Chapter 1: Patient Safety in JurongHealth
JurongHealth & Patient Safety
Patient Safety:defined as the freedom from accidental or preventable injuries produced by medical care. (AHRQ, Patient Safety Net)
JurongHealth ensures the safety of patients in accordance with the 6 dimensions of quality of care, defined by the Institute of Medicine as :
1. Providing safe care through learning from Incident Reporting 2. Ensuring efficient care structured process of Specialist Outpatient Clinic visits 3. Ensuring timeliness through quality improvement projects 4. Ensuring Patient Centeredness through Patient Safety & Quality Assurance Committees 5. Providing effective care through policies and procedures 6. Providing equitable care
(IHI, Crossing the Quality Chasm: A New Health System for the 21st Century, 2001)
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Providing safe care through learning from Incident Reporting Providing safe care for patients means to avoid harming patients from the care that is intended to help them. Learning from actual and near miss Patient Safety incidents allows improvement in system processes, which benefit patients. JurongHealth identifies Patient Safety incidents through the electronic Incident Reporting Information System (IRIS). The management encourages all staff to voluntarily report incidents. This is through the assurance that we recognise that errors are mostly due to system failure designs, and that errors are rarely only the individual’s faults. This approach is known as the nonpunitive approach. By conducting review and analysis of these incidents, we can identify thematic issues through Root Cause Analysis. Appropriate corrective measures can then be implemented to prevent recurrences. As such, we are able to rectify issues immediately and also ensure safer care for future patients.
Examples of Patient Safety incidents include medication errors, patient falls, peripheral venous complications; pressure ulcers; treatment related incidents such as skin tear during patient transfer; issues when diagnosing patients; sharps injuries and body fluid splash incidents, laboratory related incidents and conditions that are unsafe. Since the launch of IRIS in February 2013, reporting has increased from an average of 40 per month in 2012, to almost 70 reports per month in 2014. A total of 193 improvements were also carried out from January 2013 to June 2014! In summary, ensuring safe care is an essential first step to improve quality of care.
Staff can access IRIS to Report a Patient Safety incident by visiting JurongHealth intranet, under Quick Links, click on Incident Reporting Information System (IRIS) - Report an Incident.
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"When staff are willing to own up to their mistakes, they should not be punished, but commended instead! This, however, does not mean that we condone wilful disregard of established processes and policies that serve the purpose of protecting patients. Reporting incidents help our hospital to improve processes and allows us to obtain feedback on our own performance so that we can act fast (Do we really want them to act fast? We want them to be safe right?). It helps us identify risks so that learning can be carried out to prevent future occurrence" - Mr Foo Hee Jug JurongHealth CEO
“The main reason for reporting incidents is to improve patient safety by learning from incidents and near misses. It stems from the understanding that the report will be analysed in a systematic nonpunitive manner leading to enhanced learning regarding the root cause of the incident and systemic changes which will prevent it from recurring. The goal of feedback must be to learn from mistakes, and to ensure that the systems are improved for better patient safety in the future. The feedback should be through multi- sources from the frontend clinical staff right to the high-level managerial staff. It is extremely important that all staff can see something positive coming out of the incident reporting to encourage continued active participation in the process.� - Dr Chua Ai Ping Senior Consultant, Medicine
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Ensuring efficient care structured process of Specialist Outpatient Clinic visits In order to be efficient when providing medical care for patients, the use of resources in the hospital has to benefit the patients a system is intended to help. In JurongHealth, the structure of a Specialist Outpatient Clinic visit is designed in such a way that optimises doctor/patient interaction. Before an outpatient visits a doctor, he or she is first engaged by the patient service associate to have height and weight taken. The patient will then be brought to a room to have parameters and vital signs taken by a nurse. At this point, other basic questions to establish the patient’s history will be asked. By the time the patient is brought into the consultation room to see the doctor, all of the results taken previously would have been entered into the Electronic Medical Record, easily accessible for the doctor. A systematic structure like such allows for the patient to have an efficient encounter with the doctor.
Ensuring timeliness through quality improvement projects Timeliness is an important characteristic in health care. Improving response to patients’ medical needs warrants attention and focus. However, long waits are the norm in hospitals. In addition to emotional distress that patients could suffer, physical harm could result. A classic example is when a patient suffers from preventable complications from a delay in diagnosis or treatment. (IHI, Crossing the Quality Chasm: A New Health System for the 21st Century, 2001) JurongHealth implemented to ensure timely care is provided for patients is the standardisation of critical results routing rules. JurongHealth uses the Health care Messaging System (HMS) to alert clinicians on critical results that require immediate attention. If the doctor does not respond within a specific period of time, HMS will escalate the notification to another clinician based on the routing rules provided by the specialty/department.
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Previously, the doctor alerted was identified based on the patient’s last location. HMS followed the routing rules created and managed by each department responsible for that location. A significant number of incidents regarding the delay in communicating critical results were reported in 2014. A team was tasked to review these incidents, and it was revealed that the issue was with following the rules based on patient’s last location. An inpatient may be transferred to another department/specialty and location. The doctor activated by this routing rule would not be the ordering doctor. As a result, the ordering doctor would have t be traced to act on the critical results. In 2014, The Patient Safety Committee saw the need to standardise the critical results routing rules and process. The Patient Safety Officer worked with various clinicians and departments to improve the critical results routing rules and process
Now, a single routing rule with 3 tiers of escalation applies within the organisation: 3 tiers of Escalation 1st Tier: Ordering Doctor 2nd Tier: Consultant-In-Charge of the patient 3rd Tier: Call Center
With the standardisation of the routing rules, the ordering doctor and consultantin-charge would always be informed of their patients’ critical results. They would be able to make informed decisions about treating the patient based on their existing knowledge of the patient currently in their care. This improvement also effectively eliminates the delay in communicating critical results to appropriate doctors!
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Ensuring Patient Centeredness through Patient Safety and Quality Assurance Committees
The Patient Safety Committee and various sub-committees were set up to ensure that care provided by JurongHealth is respectful of and responsive to individual patient needs. These committees, as well as other Quality Assurance Committees in JurongHealth,
Some Patient Safety committees and sub-committees in JurongHealth include:
- Have purview of clinical care processes that fall across departments or facilities of JurongHealth. - Own the care processes for the areas within their purview and have the responsibilities to ensure compliance of the processes and policies in relation to their domain. - Are also responsible for stipulated key performance indicators and will update the Medical Board regularly in this respect.
For the full lists of various committees, please visit JurongHealth intranet. To ensure that Senior Management stays connected to staff on the ground, walk rounds are conducted on a regular basis. Walk rounds are visits to various parts of the hospital grounds by the management with the intention to understand issues that staff are facing. Through this platform, Senior Management can interact with the ground staff, gather feedback and show their support for Patient Safety.
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Providing effective care through policies and procedures Providing effective care means to provide services (based on evidence based knowledge) to all who could benefit, and to refrain from providing services to those unlikely to benefit. In JurongHealth, process owners who are experts in various specialised fields conduct research based on the best available scientific evidence of date and make references to other local hospitals and the Ministry of Health. Thereafter, they work with the respective workgroups and committees to develop internal policies, procedures and clinical practice guidelines for our doctors, nurses and allied health staff. Staff can make reference to these policies when delivering care for patients. We ensure that new staff are aware of these policies, procedures and guidelines through organisational and departmental orientation courses.
Providing equitable care Health care should be accessible to all, regardless of gender, language, race and religion, or income. With regard to equality in health care, all individuals should be treated fairly, based on their unique clinical needs and not personal characteristics unrelated to their health conditions. JurongHealth provides accessible care to all individuals who seek medical attention from us. All in all, JurongHealth brings these dimensions of quality together by measuring and monitoring Clinical Quality Indicators (CQIs). Measuring and monitoring indicators provides an objective demonstration of the quality of care received by the patients. CQIs are currently measured and monitored by clinical departments and Quality Assurance Committees (QACs).
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There are 4 domains of care being monitored in the Clinical Quality Dashboard:
On a monthly basis, data generated for each indicator will be uploaded into the dashboard. Subject matter experts will then conduct an analysis based on the data given and provide their comments. The information will also be presented to the management for an overview of how JurongHealth is performing. Where necessary, intervention can be made.
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Let us now follow through the journeys of patients Maria and Joseph in JurongHealth. Hello, my name is Maria. I am 59 years old this year. I will be the first inpatient whom you will follow!
Hello, my name is Joseph. I am 70 years old this year. Follow me on my inpatient journey at JurongHealth!
Along the way, important issues related to Patient Safety will be highlighted by our Patient Safety ambassadors, Elfie and Kelfie.
Hello, we are Elfie and Kelfie, JurongHealth's Patient Safety ambassadors. We will be your Patient safety guides today!
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Chapter 2: Maria's Inpatient Journey
Maria's Profile Name: Sex: Age: Medical History: Drug Allergy: Height: Weight:
Maria Wong Female 59 Frequent Urinary Tract Infection, Hypertension Aspirin 158cm 65kg
Summary of Stay in Hospital
Maria presented at the Emergency Department for complaint of severe pain at the right abdominal area and urine in blood for 3 days. She was admitted at the hospital for suspicion of kidney stone in the ureter. Patient has known drug allergy to Aspirin. A series of tests diagnosed Maria with Urinary Tract Infection and a large kidney stone at the right ureter. Maria’s UTI and fever were resolved in two days. Maria then had a Ureteroscopy done. Two days post-operation, incidental findings of positive faecal occult blood required her to undergo a colonoscopy under sedation. Patient was discharged well 5 days later.
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a. Emergency Department
One morning, a 59 year old female named Maria, presents at Emergency Department via walk-in. Maria is accompanied by her husband, Frederick.
During triage, she complains of severe abdominal pain, fever and pain when urinating since two evenings ago. Dr. Philip, the doctor on duty that morning, examines Maria. He asks for her medical history and discovers that Maria had an episode of possible drug allergy to Aspirin, a Non-Steroidal Anti-Inflammatory Drug in The Philippines. This happened 2 years ago.
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After examining Maria, Dr. Phillip decides that Maria would require urine and blood investigations. Dr. Philip applies a tourniquet on Maria’s left arm for blood taking. However, due to difficulty in accessing the vein, Dr. Andie takes over. Dr. Andie successfully draws blood from Maria on her second try.
Dr. Philip checks Maria’s left arm and removes the tourniquet. After further investigations, Maria is diagnosed with Urinary Tract Infection and suspicion of kidney stone in ureter. Dr. Philip decides to admit Maria.
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b. Admission
Intensive Care Unit
3 hours later, Maria is admitted into the hospital, under Urology. At this point, doctors, nurses and pharmacists should perform Medication Reconciliation upon Maria’s admission.
Medication Reconciliation ensures medication safety upon admission, transfer and discharge through avoiding drug related problems such as drug use without indication, drug omissions and duplication of therapy amongst others.
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The Five Rights of Medication Administration include... At 7am during the Medication Rounds, Staff Nurse Claire checks the Electronic Medical Record. Maria requires some medications to be administered. Claire is a conscientious nurse who always observes the Five Rights of Drug Administration.
1. Identifying the Right Patient By checking Name and NRIC and scanning patient’s wristband 2. Confirm the Right Medication By counterchecking the prescription listed in Medication Administration Record and what is prepared 3. Confirm the Right Route By checking on the Medication Administration Record on how the medication is to be administered 4. Confirm Right Dose By comparing the dose that has been ordered against the dose prepared 5. At the Right Time
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Claire understands the importance of not being interrupted during medication preparation and administration. She therefore wears the “Do not Disturb� Medication Safety vest as a signal to others.
Claire finishes preparing the medication for Maria. She places all the parental and nonparental drugs into a tray and wheels the computer towards Maria. Claire enters Maria’s environment and performs hand hygiene.
Why is Hand Hygiene Important? The most common mode of transmission of germs is via our hands!
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The consultant in charge of Maria, Dr. Rexford, reviews Maria during the morning rounds. Maria complains of sharp pain originating from her lower abdominal area. Dr. Rexford orders for an urgent diagnostic test for kidney stone in the uterer. A porter and nurse Claire wheel Maria to the MRI room for Magnetic Resonance Imaging (MRI) Scan. They stop outside the MRI room. A radiographer, Kelvin, ensures that Maria does not possess any metallic item. Kelvin checks and confirms that all monitoring devices are MRI Compatible. Maria is being pushed into MRI room for her diagnostic procedure. Before performing the radiological test, he remembers to perform Two Patient Identifier. After ensuring the right patient for the procedure, He then proceeds to scan Maria’s barcode on her wrist tag into the EMR.
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Kelvin proceeds to perform MRI scan for Maria. After the scan is completed, the porter pushes Maria back to her ward, accompanied by Claire. Maria’s team of doctors comes to the ward and examines Maria. Her fever and Urinary Tract Infection are resolved and she is scheduled for Ureteroscopy at 9am the next day.
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c. Surgery
The next day, nurses Claire and Joanna in the ward prepare her for surgery. All necessary pre-operative investigations ordered by doctors and anaesthetists are in order. They then conduct a pre-operation Verification with Maria. Claire and the porter wheel Maria to the Operating Theater reception and hand over Maria at the reception area. Once again, the OT nurses, Phoebe and Farhana conduct a second round of pre-operation verification.
The surgeon arrives and proceeds with site marking with reference to Maria’s kidney stone at her right ureter. Phoebe and Farhana wheel Maria to the Operating Room. At this point, Maria is still conscious. Sign in is being done with the surgeon, anaesthetist and an OT nurse. The anasethetist puts Maria to sleep. Just before incision, the circulating nurse conducts Time Out. During the surgery, the surgeon successfully removes the kidney stone one Maria’s right ureter. Just before dressing and sending Maria out, the operating team once again conducts Sign Out. Maria is being wheeled to the Intensive Care Unit for close monitoring.
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d. Intensive Care Unit
In the ICU, Maria is restless due to the discomfort at her wound area. Dr Kenneth prescribes an infusion, to dilute 200mcg of Precedex in normal saline. ICU Nurse Rachel proceeds to prepare the infusion. Rachel remembers during her training to always read the entire label when preparing IV medication. She therefore checks both the concentration and volume and notes that one vial of one vial of Precedex contains 200mcg in 2ml. Rachel conscientiously picks 1 vial and hands over the drugs for ICU Nurse Christine to countercheck.
ICU Nurse Christine counterchecks the Precedex infusion. ICU Nurse Rachel administers Precedex to Maria. Maria’s restlessness resolves within 30 minutes. Shortly after, she is deemed stable enough to be transferred to the general ward.
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e. General Ward
At the general ward, Maria’s phosphate level drops to 0.72 mmol/L. This is below the normal reference range. Doctor Wendy orders 10mmol of Phosphate Dihydrogen Phosphate Infusion to be administered for 4 hours. Upon checking of Medication Administration Record, Staff Nurse Rohaya misreads the order as 10mmol of Potassium Chloride. Rohaya takes the premix 10mmol of Potassium Chloride to administer to patient.
Maria is dispensed the right medication. Maria is being pushed to the Endoscopy Suite for colonoscopy by the porter, accompanied by Staff Nurse Rohaya.
Before administration, Rohaya asks Staff Nurse Farhana to counter check and co-sign. Thankfully, Farhana notes the discrepancy in order and what has been prepared.
In the suite, the endoscopist is about to sedate Maria. The endoscopist conducts a pre-sedation assessment to ensure that Maria is optimised for Colonoscopy.
Maria is dispensed the right medication.
Throughout the entire procedure and post-procedural care, the endoscopist and nurses monitor Maria vigilantly.
Two days post-operation, incidental findings of positive faecal occult blood require Maria to undergo a colonoscopy under sedation.
After the colonoscopy, Maria is being wheeled back into the ward.
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Refer to JHS-CLN-MAF-PD-047 Guideline on Adult Procedural Sedation for more information!
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f. Discharge
After 3 days in the general ward, Maria is now being prepared for discharge. Doctor Christine ensures that all outstanding diagnostic and laboratory results have been reviewed. She then proceeds to prescribe Maria her chronic medications. Pharmacist Leon verifies the discharge prescription in EMR and processes the medication for dispensing. While completing the discharge summary, Dr Christine notes that she missed out prescribing Atorvastatin for Maria. She quickly calls Pharmacist Leon to highlight the amendment and order for the additional medication missed out. Maria is being discharged well from the hospital!
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