النشرة الدورية للجودة العدد التاني 2-2016 فوزية مشهور3

Medical Error is a mistake committed by health professionals which result in harm tothe patient. They include errors in diagnosis, errors in the administration of drugs andother medications (medication errors), errors in the performance of surgicalprocedures, in the use of other types of therapy, in the use of equipment, and in theinterpretation of laboratory findings.Medical errors are differentiated from malpractice in that the former are regarded ashonest mistakes or accidents while the latter is the result of negligence, reprehensibleignorance, or criminal intent.Medical error is a serious problem in health care sector, it poses a threat to patientsafety around the world and medical errors considers as No. 3 causes of death.We have to understand medical errors clearly to know how to prevent it and toimprove the efficiency of the work in the hospitals.Medical errors are associated with inexperienced physicians and nurses, newprocedures, extremes of age, and complex or urgent care.Poor communication (whether in one's own language), improper documentation,illegible handwriting, inadequate nurse-to-patient ratios, and similarly namedmedications are also known to contribute to the problem. Patient actions may alsocontribute significantly to medical errors.Where errors occurErrors occur not only in hospitals but also in other health care settings, such asphysician' offices, nursing homes, pharmacies, emergency care centers and caredelivered in the home.References :- http://apps.who.int/medicinedocs/en/d/Jwhozip02e/4.html- https://en.wikipedia.org/wiki/Medical_error

By : Sana Al Eidarous :Quality Specialist Data Analyst , Six Sigma Green Belt Patient safety culture is the product of every person value , attitudes , perceptions competencies toward patient safety . it is everyone is responsible forPatient safety from boardroom to front line .Sammer et al (2002). in their review of literatures identified a board ofrange of patient safety culture. Where they organized it into sevensubcultures .1-Leadership Culture: Leaders acknowledge that it is a high-riskenvironment and support all effort for patient safety2-Teamwork Culture : working together with the spirit of collaboration,and cooperation among the all staff. Relationships are open, safe,respectful, and flexible.3-Evidence-based Culture: all Patient care are standardize practices basedon evidence practices.

4-Communication Culture: every staff member has the right and theresponsibility to speak up on behalf of a patient.5-Learning Culture: The hospital learns from its mistakes and seeks newopportunities for performance improvement.6-Just Culture: A culture that recognizes errors as system failures ratherthan individual failures and, at the same time, does not shrink fromholding individuals accountable for their actions.7-Patient-centered Culture: Patient care is centered around the patientand family. So each patient is active participant in his own care.Each subculture need A lot of effort, commitment, and sincere to be built .The Culture of Safety. it begins With Leadership expands with designingstrategy and building structure that lead to safety processes and outcomes

By: Ahlam Alghanmi , Quality Improvement ConsultantThe new requirement for Change (6.3 Planning of changes, 8.1 Operational planning and control,8.3.6 Design and development changes and 8.5.6 Control of changes in ISO 9001:2015).One of the goals of the ISO 9001:2015 revision is to enhance the requirements for addressingchanges at system and operational levels. The ISO 9001:2015 requirements provide a strong basisfor a management system for business that supports the strategic direction of the organization.Once the organization has identified its context and interested parties and then identified theprocesses that support this linkage, addressing changes becomes an increasingly importantcomponent of continued success.Enhanced leadership involvement in the management system-Risk-based thinking- Simplified language, common structure and terms-Aligning QMS policy and objectives with the strategy of the organization.These new requirements are referenced in ISO 9001:2015 as outlined below: 1. 6.3 Planning of changes When the organization determines the need for changes to the quality management system, the changes shall be carried out in a planned and systematic manner . The organization shall consider the: a) purpose of the changes and their potential consequences; b) integrity of the quality management system; c) availability of resources; d) allocation or reallocation of responsibilities and authorities. 2. 8.1 Operational planning The organization shall control planned changes and review the consequences of unintended changes, taking action to mitigate any adverse effects, as necessary. 3. 8.3.6 Design and development changes During design and development changes that are identified will be reviewed and controlled to ensure there is no impact to the conformity of the product or service.

4. 8.5.6 Control of changes The organization shall review and control changes for production or service provision, to the extent necessary to ensure continuing conformity with requirements. The organization shall retain documented information describing the results of the review of changes, the persons authorizing the change, and any necessary actions arising from the review.Things to consider when implementing the new requirement for Change o Customer feedback o Customer complaint o Product failure o Employee feedback o Innovation o Determined risk o Determined opportunity o Internal audit results o Management review results o Identified nonconformity

By :Sami Khan , MT (Supervisor Laboratory Accreditation and External Quality ,CAPLaboratory Accreditation Program Supervisor)Preface: According to international standards all Turnaround Time (TAT) data oflab tests including STAT lab tests are measured starting from receipt time toreport time. The laboratory department is responsible to deliver the report in thetime assigned by hospital policy for each individual test accordingly. According to the College of American Pathologists (CAP) we do need to dothis measure starting from order time in ED for the critical tests potassium andTroponin to fulfill the patient safety. The CAP has introduced the patient safety indicator called QT15 and knownas Turnaround Time of Troponin.Background: The timeliness with which laboratory test results are reported to clinicianswho order them is a visible and common standard by which clinicians judge thequality of laboratory services. Because the results of biochemical tests evaluating myocardial injury areessential elements in establishing diagnoses of AMI, clinicians are likely to beespecially sensitive to the timeliness with which these test results are reported. The reporting intervals will commence with the times that troponin levels areordered by ED personnel (physicians and nurses). The order to report Turnaround interval encompasses all three phases (pre-analytic, analytic, andpost-analytic) of laboratory testing. Successful completion of each phase maydepend upon health care workers other than those employed in clinicallaboratories. As such, the order to report interval is a global measurement ofsystem efficiency.

Objectives In this worldwide study the median order-to-report TAT of troponin orderedto rule out myocardial infarction, and the percent of troponin results reported byeach institution’s established deadline will be determined. Track the TAT of troponin ordered on patients presenting to ED with signsand symptoms of acute myocardial injury and determine compliance with thetroponin TAT as agreed between Lab and ED personnel.Performance Indicators What to be calculated are: - Median troponin order-to-report TAT in minutes. - Troponin TAT compliance rate (%).Guidelines for Considerable Success: (The 15 for QT15) 1- Involve the hospital Top Management and the TQM department. 2- Enroll with the CAP patient safety improvement survey: QT15. 3- Make an agreement with the ED team for the acceptable TAT of troponin for your hospital. 4- Once you set your goals with the ED of acceptable quarterly results for both Troponin Median and Compliance Rate, get the hospital Top Management approval. 5- Collect 9 TAT data per day, three data every shifts; (Day, Evening and Night Shifts). 6- Collect the 54 TAT data of each month 9 every five days. (Specific dates will be provided by CAP) 7- Report the data to CAP website every quarter. 8- Revise CAP report and compare your result to your choice of peers worldwide. 9- Build a system of periodic meeting with the ED personnel with the lab team. 10- Follow up the improvement plan to make sure that you are on the right track. 11- Annual review should be provided to the hospital top management. 12- A periodic Troponin TAT educational program should be conducted for all of the ED personnel. 13- Share your results for any further actions. 14- Repeat the previous actions and continue monitoring. (Until this becomes a habit) 15- Rewards and celebration should be supported by the hospital for every significant improvement.

Definitions of Terms Troponin: A biochemical marker of cardiac injury which is elevated in acute myocardial infarction utilized in ED and is ordered mainly as STAT. Order time: The time that a test is requested by healthcare workers in the ED. Receipt time: The time that the troponin specimen was received (logged) in the laboratory. Report time: The time that a test result is made available to healthcare personnel (i.e., the time that results are verified in the computer or phone or faxed) in the ED.

By : Dr.Ali Al Faydhi, Chairman of Ethics Committee65 years old, Female, presented to Emergency Department last April2015.  Needed central line insertion.  Rotating resident inserted right femoral line.  Chest X-ray done in Emergency Department.  Chest X-ray done in Intensive Care Unit.  Patient improved and transferred from Intensive Care Unit to Female Medical Ward.  Chest X-ray done 3 times in Female Medical Ward.  She was improved and discharged home.  All X-rays were reported by radiology department.  There was a guide wire in the x-rays but it wasn’t reported although she was in Emergency Department, Intensive Care Unit, Female Medical Ward .  5 months later, she was admitted to Female Medical Ward with chest infection. Again, several Chest X-rays were done and it wasn't reported about the guide wire which was obvious in all of her X-rays.  On April 2016, she presented with DVT right leg, this time Chest X-ray was reported with a guide wire in the right internal jugular vein (one year from the date of insertion).  Wire was removed by endovascular surgeon. Disclosure :  She and her son were explained by treating physician that the doctor who inserted the line one year ago forgot the metallic wire in the vein which could be the cause of DVT and she has the right to make an official complaint and to raise the issue to the court.  She refused to make an official complaint or ask for any compensation.

She requested that senior doctors should supervise their juniors when doing procedures not to have similar event in the future.Lessons from the case: 1. Senior doctors should always be available physically when trainee doctors are performing invasive procedures and make sure that they privileged to do such cases. 2. Patient safety requires good doctors training, but training should be under strict supervision to guarantee patient safety. 3. Junior doctors need to feel free to report any complication or event in a blame free environment. 4. Undergraduate curriculum needs to have ethical concepts in every part of it. 5. One mistake can leads to another and gets bigger (ice ball effect) and unnoticed at all levels (Swiss cheese effect). 6. Checklists can minimize human errors. 7. Proper disclosure leads to better understanding. 8. Treat patients as you wish to be treated.

Helath.Llinks(PressGaney)Team visit :King Abduaziz University Hospital wasvisited on Sunday 10th April 2016 , byMr.Donald L. Malott Jr. Vice PresidentHealth Care Analytics & SurveyMethodology Press Ganey and Mr.AdelAl-ShabaanAl-Sibai Managing Partner Health.Links, Health.Links is a specialized healthcarecompany in partnership with PressGaney, with the sole intention ofimproving patient experience in theMiddle East through developingprograms that would help patientsreceive the care they deserve and supportthem in their healing journey.The aim of the visit is to solicit feedbackfrom renowned healthcare leaders in theregion: Policy Makers, C-Suiteexecutives, Nursing, Medical, Quality andPatient Experience, as well as trackingthe patient journey across Inpatient,Outpatient, Emergency and Ambulatory,Surgery through various health careinstitutions from the Government,Private, Institutional and teachingsectors.The team met with the Hospital Director,Medical Director ,Quality Department ,Inpatient Director and ended the visitwith a tour in the hospital (Outpatient,Inpatient, Emergency) & patientinterviews .

King Abdulaziz University Hospital was visited byCBAHI team on 29th of May 2016 to evaluatethe implementation of the ESR (National EssentialSafety Requirement) , the team visited the hospitaldepartments , reviewed records and interview staffand patients .

To our colleagues for being nominated as the ideal employees for 2016 :

To the following Quality Designees for their active Contribution in Quality Improvement and for their Chairman for their support :Department /Unit Quality Designee Chairman/Head ofPhysical Medicine Fadwa Janbi Department Dr. Husam Darwish MICU Dr. Haytham Dr. Ali Al-FaydhiHome Healthcare Mohammed Nourldeen Ms. Rowaydah Michael Rudica Masoud