from all teams, head of departments & leaders.

-Availability of documentation that the QM committee review data from patient satisfaction surveys, performance indicators monitoring, risk & safety, infection control, & utilization issues.

Other QM Issues

-Availability of a process to ensure that Pediatrician Attending Cesarean Sections.

-Availability of a process to ensure physician Round on Weekend.

-Availability of a process for Morgue identification, protection and prevention of mixing of bodies (adults, babies).

-Availability of a process to ensure that the hospital regularly monitors the effectiveness of the following indicators; pressure ulcers, patient falls, ADR, medication errors, sentinel events, missing Sponge and morgue protection.


Pharmacy & Therapeutics Committee


-Availability of Pharmacy & Therapeutics committee terms of reference.

-Availability of documentation that the Pharmacy & Therapeutic committee assists in the formulation of policies relating to drugs in the hospital including drug selection & procurement, storage, transcribing, preparing & dispensing, drug administration, documentation and drug monitoring.

-Availability of documentation regarding establishing drug formulary in the hospital & its review & update every 2 years.

-Availability of documentation regarding establishing antibiotics policy.

-Availability of documentation regarding justifying any non formulary drug request & evaluate all unapproved indications of formulary drugs.

-Availability of documentation regarding a process for drug recall.

-Availability of documentation regarding establishing a process for any restrictions on the use of formulary & non formulary drugs.

-Availability of documentation regarding establishing a process to monitor & evaluate use of controlled substances & high risk medications.

-Availability of documentation regarding establishing a process for monitoring & control dispensing of free medical samples.

-Availability of documentation regarding a process to monitors reports & recommend action on medications error or adverse drug reaction.

-Availability of documentation regarding establishing a process to review all MOH circulars and ensures that policy of MOH is implemented in the hospital.

Utilization Review committee

-Availability of Utilization Review Committee terms of reference outlines the function and membership.

-Availability of a process to monitor length of stay and appropriateness of admission.

-Availability of a process to ensures the optimum use of resources by monitoring their use and searching for less costly means of providing care.

-Availability of a process to study all aspects of patient care and observing if resources status are; over utilized, under utilized, inefficiently utilized, inefficiently allocated.

Operating Room Committee

-Availability of Operating Room Committee formation order outlines its function and membership to include; medical staff, nursing staff, OR technician, infection control, and safety personnel.

-Availability of documentation to ensure that the Operating Room committee Continually review the appropriateness of use of the operating rooms/recovery rooms.

-Availability of documentation to ensure that the Operating Room committee reviews the outcome of surgical interventions, the discrepancy between preoperative and postoperative diagnoses.

-Availability of documentation to ensure that the recommendations of

the Operating Room committee are utilized in granting, renewal,

withdrawal, and amending of clinical privileges.

-Availability of documentation to ensure that Operating Room approves infection control measures, supplies, patient identification code of conduct and cancellation rate.

-Availability of documentation to ensure that the Operation Room committee makes recommendations to promote safety and enhance efficiency in utilization of operating rooms.
-Availability of documentation to ensure that the Operating Room and Recovery Room policies are approved by OR committee.

Tissue Review Committee

-Availability of Written policy on obtaining, handling and disposing specimens and /or tissues and the functions of this Committee is handled by the Chief Pathologist or his designee.

-Availability of documentation to ensure that the laboratory has a specimen collection manual that covers: obtaining and labeling specimens, methods for patient identification, methods for patient preparation, specimen collection and labeling, specimen preservation, conditions for transportation, specimen storage and reporting.

-Availability of documentation to ensure that all specimens, tissues, and “frozen section” specimens removed during surgery are sent to the laboratory for histo-pathological examination.

-Availability of documentation to ensure the accuracy and completeness of histopathology forms: site of biopsy, number of pieces taken, clinical history, previous biopsies.

-Availability of documentation to ensure that when significant disparities exist between frozen section, cytology, or gross evaluation and final pathology diagnosis, this is reconciled and documented either in the pathology report or in the departmental quality management file.

-Availability of documentation that specimens are retained for at least 1 month after the signed final pathology reports are handled to referring physicians.

-Availability of documentation to ensure the accuracy of the fine needle aspirations is monitored.
-Availability of documentation to ensure that any variation between the preoperative, the postoperative and/or the pathological diagnosis.

-Availability of documentation to ensure that any specimens or tissue removed during surgery are sent to the laboratory for histopathological examination (e.g. hernia sac or any lump).

Radiology Reporting Practice/ Radiology Safety

Availability of written comprehensive radiation safety protocol or plan in place (equipment checked and inspected by safety officer, radioactive material used by guidelines with safety officer oversight, safety warnings posted on doors, women screened for pregnancy prior to x-ray).

-Availability of a process to monitor personnel exposure to radiation periodically.

-Availability of a mechanism in place for timely reporting radiology results especially on weekends and after working hours.

-Availability of documentation to ensure that all chemical used in the radiology department are used according to the instructions of the MSDS.

-Availability of a process that guide the safety of equipment and to maintain quality control measurement on regular basis.

Needle stick Injury, Hazardous Material/Spillage

Control/ Fire Safety/Fire Alarms/Fire Exits/ Disaster Plan

Availability of Needle stick injury Policy

-Availability of Staff Health Clinic Log Book for needle stick injury and to that Staff Health Clinic Perform the necessary investigations following needle stick or sharps injury and this data is collected for trending and reported at the Safety committee and Infection control committee.

-Availability of Disaster Plan clarifying the roles and responsibilities of every employee and response to both internal and external disaster.

-Availability of the seven FMS Plans in patient care units.

-Availability of Fire Safety Plan.

-Availability of Safety Management Program.

-Availability of HazMat plan.

-Availability of Security plan.
-Availability of Emergency plans ( Internal& External ).

-Availability of Laser safety; if applicable.

-Availability of Medical Equipment safety plan.

-Availability of plan for Spillage Control.

-Availability of documentation to ensure that all nursing staff receives annual education on occupational hazards by needle stick to help reduce worker injury.

-Availability of last Disaster drill documentation.

Medication Errors

-Availability of policies and procedures that adopt a system-oriented approach to medication error reduction/

-Availability of Computerized Physician Order Entry (CPOE).

-Availability of Automated Dispensing Cabinets.

-Availability of Bar-coding in medication and patient identification.

-Availability of Smart Infusion Pumps.

-Availability of evidence that medication manufacturers is

Limited.

-Availability of standard processes for medication doses and dose timing.

-Availability of medication color differentiation.

-Availability of a medication unit dose system.

-Availability of Pharmacist during patient care rounds.

-Availability of electronic medication information.

-Availability of medication TALL man lettering.

-Availability of medication separate storage areas.

Medication Management & Reconciliation

-Availability of policy and procedure for Adverse Drug Reaction.

-Availability of written policy and procedure for Medication Reconciliation.

-Availability of written policy for handling PRN (as needed) drug orders.

-Availability of process for documentation of Antibiotics prophylaxis.

-Availability of process for monitoring Adrenalin use.

-Availability of process that guide the appropriate use of Valium in Emergency Room.

-Availability of significant or serious ADR reporting timeframe.

-Availability of ADR reporting forms.

-Availability of a process for improving ADR reporting.

-Availability of Intensive analysis is performed for all significant or serious ADRs.

-Availability of policy on Notification of treating physician regarding ADR

-Availability of evidence that the patient receives appropriate care for the ADR.

-Availability of evidence that the medical record has been flagged for known allergies.

-Availability of evidence of reporting any serious or unexpected ADR to the MOH.

-Availability of policy and evidence clarifying medication reconciliation and a process of identifying the most accurate list of all medications a patient is taking, including name, dosage, frequency, and route against the physician’s admission, transfer, and/or discharge orders.

-Staff are aware of the policy.

-Correct medical record documentation for PRN medication.


Root Cause Analysis/Sentential Events Screening

-Availability of the essential policies and procedures regarding incident report (OVR), sentential events and near misses that are reviewed and updated regularly.

-Availability of clear process regarding the person responsible for initiating the incident report, and how the occurrence is to be investigated.

-Availability of a comprehensive list of reportable occurrences.

-Availability of a clear process to conduct Root Cause Analysis for all sentential events, near misses and other reported serious incidents.

-Availability of a clear process to implement RCA action plans in order to achieve the hospital objectives in improving performance and insuring the prevention of similar incidents.

-Availability of outcome measurements (indicators) process regarding adverse events (falls, injuries, pressure error, patient fall, wrong procedure, etc.)

Infant Identification

-Availability of an approved hospital-wide Infant Identification Policy clarifying the roles and responsibilities of concerned employee.

-Availability of a process that guide the use of baby identification

bands and to check the band number with the other/father/caregiver's

number before giving the infant to either parent.

-Availability of infant identification method; Foot prints, Hand/finger

prints, Head shots, Written description of the infant, medical records.

-Availability of a process to number the umbilical cord clamps with

matching identification wrist bands.

-Availability of a process to mark infant gowns at the neckline with

the hospital name and logo so the infant is able to be quickly identified

as a patient of the hospital.

-Availability of a process to ensure that infant blankets should be


marked on all four corners so the infant is readily identified as a patient of the hospital



Medical Record Review Committee

-Availability of Medical Record Review Committee terms of reference.

-Availability of Medical record review form that includes admission assessments, operative notes, histopathology report, lab results, typed x-ray reports, and discharge summaries, documentation of patient education activity, progress notes, and plan of care.

-Availability of Recent Medical Record Review report.

Prevention of Child Abduction

-Availability of an approved hospital-wide Abduction.

-Prevention Policy clarifying the roles and responsibilities of concerned

employee with specific guidelines for staff to follow in the event of an

infant abduction.

-Availability of a process to ensure that hospital environment is assessed

for potential security measures.

-Availability of security cameras in strategic locations like the nursery,

stairwells, doorways, elevators, and hallways to monitor the incoming and

outgoing activity.

-Availability of a process to not allowing physically carrying an infant in

the hospital and can only transport a newborn by use of a crib.

-Availability of a process to ensure that all infant abduction protocols and

response plans should be in writing and known to all hospital staff.

-Availability of a process to ensure that either the mother or the nursing

staff always supervises infants (not to leave baby alone at any time).

-Availability of tightened security in maternity wards and pediatric units.

-Nurseries and maternity wards are located away from lobbies with street

access with doors always locked.

-Nursery doors should remain locked and never left unattended.

-Availability of a process to provide the parent's with educational material

and handouts explaining hospital policies in place to protect the safety of infants


-Availability of an Infant Protection Systems with baby identification bracelets and alarms


-Availability of Hospital I.D. Procedures & that all hospital personnel

Must wear photo identification badges with the hospital logo.

-Anyone transporting the infant outside of the mother's room must wear

an identification wristband.

-Staff should identify themselves to the mother, instruct the mother of

procedures their infant will be taken for, and expect the mother to question anyone not properly identified.

-All visitors must immediately sign-in at the nurses' station upon arrival.

-Distinctive stickers with the date of the visit should be obtained at the

check-in area and given to visitors to wear while in the hospital.

-Availability of hospital policy on demanding positive I.D. before allowing persons in infant/mother room


-Mothers should be asked to designate a limited number of visitors who

can come to the nursery.

-Only allow visitors up to five minutes of observation time per visit to the neonatal nursery


*Availability of recent Code Pink drill documentation.

*Staff are aware of the policy.

*Staff should know to check the same bands for corresponding numbers

before the infant is released from the hospital.PP
medical2000, مرحبا هيل, asg777 و 1 آخرون معجبون بهذا.
من مواضيع : الكفاح
التعديل الأخير تم بواسطة الكفاح ; 08-27-2012 الساعة 01:39 PM.
الكفاح غير متواجد حالياً   رد مع اقتباس
  رقم المشاركة : [ 7 ]
قديم 08-29-2012, 03:27 PM
صحي نشط
 

medical2000 will become famous soon enough
افتراضي رد: برنامج إدارة المخاطر وسلامة المرضى

معلومات قيمه جدا
ياليت تحط بموضوع منفصل ويكون اسمها
Details of the Priority Focus Areas in Risk Management


لاجديد ,,,,, ابداع متوقع كالعاده
الف شكر على جهودك المتميزه
الكفاح معجبون بهذا.
من مواضيع : medical2000
medical2000 غير متواجد حالياً   رد مع اقتباس
  رقم المشاركة : [ 8 ]
قديم 09-01-2012, 08:28 AM
افتراضي رد: برنامج إدارة المخاطر وسلامة المرضى

اشكر لك مرورك

سوف يتم عمل Details of the Priority Focus Areas in Risk Management

في موضوع مستقل

نتمنى الفائدة للجميع
من مواضيع : الكفاح
الكفاح غير متواجد حالياً   رد مع اقتباس
  رقم المشاركة : [ 9 ]
قديم 01-01-2013, 02:50 PM
صحي نشط
 

هدوء2000 will become famous soon enough
افتراضي رد: برنامج إدارة المخاطر وسلامة المرضى

شكرا لكم وبارك الله فيكم
من مواضيع : هدوء2000
هدوء2000 غير متواجد حالياً   رد مع اقتباس
  رقم المشاركة : [ 10 ]
قديم 01-27-2013, 11:56 PM
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نسائم will become famous soon enoughنسائم will become famous soon enough
افتراضي رد: برنامج إدارة المخاطر وسلامة المرضى



وعليكم السلام ورحمة الله وبركاته

يعطيك العافية على الجهد الطيب
بارك الله في وألف شكر

من مواضيع : نسائم
نسائم غير متواجد حالياً   رد مع اقتباس
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