Policies & National Initiative to Improve Patient Safety

By: Maria Linda G. Buhat, RN, Ed.D.

PHC-Assistant Director for Nursing Service (CNO)

“Technically the biggest safety systems in healthcare is the minds and hearts of the workers who keep intercepting the flaws in the system and prevent

patients from being hurt. They are the safety net, not the cause of injury.”

- Don Berwick

Regulatory Standards

Administrative Order No. 1012-0012

Rules and Regulations Governing the New Classification of Hospitals and Other Health

Facilities in the Philippines

Objective:

To protect and promote the health of the public by ensuring a minimum quality of service rendered by hospitals and other regulative health facilities and to assure the safety of patients and personnel.

Regulatory Standards

Republic Act 7875

Philippine Health Insurance Corporation

Republic Act 9241

Amendment to Philippine Health Law

Regulatory Standards

Administrative Order No. 2008-0009

Adopting the 2008 Revised List of Notifiable Diseases, Syndromes, Health-Related Events

and Conditions

Administrative Order No. 42

Creating an Inter-Agency Committee for the Formulation and Implementation of a National

Plan to Combat Antimicrobial Resistance in the Philippines

Regulatory Standards

DOH Administrative Order No. 2008

Declaring National Policy on Patient Safety

March 23, 2009

National Committee on Patient Safety to Oversee the Development of Implementing Guidelines

and Provide Technical Assistance for the Implementation of Patient Safety Program

National Patient Safety Committee

National Technical Working Group

ProfessionalOrganizations

Field ImplementationManagement Office

Centers for Health Development

Health Care Facilities

DOH Administrative Order No. 2008-0023

A key element in improving patient safety in any organization is fostering a

“CULTURE OF SAFETY”.

Initiatives

Standards on:

Use of Medical Devices

Safe Blood Use

Drugs/Pharmaceuticals

Infection Control Policies– Hand Hygiene– Use of PPE– Needle/Sharps Injuries– Mercurial Spill Clean Up

Initiatives

Standards on:

Use of Physical Restraints

Development of Clinical Practice Guidelines (CPGs Multidisciplinary)– Immediate Newborn Care/Essential Newborn Care

WHO Surgical Safety Checklist

Reporting of Sentinel Events

Use of Thermo-Regulatory Devices

Subnational Levels

Patient Safety

• Infection Control

• Medication Safety

• Sentinel Events

Subnational Levels Initiatives

Infection Control• Hand Hygiene

• Use of PPE

• Needle/Sharp Injuries

• Mercurial Spill Clean Up

• Antimicrobial Prophylaxis (preoperative use of antibiotics)

• Bundles of Care

Bundles of Care

• Ventilation-associated Pneumonia (VAP) Bundle

• Central Line Bundle

• Catheter associated Urinary Tract Infection (CAUTI) Bundle

• Surgical Site Infection (SSI) Bundle

• Pressure Sore Prevention Bundle

Medication Safety

• Reporting of Adverse Drug Reaction• Communication

–Read Back/Repeat Back–Hand off/Shift Report–SBAR

»Situation»Background»Assessment»Recommendation

Medication Safety

• Communication–Interdisciplinary Progress Notes–Prescription Writing

»No abbreviations–Medication Reconciliation–Medication Vest–10 Golden Rules on Drug Administration

Medication Safety

• Safety Measures in the Administration of High Alert Drugs

• High Alert and Narcotic Drugs Storage

• Handling and Administration of Chemotherapy Drugs

• Control of Concentrated Electrolytes

• Common Abbreviations

• Medication Incident Documentation and Reporting

“Nurses are indispensable to patients’ safety.”

External Accreditation Bodies

• PhilHealth (Bench book)

• ISO – DOH Hospitals

• JCI

• ACI

• Others

Human Factors

“Errors can happen anywhere and to anyone.”

Safety Framework

- MLGB

Environment Health Workers

Communication Systems/Processes

Patient Safety

Human Factors and Patient Safety

• A number of individual factors affect human performance, thereby predisposing a person to error.

Two factors with the greatest impact are fatigue and stress.

Nurses: Too Tired to be Safe?

Those who routinely work long, often unpredictable hours, such as shifts that exceed 12 hours, make more mistakes than those who work fewer hours.

Professional Certification/Licensing

Licensing of Health Professionals

• must pass the examination given by the Philippine Regulatory Commission prior to licensure to practice

• Renewal every three years with mandatory CME/CPE units

Certification of Competencies

DOH Order No. 2012-0181 (October 2012)

Guidelines on the Department of Health Nurse Certification Program

Certification of Competencies

DOH Order No. 2013-0100 (July 2013)

Operational Guidelines on the Implementation of DOH-NCP in Designated Hospitals

Objectives:

1. To standardize clinical competencies in various specialty areas

2. To address competency gaps

3. To improve the delivery of nursing care

Other Initiatives

Administrative Order No. 2012-0020 (October 2012) Guidelines Governing the Occupational Health and Safety of

Public Health Workers

Objectives:1. To promote occupational health safety in the health care

facilities 2. To protect public health workers from hazards and risks

associated in their work3. To prevent distress and injuries to public health workers4. To provide access to treatment, rehabilitation and

compensation of work connected illnesses and injuries affective public health workers, whenever applicable

WHO Patient Safety Curriculum

•implemented in government university (pilot)

“Most medical errors are system-related and not attributable to individual negligence

or misconduct.”

-Institute of Medicine Report (1999)

Professional Organizations

• Philippine College of Surgeons

• Infection Control Organization

• ANSAP

• Philippine Alliance for Patient Safety

• OHNAP

• Others

“Punitive Culture hinders reporting and recording of preventable errors.”

“One reason for the limited impact of many quality and safety initiatives is that they rely on only one level of intervention for example, staff

training or tightening protocols and gives insufficient attention to other factors that

influence clinical practice.”

- Charles Vincent