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eCommons@AKU Quality & Patient Safety - Gazette Publications (Newsletters, Reports, etc.) 12-2023 Quality & Patient Safety Gazette : Volume 2, Issue 4 - 2023 The Aga Khan University Hospital, Karachi Follow this and additional works at: https://ecommons.aku.edu/pakistan_qps_gazette  Part of the Patient Safety Commons, and the Quality Improvement Commons Recommended Citation The Aga Khan University Hospital, Karachi, "Quality & Patient Safety Gazette : Volume 2, Issue 4 - 2023" (2023). Quality & Patient Safety - Gazette. Book 7. https://ecommons.aku.edu/pakistan_qps_gazette/7  1  Quality & Patient Safety Gazette The Aga Khan University Hospital (AKUH), Karachi Quarter IV, 2023      Volume 2, Issue 4 About the Gazette  This gazette covers the contribu-tions made by Quality and Patient Safety Department (QPSD) and Department of  Infection Preven-tion and Hospital Epidemiology (DIPHE) team toward s maintain-ing quality  standards at AKUH. The main aim of this initiative is to educate all the employees regard-ing the understanding & Implemen-tation of JCIA standards. The sec-ondary aim is to showcase ongoing and planned activities to  maintain quality patient & staff safety. The QPSD and DIPHE team looks for-ward to your active participation in all upcoming events and it will be our  pleasure to feature you in the future edition of this newsletter.  Inside this Issue  World Quality Day 2023  Workshop on How to conduct a Root Cause Analysis   Blast from the Past  International Infection Prevention Week (IIPW) 2023   ICLNs Engagement dur-ing IIPW-2023 Activities   DIPHE Specialist Pre-sented in 13th Annual CME for Allied Health  Adverse Event Reporting  Quarterly Sessions for Embracing the Funda-mentals of JCIA Stand-ards into Clinical Practice  Awareness Session  in collaboration MEP Team on Airborne Isolation   Global Hand Washing Day   Learn with Fun  Match the Correct An-swer with JCIA Non-compliances and Find Them In The Wordsearch  Stay Tuned with Us…..  CDC Surveillance Ses-sion  Workshop on Tracer Methodology– Becoming a Clinical Auditor  Nominations Open for Infection Control Linked Nurses (ICNLs)/Staff   Update on AKUH Person Centered Care Planetree Certification  World Quality Day 2023 The QPSD at AKUH celebrated World Quality Day (WQD) on November 16th, 2023, under the theme "Quality: Realizing Your Competitive Potential." This event aimed to recognize and     appreciate the contributions of healthcare quality professionals. As part of the celebration, QPSD organized a successful quality improvement project competition. A total of 124 abstracts were received in the first round from the main campus, outreach, and off-campus hospitals. Out of which 31 clinical and 12 non-clinical projects qualified for the second round (e-poster submis-sion). Twelve e-posters proceeded to the third round of judgement i.e. oral presentations, where 3 clinical and 3 non clinical top positions were awarded with shields. All participants of WQD 2023 were honored with certificates of participation, acknowledging their hard work,             commitment, and dedication to quality and patient safety. In our relentless pursuit of excellence at Aga Khan University Hospital, quality is not merely an end goal—it is an ongoing journey. The notion of a final desti-nation implies a static endpoint, but our commitment to high standards means our aspirations evolve with each achievement. Today's benchmark is tomor-row's starting point. As we strive for the best in all our endeavors, let us em-brace the fluid nature of our pursuit, recognizing that excellence is not a fixed target but a dynamic, ever-changing milestone. Together, let's continue this journey, knowing that our dedication to quality ensures an enduring legacy of outstanding healthcare.  Workshop on How to Conduct a Root Cause Analysis  The Workshop on How to Conduct a Root Cause Analysis (RCA) was organized by the QPSD in collaboration with the Department of Continuing Professional Education (DCPE) on November 24th, 2023. The workshop, was led by Dr. Asim (CMO) , Dr. Qalab (ACMO, Patient’s Affair), and Dr. Asif Aleem (Senior Manager, Patient Experience Department). This workshop provided valuable insights into conducting comprehensive Root Cause Analyses, with a specific emphasis on adhering to JCIA Quality Improvement and Patient Safety (QPS) Standard 7, which addresses the identification and management of sentinel events. Participants utilized the standardized RCA template to review a case and identify reasons for potential patient issue and derived measurable action items to prevent any future harm. Dr. Nuzhat Faruqui Associate Chief Med-ical Officer (ACMO),  Medical Staff Affairs Seasons Greetings: Happy New Year to all of you We're dedicated to empowering healthcare workers with ongoing support and awareness to elevate the quality of care. Our focus is on continuous improvement and striving for better      clinical outcomes for patients. Join us in making a lasting impact on healthcare excellence.   2  Global Hand Washing Day  October 15 is celebrated globally as Hand Washing Day, a day dedicated to increase awareness and understanding about the importance of hand-washing with soap as an effective and affordable way to prevent diseases and save lives. To engage hospital-wide staff  an innovative online puzzle activity was organized and total of 367 staff  participated, making learning a fun and interactive experience. Clean hands pave the way to a healthier world.  International Infection Prevention Week (IIPW)2023  The IIPW at AKUH, was celebrated from October 15th-21st, 2023, focused on the theme "Fundamentals of Infection Prevention." Activi-ties included awareness sessions on Hand Hygiene, Cleaning and   Disinfection, Vaccination, Personal protective equipment (PPE),   Respiratory Etiquette, and Injection Safety. DIPHE engaged healthcare workers through various activities, and sessions to enhance learning and improve practices at the bedside. A puzzle game to          reinforce standard precautions and importance of hand hygiene for all healthcare worker categories in the "Identify the Germs on Hand" activity. The week ended up with a PCI Standards based video,      engaging quizzes, and the announcement of winners.  Winners of the IIPW were: 1st Position: Aqsa Javed- Off-Campus Garden Hospital  2nd Position: Sajida Amir Ali- Oncology Department  3rd Position: Hina Fareed- Off-Campus Karimabad Hospital  Awareness Session  in Collaboration MEP Team on Airborne Isolation  In December 2023, DIPHE and the Mechanical, Electrical and Plumbing (MEP) team conducted a session for 210 healthcare workers, emphasizing the crucial role of engineering controls. The focus was on the significance of HEPA filters and UVGI lights in airborne precautions, highlighting the importance of understanding mechanisms and meticulous maintenance for optimal functionality. The role of healthcare professionals were reinforced during airborne isolation precautions to enhance patient and staff safety. Adverse Event Reporting The Chief Medical Officer (CMO) and Chief Nursing Officer (CNO) appreciated healthcare providers for reporting adverse events, to promote a culture of safety.   Identification and Reporting of Error Related to the Consent Form:  Nasreen Jamil, OR (Department of Anesthesia) Identification and Reporting of Error Related to IPSG 1:  Anthony Rokas, GI & GS Clinic (Outpatient)  Adeela Bano, GI & GS Clinic (Outpatient) Identification and Reporting of Error Related to ABO Compatibility:  Farida Datoo, NPO (CNO Office)  Identification and Reporting of  Near Miss Incident:  Mehak Zulfiqar, D1 ((Department of Surgery)  Kainat Kanjiani, B1 (Department of Surgery)  Mehwish, D0 (Department of Peads) DIPHE Specialist Presented in 13th Annual CME for Allied Health During the 13th Annual CME on No-vember 5th, 2023, DIPHE specialist  reinforced the key role of allied health professionals for infection control practices in OR and trauma patients. Approximately 350        attendees from 30+ hospitals across Pakistan, including Sindh, Punjab, and Balochistan attended the ses-sion. The session reinforced the sig-nificance of standard precautions, aseptic techniques, and preventing exposure to blood and body fluids. It aimed to enhance allied health pro-fessionals' understanding of infec-tion management.  Quarterly Sessions for Embracing the Fundamentals of JCIA   Standards into Clinical Practice The Quality and Patient Safety Department continues the effort to incul-cate the basic concepts of JCIA standards into the clinical practice through continuously facilitating the awareness sessions on quarterly ba-sis. These are planned in collaboration with Department of Continuing professional Education (DCPE). More than 300 healthcare professionals from main hospital, outreach and off campuses attended these sessions.  ICLNs Engagement during IIPW-2023 Activities  During IIPW-2023, our Infection Control Link Nurses (ICLNs) took part in unit-wise activities and quiz competitions, showcasing their commitment to excellence. Re-markably, Ms. Hina Fareed and Ms. Sajida excelled in the quiz during the PCI session's video on JCIA Standards.  2  3  Learn with fun: Lets Check Your knowledge Match the Correct Answer with JCIA Non-compliances and Find Them In The Wordsearch   3 A delay in communication could have a serious impact on patients' treatment. This term refers to a test result that significantly falls out of the normal range. Match and Find Answers  Recovery Criteria  Labelling   Clinical Indication  Critical Results   Sign Out   Medication Reconciliation  Pediatric Cancer, Acute Stroke, CABG, Renal Failure  Patient Elopement  Bill of Rights and Responsibilities  Monitoring  Process that must be completed and documented before patient leaves the procedure room after surgery/procedure. Complex diagnosis as per the hospital policy that requires outpatient profile on my patient. Unauthorized departure of a patient from any of our inpatient units including ED will be con-sidered. An essential component during the transfer of the patient within and outside the hospital that must be documented in the medical record. Information that must be provided to initial patients (inpatient admission and outpatient visits) Identifying and resolving differences between current and newly prescribed medications is a crucial healthcare process for ensuring accurate and safe medication management. A crucial step in medication safety to be followed if medication is prepared and not adminis-tered immediately. Discharge of the patient from procedural sedation unit should be based on a criterion. A mandatory component to be included while prescribing any diagnostic imaging and clinical laboratory tests. Quality Trivia   Click Here to submit your     answers after completing the Wordsearch. Winners will be   announced in Quality Grand Round Hint:  Previous QPS Newsletters JCIA 7th Edition Patient Focus Chapter Videos  Relevant Hospital Policies    4    Dr. Aisha Noorullah Senior Instructor,  Department of  Psychiatry  Shireen Mohammad Assistant Manager, Internal Audit  Mahwish Saleem Head Nurse,  Princess Zahra Pavilion  Dr. Hasan Hayat Assistant Professor, Pathology and        Laboratory Medicine   Quality Trivia                                                                     Contributors: QPSD and DIPHE Staff Editors: Sana Jindani (Associate QPSD & DIPHE and Afsana Padaniya (Coordinator, QPSD)  Facilitators: Rozina Roshan (Senior Manager, QPSD & DIPHE), Salima Naveed Merchant                           (Assistant Manager, QPSD) & Nazleen Virani (Specialist, DIPHE)   To View All Previous QPS Newsletters   Click Here  Q3, 2023 QPS Gazette  Quality Trivia Winners  Update on AKUH Person     Centered Care Planetree      Certification   QPSD in collaboration with planetree taskforce will organize a Quality Grand Round Mandatory for all AKUH, K Leadership, Fac-ulty, Nurses and Staff to attend and the agenda will be to orient about the Person-Centered Care (PCC) & AKUH’s planetree certi-fication plan, planetree standards baseline self-assessment score, challenges and recommendation by planetree task force and expec-tations from hospital’s leadership, faculty, nurses and staff. Workshop on Tracer Methodology– Becoming a Clinical Auditor  QPSD will conduct a workshop for our clinical management teams and QIRs in collaboration with DCPE. It will provide valuable  insights into conducting individual patient tracer for evaluating the compliances to the JCIA standards and hospital policies. Do not miss out on this golden opportunity to step forward and become an      essential part of this learning               experience. CDC Surveillance Session  Stay tuned! DIPHE is             planning to conduct the                Center for Disease Control (CDC) surveillance session in February 2024 with the      collaboration of DCPE. The main objective of the CDC surveillance session is to      enhance the knowledge among healthcare workers and strengthen the                                         surveillance process.  Self Nominations Open for          Infection Control Linked Nurses (ICLNs)/Staff   Every year DIPHE invites  nominations for ICLNs/Staff in collaboration with managers, offering them opportunity to learn Infection Prevention and Control practices. The ICLNs serve as vital bridges  between units and DIPHE. The time period of this commitment will be from January to Decem-ber 2024. Please send an email to DIPHE@aku.edu with your unit nominations after discus-sion with area management. To View All JCIA 7th Edi-tion Patient Focus Chapter Videos –   JCIA made easy on your finger tips Click Here  Be Ready for The Upcoming Preparations for JCIA Survey 2024 4 Click Here to submit your         answers after completing the Wordsearch. Winners will be announced in    Quality Grand  Round 

Quality & Patient Safety Gazette : Volume 2, Issue 4 - 2023

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Quality & Patient Safety Gazette : Volume 2, Issue 4 - 2023

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