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Quality & Patient Safety 1999 Institute of Medicine Report
“To Err is Human”
To do no Harm? First public realization of the true extent of patient harm & safety in the healthcare setting
DEATHS Medical Errors Motor Vehicle Accidents Breast Cancer AIDS
98,000 43,000 42,000 16,000
Medication Errors Workplace injuries
7,000 6,000
3rd Leading Case of Death in America: GOING TO THE HOSPITAL
Source of Medical Harm Achieving Safe & Reliable Healthcare Leonard, M, et al: 2004
5%
Incompetent or poorly intended care
95%
Conscientious competent individuals trying hard to achieve a desired outcome
Source of Medical Harm Achieving Safe & Reliable Healthcare Leonard, M, et al: 2004
5%
Incompetent or poorly intended care
95%
Conscientious competent individuals trying hard to achieve a desired outcome
Definition of Patient Safety What exactly is Patient Safety?
Emanuel L et al. : Agency for Healthcare Research and Quality; 2008 Aug.
Discipline in the health care sector that applies safety science methods toward the goal of achieving a trustworthy system of health care delivery. Attribute of health care systems; it minimizes the incidence and impact of, and maximizes recovery from, adverse events.
The Science of Patient Safety to Curb Maternal Mortality Changing Women’s and Reproductive Health Care Needs in the Philippines
PATIENT SAFETY COMMITTEE , POGS
Ma. Virginia M. Santos-Abalos MD FPOGS FPSGE FPIDSOG Prof IV, Cebu Institute of Medicine
Declaration of Good Standing and Conflict of Interest Disclosure My presentation complies with FIGO’s policy for declaration of good standing and conflict of interest disclosure; I do not have a financial interest in any product or service related to my presentation; My participation at this Congress has been partially supported by the Philippine Obstetrical & Gynecological Society
To understand the urgent need of curbing maternal mortality in the Philippines. To appreciate the components of the patient safety loop as a program to curb maternal mortality in the Philippines. To learn and adopt patient safety best practices worldwide. To recognize that institutionalization is important for compliance, and assessment of impact is vital for continuous improvement.
Maternal Mortality in the Philippines: The Current Situation
>10 mothers die daily from maternity related causes
Almost 4,600 women die giving birth each year
MATERNAL MORTALITY UNFPA Phil., World Bank 2005
2015
The Philippines 5th Progress Report Millennium Development Goals: Executive Summary 2015
Implementing a Patient Safety Program for POGS to Curb Maternal Mortality: PATIENT SAFETY LOOP
Strategy of implementing Patient Safety Program for POGS Needs assessment
Inventory of interventions
Comparison of outcomes
Knowledge Transfer Framework Knowledge creation & distillation
Diffusion & dissemination
Adoption Implementation Institutionalization
PROCESS
ACTORS TARGET AUDIENCES ACTIVITIES
Nieva, Veronica F., et al. "From science to service: a framework for the transfer of patient safety research into practice." 2005
Identification of problem
Assessment of impact (dashboard/ statistics)
Adoption and institutionalization
The Safety Loop
Creation of knowledge on effective intervention
Diffusion and dissemination
Identification of problem
Assessment of impact (dashboard/ statistics)
Adoption and institutionalization
The Safety Loop
Creation of knowledge on effective intervention
Diffusion and dissemination
Evaluating needs of POGS High maternal mortality (failure to attain MDG)
To study strategies that result in measurable outcomes. Focus on POSTPARTUM HEMORRHAGE was chosen
…due to Measurable and consistently reportable outcomes Existence of simple clinical practice guidelines
Evaluating needs of POGS High maternal mortality (failure to attain MDG)
To study strategies that result in measurable outcomes. Focus on POSTPARTUM HEMORRHAGE was chosen
…due to Measurable and consistently reportable outcomes Existence of simple clinical practice guidelines
Postpartum hemorrhage is common, preventable, & manageable using simple interventions
11 Filipino women die Postpartum Hemorrhage every day from PPH (Tulali 2010)
298
0.2
17.3
Evaluating needs of POGS High maternal mortality (failure to attain MDG)
To study strategies that result in measurable outcomes. Focus on POSTPARTUM HEMORRHAGE was chosen
…due to Measurable and consistently reportable outcomes Existence of simple clinical practice guidelines
Problem: Postpartum Hemorrhage Assessment of impact
Compliance and institutionalization
The Safety Loop
Creation of Practice guideline knowledge formulationon effective dissemination intervention
Introduction of intervention Diffusion and packages (ALARM, dissemination PROMPT, TEAM STEPPS, EMOC)
Problem: Postpartum Hemorrhage
Assessment of impact
Compliance and institutionalization
The Safety Loop
Clinical Practice guidelines AMTSL
Introduction of intervention Diffusion and packages (ALARM, dissemination PROMPT, TEAM STEPPS, EMOC)
Clinical Practice Guidelines: Part of efforts to improve patient safety in OBGyn
Year 1
Survey on Awareness and Adherence to CPG
Awareness and Adherence to CPG No. of Residents No. of Respondents Response Rate
1018 785 77.11%
Total No. of Hospitals No. of Hospitals Who Responded Hospital Response Rate
89 72 80.90%
Awareness and Reading of Guidelines n= 785/ 1018 Awareness of guidelines Read guidelines
Respondents (%) 92 83
Aware of guidelines
Read guidelines
Potential Mortality & Morbidity Yes
Yes
No
No
No Answer
No Answer
POGS Patient Safety Committee, 2016
29
Consistent use of well-developed, evidence-based clinical practice guidelines results in universal application of best practices and can improve patient outcomes Ennen CS et al. Reducing adverse obstetrical outcomes through safety sciences . UptoDate 2018
Strategy of implementing Patient Safety Program for POGS
Needs assessment
Inventory of interventions
Comparison of outcomes
Problem: Postpartum Hemorrhage
Assessment of impact
Compliance and institutionalization
The Safety Loop
Practice guideline formulation dissemination
Introduction of intervention packages (ALARM, PROMPT, TEAM STEPPS, EMOC)
TEAMWORK and COMMUNICATION FAILURES contribute to 70% of sentinel events in obstetrics. Joint Commission on Accreditation of Healthcare Organizations. JCAHO sentinel event alert #30. 2004. American College of Obstetricians and Gynecologists Committee Committee on Patient Safety and Quality Improvement. ACOG Committee Opinion No. 447: Patient safety in obstetrics and gynecology. Obstet Gynecol 2009
Linking Patient Safety Education with traditional OB GYN SPECIALTY TRAINING Traditional curricula for Ob Gynecologists have focused on PURE CLINICAL SKILLS: diagnosis of illness, treatment of disease, after-care and follow-up TEAM WORKING, QUALITY IMPROVEMENT and RISK MANAGEMENT have been overlooked. These are the skills fundamental to patient safety.
TEAM STRATEGIES AND TOOLS to Enhance Performance and Patient Safety
Core Teamwork Skills
Communication Leadership Mutual Support Situation Monitoring
PATIENT CARE TEAM 36
Problem: Postpartum Hemorrhage
Assessment of impact
Compliance and institutionalization
The Safety Loop
Practice guideline formulation dissemination
Introduction of intervention packages (ALARM, PROMPT, TEAM STEPPS, EMOC)
Year 2 Focus Group Discussion on Adoption and Implementation of Interventions to Decrease Postpartum Hemorrhage
Year 2 Focus Group Discussion on Adoption and Implementation of Interventions to Decrease Postpartum Hemorrhage What interventions do you use in your institution for PPH and other obstetric emergencies? What are the sources of these interventions? Who/where/how were these interventions acquired?
Year 2 –Adoption & Implementation of Interventions to Decrease PPH Focus Group Discussion 1 Utilization of clinical practice guidelines + Audit of management of obstetric emergencies + Training for obstetric emergencies Specify: ALARM + PROMPT + PATIENT SAFETY + ALARM for REMARKS personal; PROMPTreal
2 +
3 + + +
4 +
+
+ +
Year 2 –Adoption and Implementation of Interventions to Decrease PPH Focus Group Discussion 1 Utilization of clinical practice guidelines + Audit of management of obstetric emergencies + Training for obstetric emergencies Specify: ALARM + PROMPT + PATIENT SAFETY + Alarm for REMARKS
personal; PROMPTreal
2 +
3 + + +
4 +
+
+ +
Year 2 –Adoption and Implementation of Interventions to Decrease PPH Focus Group Discussion 1 Utilization of clinical practice guidelines + Audit of management of obstetric emergencies + Training for obstetric emergencies Specify: ALARM + PROMPT + PATIENT SAFETY + Alarm for REMARKS
personal; PROMPTreal
2 +
3 + + +
4 +
+
+ +
What factors do you think can improve current interventions? Focus Group Discussion Physical plant and facilities __ patient monitor e.g. pulse ox __ laboratory with timely results __ blood bank __ embolization facilities __ surgical equipment __ others____ Training and educational resources Clinical and medical resources __ surgeon with advanced skills __ interventional radiologist __ others Referral systems
1
2
3
+ + +
+ Private hospitals less exposed
Red cross blood bank Drug availability
Make protocol
CPG
Virtual training
Referral for human resources
Practice drills
Referral CPG checklist
4
+ ALARM PROMPT + +
ALARM
What factors do you think can improve current interventions? Focus Group Discussion
1
Very effective
+
Somewhat effective
2
3
4
+
+
+
Not effective
Comment
Decrease mortality rate and blood utilization
CPG
Communicate
Based on mortality and morbidity
Problem: Postpartum Hemorrhage
Assessment of impact
Compliance and institutionalization
The Safety Loop
Practice guideline formulation dissemination
Introduction of intervention packages (ALARM, PROMPT, TEAM STEPPS, EMOC)
What parameters do you use to measure effectiveness? What indicators/factors do you use to evaluate/measure effectiveness? Focus Group Discussion
1
2
Auditable standards: Specify Only B Lynch + • Rate of PPH and TAH are B Lynch and • Rate of use blood transfusion done internal iliac • Rate of use prophylactic uterotonic administration • Rate of uteretonic administration for PPH • Rate of use maneuvers for PPH, bimanual compression, etc. • Rate of use surgical management of PPH Specify: B Lynch, uterine artery ligation, internal iliac ligation, hysterectomy, others •
Morbidity and mortality statistics for PPH
+
•
Use of checklist for obstetric emergencies
+
+
3
4
+
+ Mortality Blood transfusion Hospital stay Surgical intervention Number of drugs used / utilized Reopening / surgical infection - ICU
Patient notification
What additional interventions would you like to avail of to improve obstetric practice and outcomes? 1 2 3 Focus Group Discussion
4
Physical Plant Training
+
Clinical Resources
+
Referral Network
+
Others
+
+ +
Prenatal of patient Poor prenatal check up in local centers
How would you like to avail of these additional interventions? Focus Group Discussion
1
SELF
+
DOH
+
POGS
+
+
+
INDUSTRY
+
+
+
OTHERS
2
3
4
+ +
EXPERTS
What is your opinion on the results of the survey on CPG on PPH? Focus Group Discussion
1
2
3
4
+
+
+
Very reflective Somewhat reflective Not reflective comment
The options are really not done in the Philippines
CPG
Answers sometimes were personal
Problem: Postpartum Hemorrhage
Assessment of impact
PENDING Compliance and institutionalization
The Safety Loop
Practice guideline formulation dissemination
Introduction of intervention packages (ALARM, PROMPT, TEAM STEPPS, EMOC)
Problem: Postpartum Hemorrhage
Assessment of impact
Compliance and institutionalization
The Safety Loop
Practice guideline formulation dissemination
Introduction of intervention packages (ALARM, PROMPT, TEAM STEPPS, EMOC)
POGS Patient Safety Committee: Future Plans
Strategy of implementing Patient Safety Program for POGS
Needs assessment
Inventory of interventions
Comparison of outcomes
Plan of action: DONE Needs assessment
Provide feedback to centers
Elicit solutions to perceived gaps
Responding to Perceived GAPS Constant update and review of clinical practice guidelines Continuous TEAM TRAINING and DRILLS HIGH-RISK EVENTS e.g. ALARM, PROMPT, TeamSTEPPS Audit of management of obstetric emergencies Institutionalization of Patient Safety interventions E-Learning Modules Patient Safety Bundles
e-Learning Aggregate of digitally-mediated education activities Instructional materials Simulators (virtual patients) Case and problem-based learning Includes an assessment ( both formative and summative) Advantages Reach Convenience Tracking
Patient Safety Bundles Multidisciplinary approach Algorithms of care Adopt best practice from Society guidelines
Plan of action Inventory of
interventions
Document centers that received/ implemented training interventions
Agree on standard measures (Incidence of PPH, Rate of blood transfusions, Number & type of medical & surgical interventions employed)
Patient Safety Series
www.AJOG.org
Reviews
What indicators can we use in obstetrics? TABLE 2
Perinatal- and neonatal-related agency for health care research and quality patient safety indicators
Perinatal & Neonatal-related agency for health care research & quality patient safety indicators This image cannot currently be displayed. Indicator
Definition
Complications of anesthesia
Anesthetic overdose, reaction, or endotracheal tube misplacement
Death in low-mortality diagnosisrelated groups
In hospital deaths of patients with !0.5% mortality rate; excludes trauma, immunocompromised, and cancer patients
Postoperative hemorrhage or hematoma
Postoperative hemorrhage, postoperative hematoma, postoperative control for hemorrhage (must occur on same day or after principal procedure), or drainage of hematoma; excludes immunocompromised or cancer patients
INDICATOR
DEFINITION
................................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................
Selected infections because of medical care
Excludes immunocompromised or cancer patients
Transfusion reaction
Cases of transfusion reaction
Birth trauma: injury to neonate
Cases of birth trauma; excludes some preterm infants and infants with osteogenic imperfecta
................................................................................................................................................................................................................................................................................................................................................................................ ................................................................................................................................................................................................................................................................................................................................................................................ ................................................................................................................................................................................................................................................................................................................................................................................
Obstetric trauma
.......................................................................................................................................................................................................................................................................................................................................................................
Cesarean delivery
Cases of obstetric trauma (fourth-degree lacerations, other obstetric lacerations)
Vaginal delivery with instrument
Cases of obstetric trauma (fourth-degree lacerations, other obstetric lacerations) with instrument
Vaginal delivery without instrument
Cases of obstetric trauma (fourth-degree lacerations, other obstetric lacerations) without instrument
....................................................................................................................................................................................................................................................................................................................................................................... ....................................................................................................................................................................................................................................................................................................................................................................... ................................................................................................................................................................................................................................................................................................................................................................................
Adapted, with permission, from Johnson.24
Pronovost. Progress in patient safety. Am J Obstet Gynecol 2011.
Sample report Name of Hospital Intervention: __ Patient Safety Seminar __ CPG __ ALARM __ PROMPT __ BEMOC/EMOC __ others
Parameters
Observation Period: Jan – Dec 20__ to 20__
Baseline
Incidence of PPH
No.__/1000 deliveries/Year
Rate of Blood Transfusions
No. of patients ??
Medical interventions employed
Use of oxytocin , ergonovine, carbetocin, carboprost
Surgical interventions employed
Uterine artery ligation, internal iliac ligation, B-Lynch procedure, hysterectomy
Other interventions
Balloon tamponade, etc
Post-intervention No.__/1000 deliveries/Year
Plan of action Needs assessment Inventory of interventions Outcome comparisons
Provide feedback to centers
Elicit solutions to perceived gaps
Document centers that received/implemented training/interventions
Agree on standard measures (Incidence of PPH, Rate of blood transfusions, Number & type of medical & surgical interventions employed)
Measure baseline pre interventions
Evaluate effectiveness of interventions by comparing post intervention outcomes with baseline
This image cannot currently be displayed.
>10 mothers die daily from maternity related causes
Almost 4,600 women die giving birth each year
MATERNAL MORTALITY UNFPA Phil., World Bank 2005
Maternal mortality in the Philippines remains high at 114, with more than 10 mothers dying daily from maternity-related causes Postpartum hemorrhage is one of the top 3 causes of maternal mortality. It is preventable & manageable using simple interventions. Therefore, it is a good target measure to curb maternal mortality. The patient safety loop consists of: identification of the problem, practice guideline formulation & dissemination, introduction of intervention packages, compliance & institutionalization, and lastly, assessment of impact for continuous improvement.
“To Err is Human”
To do no Harm? First public realization of the true extent of patient harm & safety in the healthcare setting
DEATHS Medical Errors Motor Vehicle Accidents Breast Cancer AIDS
98,000 43,000 42,000 16,000
Medication Errors Workplace injuries
7,000 6,000
3rd Leading Case of Death in America: GOING TO THE HOSPITAL
Source of Medical Harm Achieving Safe & Reliable Healthcare Leonard, M, et al: 2004
5%
Incompetent or poorly intended care
95%
Conscientious competent individuals trying hard to achieve a desired outcome
Source of Medical Harm Achieving Safe & Reliable Healthcare Leonard, M, et al: 2004
5%
Incompetent or poorly intended care
95%
Conscientious competent individuals trying hard to achieve a desired outcome
Definition of Patient Safety What exactly is Patient Safety?
Emanuel L et al. : Agency for Healthcare Research and Quality; 2008 Aug.
Discipline in the health care sector that applies safety science methods toward the goal of achieving a trustworthy system of health care delivery. Attribute of health care systems; it minimizes the incidence and impact of, and maximizes recovery from, adverse events.
The Science of Patient Safety to Curb Maternal Mortality Changing Women’s and Reproductive Health Care Needs in the Philippines
PATIENT SAFETY COMMITTEE , POGS
Ma. Virginia M. Santos-Abalos MD FPOGS FPSGE FPIDSOG Prof IV, Cebu Institute of Medicine
Declaration of Good Standing and Conflict of Interest Disclosure My presentation complies with FIGO’s policy for declaration of good standing and conflict of interest disclosure; I do not have a financial interest in any product or service related to my presentation; My participation at this Congress has been partially supported by the Philippine Obstetrical & Gynecological Society
To understand the urgent need of curbing maternal mortality in the Philippines. To appreciate the components of the patient safety loop as a program to curb maternal mortality in the Philippines. To learn and adopt patient safety best practices worldwide. To recognize that institutionalization is important for compliance, and assessment of impact is vital for continuous improvement.
Maternal Mortality in the Philippines: The Current Situation
>10 mothers die daily from maternity related causes
Almost 4,600 women die giving birth each year
MATERNAL MORTALITY UNFPA Phil., World Bank 2005
2015
The Philippines 5th Progress Report Millennium Development Goals: Executive Summary 2015
Implementing a Patient Safety Program for POGS to Curb Maternal Mortality: PATIENT SAFETY LOOP
Strategy of implementing Patient Safety Program for POGS Needs assessment
Inventory of interventions
Comparison of outcomes
Knowledge Transfer Framework Knowledge creation & distillation
Diffusion & dissemination
Adoption Implementation Institutionalization
PROCESS
ACTORS TARGET AUDIENCES ACTIVITIES
Nieva, Veronica F., et al. "From science to service: a framework for the transfer of patient safety research into practice." 2005
Identification of problem
Assessment of impact (dashboard/ statistics)
Adoption and institutionalization
The Safety Loop
Creation of knowledge on effective intervention
Diffusion and dissemination
Identification of problem
Assessment of impact (dashboard/ statistics)
Adoption and institutionalization
The Safety Loop
Creation of knowledge on effective intervention
Diffusion and dissemination
Evaluating needs of POGS High maternal mortality (failure to attain MDG)
To study strategies that result in measurable outcomes. Focus on POSTPARTUM HEMORRHAGE was chosen
…due to Measurable and consistently reportable outcomes Existence of simple clinical practice guidelines
Evaluating needs of POGS High maternal mortality (failure to attain MDG)
To study strategies that result in measurable outcomes. Focus on POSTPARTUM HEMORRHAGE was chosen
…due to Measurable and consistently reportable outcomes Existence of simple clinical practice guidelines
Postpartum hemorrhage is common, preventable, & manageable using simple interventions
11 Filipino women die Postpartum Hemorrhage every day from PPH (Tulali 2010)
298
0.2
17.3
Evaluating needs of POGS High maternal mortality (failure to attain MDG)
To study strategies that result in measurable outcomes. Focus on POSTPARTUM HEMORRHAGE was chosen
…due to Measurable and consistently reportable outcomes Existence of simple clinical practice guidelines
Problem: Postpartum Hemorrhage Assessment of impact
Compliance and institutionalization
The Safety Loop
Creation of Practice guideline knowledge formulationon effective dissemination intervention
Introduction of intervention Diffusion and packages (ALARM, dissemination PROMPT, TEAM STEPPS, EMOC)
Problem: Postpartum Hemorrhage
Assessment of impact
Compliance and institutionalization
The Safety Loop
Clinical Practice guidelines AMTSL
Introduction of intervention Diffusion and packages (ALARM, dissemination PROMPT, TEAM STEPPS, EMOC)
Clinical Practice Guidelines: Part of efforts to improve patient safety in OBGyn
Year 1
Survey on Awareness and Adherence to CPG
Awareness and Adherence to CPG No. of Residents No. of Respondents Response Rate
1018 785 77.11%
Total No. of Hospitals No. of Hospitals Who Responded Hospital Response Rate
89 72 80.90%
Awareness and Reading of Guidelines n= 785/ 1018 Awareness of guidelines Read guidelines
Respondents (%) 92 83
Aware of guidelines
Read guidelines
Potential Mortality & Morbidity Yes
Yes
No
No
No Answer
No Answer
POGS Patient Safety Committee, 2016
29
Consistent use of well-developed, evidence-based clinical practice guidelines results in universal application of best practices and can improve patient outcomes Ennen CS et al. Reducing adverse obstetrical outcomes through safety sciences . UptoDate 2018
Strategy of implementing Patient Safety Program for POGS
Needs assessment
Inventory of interventions
Comparison of outcomes
Problem: Postpartum Hemorrhage
Assessment of impact
Compliance and institutionalization
The Safety Loop
Practice guideline formulation dissemination
Introduction of intervention packages (ALARM, PROMPT, TEAM STEPPS, EMOC)
TEAMWORK and COMMUNICATION FAILURES contribute to 70% of sentinel events in obstetrics. Joint Commission on Accreditation of Healthcare Organizations. JCAHO sentinel event alert #30. 2004. American College of Obstetricians and Gynecologists Committee Committee on Patient Safety and Quality Improvement. ACOG Committee Opinion No. 447: Patient safety in obstetrics and gynecology. Obstet Gynecol 2009
Linking Patient Safety Education with traditional OB GYN SPECIALTY TRAINING Traditional curricula for Ob Gynecologists have focused on PURE CLINICAL SKILLS: diagnosis of illness, treatment of disease, after-care and follow-up TEAM WORKING, QUALITY IMPROVEMENT and RISK MANAGEMENT have been overlooked. These are the skills fundamental to patient safety.
TEAM STRATEGIES AND TOOLS to Enhance Performance and Patient Safety
Core Teamwork Skills
Communication Leadership Mutual Support Situation Monitoring
PATIENT CARE TEAM 36
Problem: Postpartum Hemorrhage
Assessment of impact
Compliance and institutionalization
The Safety Loop
Practice guideline formulation dissemination
Introduction of intervention packages (ALARM, PROMPT, TEAM STEPPS, EMOC)
Year 2 Focus Group Discussion on Adoption and Implementation of Interventions to Decrease Postpartum Hemorrhage
Year 2 Focus Group Discussion on Adoption and Implementation of Interventions to Decrease Postpartum Hemorrhage What interventions do you use in your institution for PPH and other obstetric emergencies? What are the sources of these interventions? Who/where/how were these interventions acquired?
Year 2 –Adoption & Implementation of Interventions to Decrease PPH Focus Group Discussion 1 Utilization of clinical practice guidelines + Audit of management of obstetric emergencies + Training for obstetric emergencies Specify: ALARM + PROMPT + PATIENT SAFETY + ALARM for REMARKS personal; PROMPTreal
2 +
3 + + +
4 +
+
+ +
Year 2 –Adoption and Implementation of Interventions to Decrease PPH Focus Group Discussion 1 Utilization of clinical practice guidelines + Audit of management of obstetric emergencies + Training for obstetric emergencies Specify: ALARM + PROMPT + PATIENT SAFETY + Alarm for REMARKS
personal; PROMPTreal
2 +
3 + + +
4 +
+
+ +
Year 2 –Adoption and Implementation of Interventions to Decrease PPH Focus Group Discussion 1 Utilization of clinical practice guidelines + Audit of management of obstetric emergencies + Training for obstetric emergencies Specify: ALARM + PROMPT + PATIENT SAFETY + Alarm for REMARKS
personal; PROMPTreal
2 +
3 + + +
4 +
+
+ +
What factors do you think can improve current interventions? Focus Group Discussion Physical plant and facilities __ patient monitor e.g. pulse ox __ laboratory with timely results __ blood bank __ embolization facilities __ surgical equipment __ others____ Training and educational resources Clinical and medical resources __ surgeon with advanced skills __ interventional radiologist __ others Referral systems
1
2
3
+ + +
+ Private hospitals less exposed
Red cross blood bank Drug availability
Make protocol
CPG
Virtual training
Referral for human resources
Practice drills
Referral CPG checklist
4
+ ALARM PROMPT + +
ALARM
What factors do you think can improve current interventions? Focus Group Discussion
1
Very effective
+
Somewhat effective
2
3
4
+
+
+
Not effective
Comment
Decrease mortality rate and blood utilization
CPG
Communicate
Based on mortality and morbidity
Problem: Postpartum Hemorrhage
Assessment of impact
Compliance and institutionalization
The Safety Loop
Practice guideline formulation dissemination
Introduction of intervention packages (ALARM, PROMPT, TEAM STEPPS, EMOC)
What parameters do you use to measure effectiveness? What indicators/factors do you use to evaluate/measure effectiveness? Focus Group Discussion
1
2
Auditable standards: Specify Only B Lynch + • Rate of PPH and TAH are B Lynch and • Rate of use blood transfusion done internal iliac • Rate of use prophylactic uterotonic administration • Rate of uteretonic administration for PPH • Rate of use maneuvers for PPH, bimanual compression, etc. • Rate of use surgical management of PPH Specify: B Lynch, uterine artery ligation, internal iliac ligation, hysterectomy, others •
Morbidity and mortality statistics for PPH
+
•
Use of checklist for obstetric emergencies
+
+
3
4
+
+ Mortality Blood transfusion Hospital stay Surgical intervention Number of drugs used / utilized Reopening / surgical infection - ICU
Patient notification
What additional interventions would you like to avail of to improve obstetric practice and outcomes? 1 2 3 Focus Group Discussion
4
Physical Plant Training
+
Clinical Resources
+
Referral Network
+
Others
+
+ +
Prenatal of patient Poor prenatal check up in local centers
How would you like to avail of these additional interventions? Focus Group Discussion
1
SELF
+
DOH
+
POGS
+
+
+
INDUSTRY
+
+
+
OTHERS
2
3
4
+ +
EXPERTS
What is your opinion on the results of the survey on CPG on PPH? Focus Group Discussion
1
2
3
4
+
+
+
Very reflective Somewhat reflective Not reflective comment
The options are really not done in the Philippines
CPG
Answers sometimes were personal
Problem: Postpartum Hemorrhage
Assessment of impact
PENDING Compliance and institutionalization
The Safety Loop
Practice guideline formulation dissemination
Introduction of intervention packages (ALARM, PROMPT, TEAM STEPPS, EMOC)
Problem: Postpartum Hemorrhage
Assessment of impact
Compliance and institutionalization
The Safety Loop
Practice guideline formulation dissemination
Introduction of intervention packages (ALARM, PROMPT, TEAM STEPPS, EMOC)
POGS Patient Safety Committee: Future Plans
Strategy of implementing Patient Safety Program for POGS
Needs assessment
Inventory of interventions
Comparison of outcomes
Plan of action: DONE Needs assessment
Provide feedback to centers
Elicit solutions to perceived gaps
Responding to Perceived GAPS Constant update and review of clinical practice guidelines Continuous TEAM TRAINING and DRILLS HIGH-RISK EVENTS e.g. ALARM, PROMPT, TeamSTEPPS Audit of management of obstetric emergencies Institutionalization of Patient Safety interventions E-Learning Modules Patient Safety Bundles
e-Learning Aggregate of digitally-mediated education activities Instructional materials Simulators (virtual patients) Case and problem-based learning Includes an assessment ( both formative and summative) Advantages Reach Convenience Tracking
Patient Safety Bundles Multidisciplinary approach Algorithms of care Adopt best practice from Society guidelines
Plan of action Inventory of
interventions
Document centers that received/ implemented training interventions
Agree on standard measures (Incidence of PPH, Rate of blood transfusions, Number & type of medical & surgical interventions employed)
Patient Safety Series
www.AJOG.org
Reviews
What indicators can we use in obstetrics? TABLE 2
Perinatal- and neonatal-related agency for health care research and quality patient safety indicators
Perinatal & Neonatal-related agency for health care research & quality patient safety indicators This image cannot currently be displayed. Indicator
Definition
Complications of anesthesia
Anesthetic overdose, reaction, or endotracheal tube misplacement
Death in low-mortality diagnosisrelated groups
In hospital deaths of patients with !0.5% mortality rate; excludes trauma, immunocompromised, and cancer patients
Postoperative hemorrhage or hematoma
Postoperative hemorrhage, postoperative hematoma, postoperative control for hemorrhage (must occur on same day or after principal procedure), or drainage of hematoma; excludes immunocompromised or cancer patients
INDICATOR
DEFINITION
................................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................
Selected infections because of medical care
Excludes immunocompromised or cancer patients
Transfusion reaction
Cases of transfusion reaction
Birth trauma: injury to neonate
Cases of birth trauma; excludes some preterm infants and infants with osteogenic imperfecta
................................................................................................................................................................................................................................................................................................................................................................................ ................................................................................................................................................................................................................................................................................................................................................................................ ................................................................................................................................................................................................................................................................................................................................................................................
Obstetric trauma
.......................................................................................................................................................................................................................................................................................................................................................................
Cesarean delivery
Cases of obstetric trauma (fourth-degree lacerations, other obstetric lacerations)
Vaginal delivery with instrument
Cases of obstetric trauma (fourth-degree lacerations, other obstetric lacerations) with instrument
Vaginal delivery without instrument
Cases of obstetric trauma (fourth-degree lacerations, other obstetric lacerations) without instrument
....................................................................................................................................................................................................................................................................................................................................................................... ....................................................................................................................................................................................................................................................................................................................................................................... ................................................................................................................................................................................................................................................................................................................................................................................
Adapted, with permission, from Johnson.24
Pronovost. Progress in patient safety. Am J Obstet Gynecol 2011.
Sample report Name of Hospital Intervention: __ Patient Safety Seminar __ CPG __ ALARM __ PROMPT __ BEMOC/EMOC __ others
Parameters
Observation Period: Jan – Dec 20__ to 20__
Baseline
Incidence of PPH
No.__/1000 deliveries/Year
Rate of Blood Transfusions
No. of patients ??
Medical interventions employed
Use of oxytocin , ergonovine, carbetocin, carboprost
Surgical interventions employed
Uterine artery ligation, internal iliac ligation, B-Lynch procedure, hysterectomy
Other interventions
Balloon tamponade, etc
Post-intervention No.__/1000 deliveries/Year
Plan of action Needs assessment Inventory of interventions Outcome comparisons
Provide feedback to centers
Elicit solutions to perceived gaps
Document centers that received/implemented training/interventions
Agree on standard measures (Incidence of PPH, Rate of blood transfusions, Number & type of medical & surgical interventions employed)
Measure baseline pre interventions
Evaluate effectiveness of interventions by comparing post intervention outcomes with baseline
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>10 mothers die daily from maternity related causes
Almost 4,600 women die giving birth each year
MATERNAL MORTALITY UNFPA Phil., World Bank 2005
Maternal mortality in the Philippines remains high at 114, with more than 10 mothers dying daily from maternity-related causes Postpartum hemorrhage is one of the top 3 causes of maternal mortality. It is preventable & manageable using simple interventions. Therefore, it is a good target measure to curb maternal mortality. The patient safety loop consists of: identification of the problem, practice guideline formulation & dissemination, introduction of intervention packages, compliance & institutionalization, and lastly, assessment of impact for continuous improvement.
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