STEEEP

1.SAFETY
2.TIMELINESS
HEALTHCARE 3.EQUITY
QUALITY
DOMAINS 4. EFEECTIVENESS

5.EFFICIENCY
6.PATIENT
CENTERED
WHAT IS PATIENT SAFETY….
 the absence of preventable harm to a patient and reduction
of risk of unnecessary harm associated with health care to an
acceptable minimum.(WHO SEP.2023)
 DO NO HARM…… how!!!

PREVENTION

REDUCTION

REPORTING

ANALYSIS OF THE ERROR

PREVENTION AND
REDUCTION
1-Standardized system and practice provision
- policies and procedures compliance
-Monitoring and continuous improvement
2-Enhance effective communication through effective medical record
use.
3- Patient Engagement
4- improve Awareness of the healthcare staff
5-improve and evaluate competency of the healthcare staff
STANDARDIZED
HEALTHCARE PRACTICE
POLICY PROCEDURE

 A statement of rules and A specific way of performing

principles to guide decisions a task, usually including step-
and actions for the by-step instructions to
organization (JCI, 7th Ed.) comply with a policy
 (JCI, 7th Ed.)

 “What” is required
 “Why “ is required “How” to implement a policy
“When”
“Who”
MEDICAL RECORD

Medical records

are the document that explains all detail about the patient’s
history, clinical findings, diagnostic test results, pre and postoperative
care, patient’s progress and medication.

A good medical record serves the interest of the medical

practitioner as well as his patients.

 It is very important for the treating doctor to properly

document the management of the patient under his care.
MEDICAL RECORD
DOCUMENTATION
COMPLETENESS

EFFECTIVE
DEALING WITH
LEGIBILITY
MEDICAL
RECORD

INTEGRATION
REPORTING AND ANALYSIS
 Through establishing strong safety culture in the organization
 Strong reliable reporting system
 Applying the JUST-CULTURE work environment (balancing
accountability and no blame culture)
 Analysis to detect the areas for improvement in the organization
practice
 Act to prevent recurrence of incidents which may affect the safety

Our approach in reporting the occurrence or the incident rely upon using
OVR FORMS
 OVR
(OCCURANCR VARIANCE
REPORT)
 internal forms used to

document

 1-the details of the incident

 2- the investigation of an

occurrence

 3-the corrective actions taken.

‫نموذج الحدث غير المتوقع‪OVR FORM‬‬
GAHAR
STANDARDS
WHAT IS GAHAR?
WHAT IS REPORTING?
 GAHAR is the

The General Authority for Healthcare Accreditation &

Regulation
Accreditation is a process of review, that allows healthcare organizations
to demonstrate their ability to meet regulatory requirements and standards
established by a recognized accreditation organization such as GAHAR.

 STANDARD is the
a desired and achievable level of performance against which actual
performance is measured
 NATIONAL SAFETY
REQUIREMENTS

SURGERY,
MEDICATION ENVIROMENTAL
GENERAL ANEASTHESIA
MANAGEMENT AND FACILITY
PATIENT SAFETY SEDATION
SAFETY SAFETY
SAFETY
 General patient safety requirement
NSR 1 : Patient identification
‫التعريف الصحيح للمريض‬
NSR 2 : Verbal and telephone order
‫االوامر الشفهية والتليفونية‬
NSR 3 : Hand hygiene
‫غسل االيدي‬
NSR4 : Catheter and tube misconnection
‫التوصيل الخاطئ للقساطر واالنابيب‬
NSR 5 : Fall screening and prevention
‫تقييم احتمالية السقوط والوقاية منها‬
NSR 11 : Critical result‫النتائج الحرجة‬
NSR 6 : Pressure ulcer prevention
‫الوقاية من قرح الفراش‬
NSR 7 : Handover communication
‫التواصل الفعال عند التسليم والتسلم‬
NSR 8 : Critical alarms
‫االنذارات الحرجة‬
NSR 9 :recognition of and response of
clinical deterioration
‫اكتشاف عالمات التدهور االكلينيكي واألستجابه له‬
NSR 10 : VTE reduction
‫تقليل خطر الجلطات الوريديه العميقه‬
MEDICATION MANGEMENT
AND SAFETY
NS • ABBREVIATION • HIGH ALERT
R. NS MEDICATIONAND
12 CONCERATED
R. ELECTROLYTES
• MEDICATION 15
NS RECONCILIATION
R. NS • LOOK-ALIKE AND SOUND-
13 LIKE MEDICATION
R.
• MEDICATION STORAGE 16
NS AND LABELLING
R.
14
NSR.12
KEY WORD: ABBREVIATIONS
 Usually, the use of abbreviations is done to squeeze a lot of writing and
this may cause miscommunication between healthcare professionals and
potential errors in patient care.
 Policy and procedure is needed to adjust and control the use of
abbreviations

• No use of not –to-use abbreviation in medication sheet or un

approved abbreviations
NO • No use of abbreviations even the approved in any document
will be received by patient

YE • Full WORDS for not permitted abb.

• Call the physician and ask to redocument the
S order clearly
NSR.13
KEY WORD: MEDICATION RECONCILIATION
 Medication Reconciliation -- The process of identifying the most
accurate list of all medications that the patient is taking, including name,
dosage, frequency, and route, by comparing the medical record to an
external list of medications obtained from a patient, hospital, or other
provider.
 Compare then confirm

Admission • BPMH +MAOs

Transition • BPMH+MAR+NEW TRANSFER ORDER

Discharge
• BPMH +MAR(LAST 24Hr)+discharge
medication
 STEPS

Communicate the
reconciled
Develop a list of a Develop a list of Compare the Make clinical
medication list to
patient's current medications to be medications on the decisions based on
the patient and
medications. prescribed lists. the comparison.
appropriate
caregivers
NSR.14
MEDICATION STORAGE AND
LABELING
-Medication are stored under manufacture\marketing authorization holder
recommendations
-labeling and narcotics stored according to applicable laws
-Multi dose drugs approved process of storage requirements

Stability

labeling security
 NSR.15
HIGH ALERT MEDICATION & HIGH CONCENTRATED
ELECTROLYTE

DEFINITION:
drugs that have a heightened risk of causing significant patient harm when they are used in error.
High risk medicines include medicines: with a low therapeutic index. that present a high risk
when administered by the wrong route or when other system errors occur.

PREVENTIVE MEASURES
1- upon storing
2-at dispensing
3-on administration

Use red labelling color for labeling high risk medication

Use orange labelling color for high concentrated electrolyte
NSR.16
LOOK-ALIKE AND SOUND-ALIKE
MEDICATION
Definition
drugs with similar looking and similar sounding names
Due to this similarity, the risk of confusion is particularly high with
LASA drugs.
Error Preventive measures
1-segregation of the medications in different bins or locations.
2-distinguish medications by using “tall man lettering ”, i.e. upper case
letters.
3- sticker identification to identify LASA medications on your
organization's list.
Use GREEN labelling color
SURGICAL,
ANAETHESIA,SEDATION
SAFETY
• Black arrow to the site
SURGICAL SITE
MARKING

• Before patient call

PREOPERATIVE • 4 checklists
CHECKLIST • (medication,instrument,supllies , equipement)

TIME OUT

INSTRUMENT
PREVENTION
RETENTION
WHOME TO BE TARGETED
………
ENVIROMENTAL AND
FACILITY SAFETY
Fire safety

Utility safety Drill plan

Biomedical
Safety plan
equipement safety

Laboratory Hazardous
safety material safety

Radiation safety
Thank you
Quality team