Hindra Irawan Satari

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A Culture of Patient Safety (1)
A culture of patient safety involves

HIS - PATIENT SAFETY

 A Culture of Patient Safety (2)

A Culture of Safety Affects Infection Outcomes

Individual
Individual and
and Infection
Infection
Culture
Culture Of
Of Patient
Patient Organisational
Organisational Prevention
Collective
Collective Prevention
Safety
Safety Performance
Performance Outcomes
Behaviour
Behaviour Outcomes

HIS - PATIENT SAFETY

Leadership
These characteristics included leaders who:

Jens Martensson
HIS - PATIENT SAFETY Perkumpulan Pengendali Infeksi Indonesia
 Jens Martensson
HIS - PATIENT SAFETY Perkumpulan Pengendali Infeksi Indonesia
 Teamwork and collaboration
combine the talents and skills
of each member of a team
and serve as a check and
balance method for care that
is integral to patient safety
and infection risk reduction

HIS - PATIENT SAFETY

 Jens Martensson
HIS - PATIENT SAFETY Perkumpulan Pengendali Infeksi Indonesia
Communication Strategies for IPC professionals :
Make
Make routine
routine rounds
rounds and
and discuss
discuss
patients
patients with
with infections
infections or
or those
those at
at Share
Share surveillance
surveillance Develop
Develop aa secure
secure system
system
risk
risk of
of infection
infection with
with the
the direct
direct data
data and
and new
new for
for staff
staff to
to report
report

Jens Martensson
care
care providers
providers and
and listen
listen to
to staff
staff information
information infection
infection risks
risks
concerns
concerns

Encourage
Encourage open
open discussion
discussion Use
Use checklists
checklists and
and other
other
about
about infection
infection risks
risks with
with documents
documents to to help
help
leaders
leaders and
and ask
ask them
them to
to convey
convey communicate
communicate (Also
(Also see
see human
human
the
the infor-mation
infor-mation toto the
the factors
factors section).
section).
organisation
organisation

HIS - PATIENT SAFETY Perkumpulan Pengendali Infeksi Indonesia

Evidence-Based Practice Strategies for IPC professionals

Jens Martensson
HIS - PATIENT SAFETY Perkumpulan Pengendali Infeksi Indonesia
Organisational Learning Strategies for IPC professionals

Jens Martensson
HIS - PATIENT SAFETY Perkumpulan Pengendali Infeksi Indonesia
Measurement Strategies for IPC Professionals

Jens Martensson
HIS - PATIENT SAFETY Perkumpulan Pengendali Infeksi Indonesia
Systems Thinking Strategies for IPC professionals

Jens Martensson
HIS - PATIENT SAFETY
Perkumpulan Pengendali Infeksi Indonesia
 Consider
Consider change
change efforts
efforts as
as itit
relates
relates to
to organisational
organisational culture
culture
and
and human
human behaviour
behaviour models
models

Human Behaviour Engage

Engage staff
staff in
in change
change efforts
efforts to
to
Strategies for IPC better
better understand
understand their
their values
values
Professionals and
and motivations
motivations

Use
Use behaviour
behaviour models
models when
when
possible
possible to
to implement
implement change
change
and
and improvement
improvement strategies
strategies that
that
will
will reduce
reduce infection
infection risk.
risk.
HIS - PATIENT SAFETY
HIS - PATIENT SAFETY
 Anticipate
Anticipate potential
potential process
process
failures
failures in
in IPC
IPC strategies
strategies and
and

IFIC Basic
incorporate
incorporate methods
methods to
to prevent
prevent
them
them

Concepts of Ensure
Ensure that
that individuals
individuals performing
performing the the

Infection
work
work are
are competent,
competent, there
there is
is clarity
clarity about
about
the
the task
task being
being performed,
performed, that
that the
the tools
tools
and
and technologies
technologies involved
involved work
work properly,
properly,

Control, 3 rd and
and the
the environment
process.
process.
environment sup-ports
sup-ports thethe care
care

edition, Think
Think about
about human
human factors
factors

2016 changes
changes as
that
that an
as aa systemic
systemic rather
an individual
rather
individual change.
change.

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HIS - PATIENT SAFETY
 Jens Martensson
HIS - PATIENT SAFETY Perkumpulan Pengendali Infeksi Indonesia
 Table 1.2. Human Factors Engineering: Challenges for IPC*
Challenging Effect
Principle
• No observable outcome of action from a less
than desirable IPC action.
Delayed Feedback • May be observed later by persons who were
not involved.
• Cause and effect are unclear.
• Tangible positive result is not generally
apparent to the staff who performed IPC
procedure correctly because of time
differences.
• May reduce motivation to perform
Lack of Connection with correctly again
a Positive Outcome for • Intensifies the disconnection between
Pre- venting Infection the staff action and the patient outcome
• Surveillance data not available “in-time”, so
not as effective for behaviour change.
• Positive deviance not always considered. *
• Training does not always provide immediate
feedback of positive performance.
• IPC tasks that are not supported with human
factors engineering, such as placement of
Complexity and supplies, time to complete the task, or number of
Inefficiency steps in a procedure, may delay the process or
cause staff to forget it or eliminate it from their
practice.
HIS - PATIENT SAFETY
Potential Solutions
Improve feedback using products that provide information,
e.g.,
•product that glows when hand hygiene inadequate,
•environmental markers for cleaning,
•volume and use of alcohol-based hand rub for hand hygiene,
•electronic badges to monitor hand hygiene.
• Supplement standard surveillance procedures with data
reported monthly, bi-annually or yearly to immediate
real-time analysis of each infection identified. This helps
staff remember circumstances, can involve more people,
Jens Martensson
provides more immediate feedback for action.
• Consider positive deviance observe successful providers
and spread their techniques and methods to other
providers. Focus on successful providers, e.g., those who
reduce Clostridium difficile with presumptive isolation,
or redesign the workspace and supplies to enable more
prompt isolation.
• Simulation training that provides immediate feedback,
e.g., how to properly insert a urinary catheter or central
line.
• Reduce complexity and inefficiency with product redesign
and human factors considerations.
• Examples: infusion pumps that do not allow incorrect
settings; antimicrobial stewardship programs requiring
approval before administering certain drugs; time-limited
orders to remind the provider to take action, e.g., remove
urinary catheter; intravenous connectors that do not allow
incorrect connections.
Perkumpulan Pengendali Infeksi Indonesia
 Table 1.2. Human Factors Engineering: Challenges for IPC*
Challenging Effect
Principle
• When time pressure is in place, other tasks than infection
prevention may take priority, provide immediate feedback, and
Time Pressure and are more connected with positive results..
Workload • Cognitive challenge to maintain IPC practice as relevant when
no perception of how it is affecting the patient, e.g.,
microorganism entry into a wound.
• Few embedded cues for IPC to indicate to staff when to stop or
Potential Solutions
Use task observation and analysis to identify process flow and
gaps. Examples:
•Observe healthcare workers gather supplies for central catheter
placement; may demonstrate many steps; bundling helps reduce
inefficiency.
•Reducing interruptions during central line placement by posting
large sign saying Do Not Disturb.
•Observing whether more staff or equipment is needed.
•Identifying deficiencies in the layout of the room that may
predispose to cross-contamination.

Jens Martensson
Few Infection change procedure, e.g., if central line is placed in wrong
• Use of badges or flashing lights to provide a clue to behaviour
Prevention and location or if antiseptic is applied using incorrect technique or
such as hand hygiene.
Control Cues to not allowed to dry.
• Pictures, stickers, colour coding are all examples.
Guide Staff • Clues should not disrupt the workflow and lead staff to avoid a
task.
• Placement of resources used by caregivers to reduce infection
• Include and use ergonomic design principles when designing
Inconsistent risk may be inappropriate, e.g., hand hygiene dispensers
workplace layout, e.g., the placement of alcohol-based hand rub
Ergonomic De- sign inaccessible or ab- sence or lack of hand washing supplies,
dispensers in visible and accessible locations
for the Work gowns, or gloves.
• Provide signage to indicate location of supplies and store them
Environ- ment • Poor visibility, difficulty of access, wrong heights, and
at reasonable heights in easily accessible locations.
separation of tools used in se- quence are issues.
• Look at broader systems issues when analysing challenges
that may allow gaps or breaches of care to occur, e.g., badly • Use effective problem solving techniques that address system
Need Additional
designed patient care space, mixing clean and dirty, poor issues, e.g., root cause analysis to include the team involved,
Problem Solving
environmental cleaning, lack of appropriate timing of observations of the workflow and the environment, policies and
Tools for IPC
preoperative antimicrobial prophylaxis, or understaffing of procedures, training, etc.
caregivers.
*Adapted from: Anderson J, Gosbee LL, Bessesen M, Williams L. Using human factors engineering to improve the effectiveness of infection prevention and con- trol.
Crit Care Med 2010;
HIS -38 (8) Suppl:
PATIENT s269-281.
SAFETY Perkumpulan Pengendali Infeksi Indonesia
 Mai ntaining a “zero
ain
tolerance” apapproach
saffeettyy is
to patient sa
crucial for safer care.

To minimise infections
(or errors), leaders must
not tolerate non-
adherence to proven
prevention measures.

HIS - PATIENT SAFETY

 Jens Martensson
HIS - PATIENT SAFETY Perkumpulan Pengendali Infeksi Indonesia
High Reliability Strategies for IPC professionals

HIS - PATIENT SAFETY

What does New technology will emerge to help
prevent infections, as will highly

the future pathogenic micro-organisms, such as

Severe Acute Respiratory Syndrome,
Ebola and MERs CoV and the Influenza

hold for viruses. These pathogens require prompt

attention and a robust, evidence-based
response. Medications and therapies will

patient
become more sophisticated, and the body
of science for IPC will continue to grow
and help guide practitioners in their work.

safety and
Consistent use of basic infection
prevention principles and incorporation of
new evidence-based care into the culture
of patient safety will help to achieve better
IPC? quality of care for patients and reduce
infection risks.

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HIS - PATIENT SAFETY
 Jens Martensson
Giving
Giving medications
medications
Giving
Giving blood
blood and
and blood
blood
products
products
Taking
Taking blood
blood samples
samples

Taking
Taking other
other samples
samples for
for
clinical
clinical testing
testing
Providing
Providing treatment
treatment or
or
procedure
procedure

HIS - PATIENT SAFETY Perkumpulan Pengendali Infeksi Indonesia

HIS - PATIENT SAFETY
 Jens Martensson
HIS - PATIENT SAFETY Perkumpulan Pengendali Infeksi Indonesia
 Collaboratively
Collaboratively develop
develop aa Uses
Uses an
an instantly
instantly recognized
recognized
policy/procedure
policy/procedure that
that mark
mark for
for surgical-site
surgical-site
includes
includes :: identification
identification
Definition of surgery that incorporates at involves the patient in the marking process
least those procedures that investigate
and/or treat diseases and disorders of the
human body through cutting removing,
altering, or insertion of Polices/procedures
Polices/procedures are
are
diagnostic/therapeutic scopes developed
developed support
support uniform
uniform
process
process to
to ensure
ensure correct
correct site,
site,
procedure,
procedure, ad
ad patient
patient
Involves
Involves the
the full
full surgical
surgical
team
team and
and is
is documented
documented just
just including medical and dental procedures
before
before starting
starting aa surgical
surgical
procedure
procedure

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 Jens Martensson
HIS - PATIENT SAFETY Perkumpulan Pengendali Infeksi Indonesia
 Implements
Implements aa process
process for
for the
the
initial
initial assessment
assessment of
of patients
patients for
for
fall
fall risk
risk and
and reassessment
reassessment of of Measures
Measures are
are implemented
implemented to to
patients
patients when
when indicated
indicated by
by aa reduce
reduce fall
fall risk
risk for
for those
those
change
change inin condition
condition or
or assessed
assessed to
to be
be at
at risk.
risk.
medications,
medications, among
among others.
others.

Measured
Measured areare monitored
monitored for
for Policy/procedures
Policy/procedures forfor result,
result, both
both
results,
results, both
both successful
successful successful
successful of
of risk
risk of
of patient
patient harm
harm
fall
fall injury
injury reduction
reduction and
and any
any resulting
resulting from
from fall
fall in
in the
the
unintended
unintended related
related consequences.
consequences. organization
organization

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CONCLUSION
• Goal 1: Identify patients correctly.
• Goal 2: Improve effective communication.
• Goal 3: Improve the safety of high-alert medications.

Jens Martensson
• Goal 4: Ensure safe surgery.
• Goal 5: Reduce the risk of health care-associated infections.
• Goal 6: Reduce the risk of patient harm resulting from falls.

HIS - PATIENT SAFETY Perkumpulan Pengendali Infeksi Indonesia

References
• Chapter 1: Patient Safety. Soule, Barbara M. International Federation of
Infection Control.
• https://www.jointcommissioninternational.org/improve/international-patient-saf
ety-goals/

Jens Martensson
HIS - PATIENT SAFETY Perkumpulan Pengendali Infeksi Indonesia
THAN
K YOU
HINDRA IRAWAN SATARI
hsatari@ikafkui.net

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