PATIENT SAFETY PROGRAM

Patient Safety Program Key Elements

             Patient Safety Program Policy

             JCAHO Patient Safety Policy

           Unanticipated Outcomes Policy

1. Patient Safety Program Policy:
2. Authority:
   1. Board of Trustees
   2. Executive Director
   3. Medical Staff
   4. Management Team
   5. Line Staff
3. Program Elements:
   1. When Designing or Redesigning a process, keep safety in mind
   2. Identify potential safety issues through:
4. Literature-Sentinel Events Alerts
5. PI Program
6. Incident Reports, Sentinel Events or Critical Events
7. Processes identified by Regulatory Bodies
8. Performance Related to Patient Safety:
   1. Survey of:
      1. Patients on their perceptions of safety practices, reported monthly

b.Staff reluctance to report errors, done semi-annually

1. Proactive Risk Assessment: Do Before an Event Happens
   1. Failure Mode and Effects Analysis (FMEA)
   2. Find steps in a process that can fail
2. Responding to Error – Sentinel Events and Critical Events
   1. Root Cause Analysis (RCA)
   2. Finds the cause(s) of what happened
3. Support of Staff Involved in Error – Done Trough Human Resources
   1. Time off
   2. Counseling
   3. Job Change
4. Education of Patient on Error Prevention – Done by Staff and In Patient Handbook
5. Reporting Medical Errors
   1. Report to Director of Nursing and to the Director of Quality Improvement who will report to the Executive Director.
   2. Do Not Report to JCAHO
   3. Executive Director does not report incident to Licensing Department
      Annual Review of Effectiveness of the Patient Safety Program
   4. Annual
   5. Report done and reported to Safety Committee and the Board
   7. JCAHO Patient Safety Goals – See Attachment

4. Unanticipated Outcomes Policy

1. Definition of Unanticipated Outcome:

An unanticipated outcome is defined as a negative or unexpected result stemming from a diagnostic test, medical judgment or treatment, surgical intervention or from the failure to perform a test, treatment or intervention. The unanticipated outcome may or may not be the result of error or negligence.

An unanticipated outcome is different from a known possible risk/complication. If the outcome is not unanticipated, then it is not subject to the unanticipated outcome disclosure requirements.

1. Executive Director and Medical Director decide if definition is met.
2. Attending psychiatrist is responsible to tell patient unless he/she feels it is contraindicated.
3. If the psychiatrist feels it is contraindicated, then the Chief Medical Officer must concur.
4. Patient must be told:
   1. Nature of the unanticipated outcome that has occurred
   2. Any possible repercussions this may have on the patient.
   3. Point of contact for questions
5. Psychiatrist will document discussion with the patient in the progress notes.
6. Chart will be referred to Peer Review in all cases.

PATIENT SAFETY PROGRAM

Patient Safety Program Key Elements

             Patient Safety Program Policy

             JCAHO Patient Safety Policy

           Unanticipated Outcomes Policy

2. Patient Safety Program Policy:
3. Authority:
   1. Board of Trustees
   2. Executive Director
   3. Medical Staff
   4. Management Team
   5. Line Staff
4. Program Elements:
   1. When Designing or Redesigning a process, keep safety in mind
   2. Identify potential safety issues through:
5. Literature-Sentinel Events Alerts
6. PI Program
7. Incident Reports, Sentinel Events or Critical Events
8. Processes identified by Regulatory Bodies
9. Performance Related to Patient Safety:
   1. Survey of:
      1. Patients on their perceptions of safety practices, reported monthly

b.Staff reluctance to report errors, done semi-annually

1. Proactive Risk Assessment: Do Before an Event Happens
   1. Failure Mode and Effects Analysis (FMEA)
   2. Find steps in a process that can fail
2. Responding to Error – Sentinel Events and Critical Events
   1. Root Cause Analysis (RCA)
   2. Finds the cause(s) of what happened
3. Support of Staff Involved in Error – Done Trough Human Resources
   1. Time off
   2. Counseling
   3. Job Change
4. Education of Patient on Error Prevention – Done by Staff and In Patient Handbook
5. Reporting Medical Errors
   1. Report to Director of Nursing and to the Director of Quality Improvement who will report to the Executive Director.
   2. Do Not Report to JCAHO
   3. Executive Director does not report incident to Licensing Department

1. Annual Review of Effectiveness of the Patient Safety Program
   1. Annual
   2. Report done and reported to Safety Committee and the Board
   4. JCAHO Patient Safety Goals – See Attachment

4. Unanticipated Outcomes Policy

1. Definition of Unanticipated Outcome:

An unanticipated outcome is defined as a negative or unexpected result stemming from a diagnostic test, medical judgment or treatment, surgical intervention or from the failure to perform a test, treatment or intervention. The unanticipated outcome may or may not be the result of error or negligence.

An unanticipated outcome is different from a known possible risk/complication. If the outcome is not unanticipated, then it is not subject to the unanticipated outcome disclosure requirements.

1. Executive Director and Medical Director decide if definition is met.
2. Attending psychiatrist is responsible to tell patient unless he/she feels it is contraindicated.
3. If the psychiatrist feels it is contraindicated, then the Chief Medical Officer must concur.
4. Patient must be told:
   1. Nature of the unanticipated outcome that has occurred
   2. Any possible repercussions this may have on the patient.
   3. Point of contact for questions
5. Psychiatrist will document discussion with the patient in the progress notes.
6. Chart will be referred to Peer Review in all cases