JINKA GENERAL HOSPITAL

PATIENT SAFETY STRATEGY

2015/2022 -2020/2027

BY QIU SEPTEMBER 2022

JINKA SNNP ETHIOPIA
Contents page
Foreword:.......................................................................................................................................................2

Introduction....................................................................................................................................................3

The seven strategic objectives of the Global Patient Safety..........................................................................4

Health Service Movement for Patient Safety.................................................................................................4

Our Vision, Objective and Ambitions for Patient Safety..............................................................................5

Our Commitments to Patient Safety..............................................................................................................6

Commitment 1: Empowering and Engaging Patients to Improve Patient Safety......................................6

Commitment 1: Empowering and Engaging Patients to Improve Patient Safety Actions........................7

Commitment 2: Empowering and Engaging Staff to Improve Patient Safety...........................................7

Commitment 2: Empowering and Engaging Staff to Improve Patient Safety Actions.............................8

Commitment 3: Anticipating and Responding to Risks to Patient Safety.................................................8

Commitment 3: Anticipating and Responding to Risks to Patient Safety Actions...................................9

Commitment 4: Reducing Common Causes of Harm...............................................................................9

Patient Safety Improvement Priorities:....................................................................................................10

Commitment 4: Reducing Common Causes of Harm Actions................................................................10

Commitment 5: Using Information to Improve Patient Safety................................................................10

References....................................................................................................................................................12

Foreword:
Keeping patients and those who use our services safe is the overriding priority for those of us
working in, or overseeing the work of the health service.

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National and international evidence however shows us that as many as 1 in 8 patients suffer
harm while using healthcare services and up to 70% of this harm could have been prevented.
This is not acceptable and we must make every effort to reduce these devastating statistics. It is
for this reason that the development and implementation of the first overarching Patient Safety
Strategy 2015/2022/-2020/2027 for the health service is a priority.

The Board of the JGH, together with its Safety and Quality Committee and the JGH’s Executive
Management Team, acknowledges that many excellent patient safety initiatives have been
implemented in recent years resulting in measureable improvements. Many of these have been taken
in response to serious patient safety incidents.

The development of the Strategy builds on this and is an important example of how real and
meaningful partnerships between patients and those working at each level of the health service
can generate a shared vision for a more compassionate health service, one that learns when
things go wrong, responds accordingly and reduces harm to those who entrust their lives and
care to us.

Our vision for patient safety is that all patients using our health and social care services will
consistently receive the safest care possible. Nurturing a culture of patient safety which places
emphasis on a culture of transparency and organizational learning is key to this. This must be
supported by meaningful involvement of patients and staff, effective governance and leadership
and a commitment to enhancing our safety capability, including embracing safety science, in
order to design safe systems of care. The practice of patient safety involves coordinated action
to prevent harm to patients, caused by the processes of health care themselves. Patient safety is
a strategic priority for modern health care and is central to countries’ efforts in working
towards universal health coverage.

In this Strategy we make 6 Commitments. We will:

Empower and Engage Patients to Improve Patient Safety
Empower Staff to Improve Patient Safety
Anticipate and Respond to risks to Patient Safety
Reduce Common Causes of Harm
Measure and Learn to Improve Patient Safety
Provide effective Leadership and Governance to Improve Patient Safety

The Strategy provides a framework for our staff and participants in the provision of healthcare to guide
the: Development of quality plans, Measurement and assessment of quality, Design and implementation
of continuous quality improvement
Critically, the Patient Safety Strategy will align closely with the implementation of Sláintecare, the
blueprint for the reform and development of our health services over the next decade and beyond.

Introduction
Today, patient harm due to unsafe care is a large and growing global public health challenge and is one of
the leading causes of death and disability worldwide. Most of this patient harm is avoidable. As countries
strive to achieve universal health coverage and the Sustainable Development Goals, the beneficial effects
of improved access to health services can be undermined by unsafe care. Patient safety incidents can
cause death and disability, and suffering for victims and their families. The financial and economic costs
of safety lapses are high. There is often reduced public confidence and trust in local health systems when

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such incidents are publicized. Health workers involved in serious incidents involving death or serious
harm to a patient can also suffer lasting psychological harm and deep-seated feelings of guilt and self-
criticism. The benefits of having a strategic and coordinated approach to patient safety, addressing the
common causes of harm and the approaches to preventing it, have been recognized by policy-makers and
political and health leaders worldwide.
What is Patient Safety?
Patient safety can, at its simplest, be defined as: The avoidance, prevention and amelioration of adverse
outcomes or injuries stemming from the process of healthcare. (Charles Vincent, 2006)
Patient safety is: “A framework of organized activities that creates cultures, processes, procedures,
behaviors, technologies and environments in health care that consistently and sustainably lower risks,
reduce the occurrence of avoidable harm, make errors less likely and reduce the impact of harm when it
does occur.”{Global patient safety}
Why focus on Patient Safety?
During our lifetimes, each of us will at some stage be a patient or will be a user of our health and social
care services. We will expect the safest and best care possible, placing our trust in professionals to
improve our health or provide a service that will support us in living fulfilled lives. Maintaining the
highest levels of patient safety is a fundamental priority for patients and for healthcare organizations. 17%
of all hospitalizations are affected by one or more adverse events, with 30-70% potentially preventable
harm.
Patient Safety must be Everyone’s Business!
Patient safety is everybody’s business and requires the active participation of many key partners ranging
from patients and their families to governmental, nongovernmental and professional organizations. They
include:
Governments. Ministries of health and their executive agencies at both national and subnational levels,
legislative institutions, other concerned ministries, and regulatory bodies.
Health care facilities and services. All health care facilities ranging from primary health centers to large
teaching hospitals, irrespective of ownership and scope of services.
Stakeholders. Nongovernmental organizations, patients and patient organizations, professional bodies
and scientific associations and societies, academic and research institutions and civil society
organizations.
WHO Secretariat. WHO at all levels – country offices, regional offices and headquarters.
Throughout the Strategy the term “we will” means that actions will be developed and implemented at
every level of our health and social care services, within both community and acute hospital services, to
improve patient safety. In addition, in the context of this Strategy, the term ‘Patient’ is intended to include
all people who attend/ use our health and social care services; “Staff” refers to all Healthcare
Professionals, Clinicians, Support Workers, Managers and Administration Staff who all have a role to
play in making our health systems safer.

The seven strategic objectives of the Global Patient Safety

Action Plan 2021–2030 are as follows;-
1) Make zero avoidable harm to patients a state of mind and a rule of engagement in the planning
and delivery of health care everywhere.

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 2) Build high-reliability health systems and health organizations that protect patients daily from
harm.
3) Assure the safety of every clinical process.
4) Engage and empower patients and families to help and support the journey to safer health care.
5) Inspire, educate, skill and protect every health worker to contribute to the design and delivery of
safe care systems.
6) Ensure a constant flow of information and knowledge to drive mitigation of risk, a reduction in
levels of avoidable harm and improvements in the safety of care.
7) Develop and sustain multispectral and multinational synergy, partnership and solidarity to
improve patient safety and quality of care

Health Service Movement for Patient Safety

Our Implementation Philosophy: Supporting Front Line Action for Patient Safety, Continuing
improvements in healthcare and health outcomes come at a time when the way in which healthcare is
delivered is becoming increasingly complex. Complexity always creates more potential for risk, and this
includes risks to the safety of those who use our services. This Patient Safety Strategy therefore
recognizes the significant action already taken and seeks to build on and support this work through:
Strategy Commitments: The six commitments set out in the Strategy serve as a health service Charter
for Patient Safety. We aim to embed these commitments at every level of the health service so that they
serve as a basis for building a movement for patient safety.
Strategy Actions: Each commitment comes with a set of associated actions. These actions are designed
for adoption by local services as part of their local plans.
It is the vision of the Patient Safety Strategy that all patients will consistently receive the safest care
possible. This care is provided best by staff who feel engaged and valued, are emotionally connected to
and are fully involved in and enthusiastic about their work. The health service workforce is deeply
committed to providing an excellent service and when fully engaged we know that what we do and say
matters and makes a difference. An engaged workforce is also linked to reductions in the number of
safety incidents and improved clinical care. The Strategy also recognizes that patients are the best
advocates for and often best placed to inform and support safety improvement. That is why the Strategy
places a significant emphasis on them being central to the planning and implementation of the Strategy.

The Patient Safety Strategy has therefore been developed primarily to guide further safety improvements
at service level. It is recognized that this change cannot be centrally or nationally implemented. It can
however be supported nationally.

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Our Vision, Objective and Ambitions for Patient Safety

Vision Objective
All patients engaging with To improve the safety of all
Our health and social care Patients by identifying and
Services will consistently Reducing preventable harm
Receive the safest care Within the health and social
Possible. Care system .

Our Ambitions
1 for Patient Safety

For Staff
Staff have the information, knowledge, skills, environment, equipment, time and supports required to do
their job, to work effectively with others for safety, to improve safety and to identify, implement and
sustain new safety practices.
For Patients
Patients have the information, knowledge, skills and supports that they need to feel safe, to take
responsibility for their own safety, to contribute to improvements in patient safety and to partner with
health and social care services to inform and influence the future development of safe and person-
centered care.
For Organizational Learning
We have a culture of patient safety which actively promotes, captures, shares, spreads and implements
learning to improve patient safety at every level of the organization
For Systems
We have resilient and safe systems where staff are supported to do their jobs safely and to work together
effectively. There is co-production of safe healthcare with patients and a culture of meaningful
measurement and improvement for safety.

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Our Commitments to Patient Safety
The vision and objective of the Patient Safety Strategy will be supported through the achievement of
the 6 strategic commitments set out below.

Patient Safety Commitments:

1) Empowering and Engaging Patients to Improve Patient Safety

We will foster a culture of partnership to maximize positive patient experiences and
outcomes and minimize the risk of error and harm. This will include working with and
learning from patients to design, deliver, evaluate and improve care.
2) Empowering and Engaging Staff to Improve Patient Safety
We will work to embed a culture of learning and improvement that is compassionate, just,
fair and open. We will support staff to practice safely, including identifying and reporting
safety deficits and managing and improving patient safety.
3) Anticipating and Responding to Risks to Patient Safety
We will place an increased emphasis on proactively identifying risks to patient safety to
create and maintain safe and resilient systems of care, designed to reduce adverse events and
improve outcomes.
4) Reducing Common Causes of Harm
We will undertake to reduce patient harm, with particular focus on the most common causes
of harm.
5) Using Information to Improve Patient Safety
We will use information from various sources to provide intelligence that will help us
recognize when things go wrong, learn from and support good practice and measure, monitor
and recognize improvements in patient safety
6) Leadership and Governance to Improve Patient Safety
We will embed a culture of patient safety improvement at every level of the health and social
care service through effective leadership and governance.

Commitment 1: Empowering and Engaging Patients to Improve

Patient Safety
We will foster a culture of partnership to maximize positive patient experiences and outcomes and
minimize the risk of error and harm. This will include working with and learning from patients to
design, deliver, evaluate and improve care.

Rationale

 Key to patient safety and person-centered care is a culture where patients, careers, families,
advocates and health care professionals work together in partnership to ensure positive patient
experiences, maximize positive health outcomes and minimize the risk of error and harm. The
goal is to achieve a culture that welcomes authentic patient-partnership in their care and in the
process of co-producing, delivering and improving care.

Patient Safety Principle

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Patients are supported with the knowledge, skills and supports that they need to take responsibility for
improving their own safety in partnership with staff. Patients, families, careers and advocates are listened
to and actively involved in making our services safer.

Commitment 1: Empowering and Engaging Patients to Improve

Patient Safety Actions
a) We will foster a culture and practices in which patients are fully informed and engaged in
decisions about their care and are facilitated to best support their own safety.
b) We will implement initiatives so that patients will have the required skills, information and
knowledge about their condition, complex care needs and treatment options.
c) In partnership with patients, we will continue to develop mechanisms to empower patients to
contribute to the safety of health and social care services. This will include their involvement as
partners in key governance structures and processes.
d) We will continue to participate in the National Care Experience Programme and associated
experience surveys to enhance the ability of the health and social care services to listen to and act
on the voice of patients.
e) We will develop resources and supports with patients that draw on their experiences and expert
knowledge.
f) We will identify and address the training and information needs of patients, families, careers,
patient representatives and advocates to enable them to contribute to preventing harm and
improving patient safety including reporting incidents and patient safety issues.
g) We will strengthen our partnerships with patient representative groups and, in particular, with
those groups that focus on patient safety improvement such as the WHO’s recommendations. We
will inform patients about partnerships at local and national level and how to be involved.
h) We will develop a national function reporting to the Chief Clinical Officer with particular
responsibility for enhancing our approach to meaningful partnerships with patients.
i) We will further embed a culture where we acknowledge when things go wrong, offer meaningful
apologies, and act to put things right through the implementation of relevant legislative
provisions and policies in relation to Patient Safety and Open Disclosure
j) We will support patients and families following an adverse event through open communication
and engagement, understanding what went wrong and the identification of measures to reduce the
recurrence of the preventable causes of harm.
k) We acknowledge the psychological distress caused to patients and families when adverse events
occur and we will further develop resources and supports in this area.

Commitment 2: Empowering and Engaging Staff to Improve

Patient Safety
We will work to embed a culture of learning and improvement that is compassionate, just, fair and open.
We will support staff to practice safely, including identifying and reporting safety deficits and managing
and improving patient safety.
Rationale
Creating and maintaining a positive safety culture and designing safe systems of care is central to the
mission of our health and social care services. It is a culture where safety is seen as an organizational
wide priority, there is learning from failures and successes, there is an understanding of the current
climate and its challenges and meaningful actions for improvement are implemented. Staff must be
actively encouraged to speak up for safety, feel psychologically safe, be involved in decisions which

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affect the safe delivery of care and be provided with the skills, support and time to engage in safety
improvement initiatives.
Patient Safety Principle
Health and social care service staff will understand the importance of patient safety and the contribution
they can make to ensuring safe care is provided. They will be supported to deliver care safely and
reliably, to be sensitive to the situations within which they work and to respond with transparency,
openness and compassion to harm events when they occur.

Commitment 2: Empowering and Engaging Staff to Improve

Patient Safety Actions
a) We will support staff to deliver safe, high quality care by ensuring their work environment and
health care structures and processes are designed and managed to facilitate safe practice.
b) We will facilitate and co-ordinate efforts to assess, plan and manage workforce and resource
requirements, using risk based prioritization, to ensure safe systems of work and safe staffing
levels that support improvements to patient safety.
c) Systems and processes will be further developed to ensure that staff are effectively listened to,
communicated with and are fully involved and engaged in the planning and delivery of the
services they provide and that they are supported and facilitated to raise safety concerns and
improve patient safety.
d) We will enhance the capacity and capability of health and social care services and staff to
improve patient safety by designing and delivering safety information and training to include
patient safety and reliability science, systems thinking, audit, quality improvement
methodologies, change management, human factors and multidisciplinary team working for
safety.
e) In partnership with staff and training bodies, we will develop strategies to promote behaviors that
support a culture of safety including collective leadership, communication and multidisciplinary
team working. This will include strategies that enhance situational awareness, for example ‘safety
pauses’ for teams.
f) We will facilitate the continued coordination, networking, sharing and learning for patient safety
amongst patient safety leaders, staff, health care providers and external agencies such as the
Health Information and Quality Authority, Mental Health Commission, Health and Safety
Authority and State Claims Agency.
g) We will continue to support staff in reporting and learning from incidents and implement
strategies to enhance and improve incident reporting and reviews.
h) We will improve and develop supports (including psychological support) and care for staff
affected by serious patient safety incidents.
i) We will continue to support programs promoting a patient safety culture and person centeredness.
j) We will measure the culture of patient safety across health and social care services and identify
and implement actions to address identified deficits.

Commitment 3: Anticipating and Responding to Risks to Patient

Safety
We will place an increased emphasis on proactively identifying risks to patient safety to create and
maintain safe and resilient systems of care, designed to reduce adverse events and improve outcomes.

Rationale

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Anticipating risks before they occur and acting to address these risks, will allow us to keep the people
who use our services safer, will provide better outcomes for patients and staff and will help develop trust
and confidence in health and social care services. Key to this is supporting services to change the way
they handle safety, by moving from a reactive and incident-based approach to a more proactive and risk
mitigation-based one.
Patient Safety Principle
Health and social care services will be trusted by patients to identify and manage risks to their safety,
learn from things that go wrong, learn from examples of good practice and show measureable progress in
reducing levels of preventable harm

Commitment 3: Anticipating and Responding to Risks to Patient

Safety Actions
a) Governance arrangements for the management of risk will be closely integrated into the
organization’s overall management processes.
b) Addressing risks to patient safety will be a priority area of focus in all health and social care
service strategic planning and commissioning.
c) Key strategic and policy decisions taken by management teams will be routinely risk assessed so
that unintended consequences that might impact on patient safety are avoided.
d) We will change the way services address safety risks, from the prevailing reactive and incident-
based approach, to a more proactive and risk mitigation-based one.
e) We will put in place systems to continuously improve the quality and analysis of patient safety
data and intelligence to allow us assess risks to patient safety. We will then put in place
appropriate actions to mitigate identified risks, including building the response to these risks into
planning and resource allocation decisions.
f) We will improve the quality and timeliness of incident reviews and ensure that learning from the
review of incidents is optimized and routinely used to inform system change and the development
of safety programs.
g) We will put in place formal processes for the communication of risk in line with the
organization’s accountability arrangements.
h) We will integrate patient safety information and data to allow us to analyze the reliability of
health and social care processes, proactively identify areas of risk to patient safety, and learn from
where things go wrong and from examples of good practice in a way that will inform safety
improvement programs.
i) We will publish data in relation to patient safety across the health and social care system.
j) We will seek to put in place resourcing for the full implementation of National Clinical
Guidelines produced by the National Clinical Effectiveness Committee.
k) We will strengthen clinical audit structures and processes to improve both patient outcomes and
safety outcomes within our health and social care services.

Commitment 4: Reducing Common Causes of Harm

We will undertake to reduce patient harm, with particular focus on the most common causes of harm
Rationale
International evidence indicates a number of high impact patient safety risks which, if tackled effectively,
can result in improving safety in healthcare organizations.
Patient Safety Principle
Health and social care services will implement best practices for patient safety, incorporating safety
improvement methodologies, to achieve a measurable reduction in patient harm in prioritized safety areas.

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Patient Safety Improvement Priorities:
o Reducing Healthcare Associated Infection and Antimicrobial Resistance
o Recognition and Response to Clinically Deteriorating Patients
o Recognizing, Reducing and Managing Venous Thromboembolism (VTE)
o Safeguarding Vulnerable Patients
o Ensuring Safe Practices of Care within High Risk Environments
o Reducing and Managing Sepsis
o Prevention of Violence, Harassment and Aggression
o Reducing Medication Related Harm
o Reducing the Risk of Harm from fall
o Improving Safety for those with Disabilities and Mental Health Needs
o Prevention and Management of Pressure Ulcers
o Improving Safety at Transitions of Care including Clinical Handover
o Reducing the Number of Preventable Birth Injuries in Babies

Commitment 4: Reducing Common Causes of Harm Actions

a) We will put in place integrated governance structures with clear accountability for planning,
managing and addressing the above patient safety priorities.
b) We will develop implementation plans and prioritize initiatives to address these and other
emerging priorities for patient safety improvement as part of our annual and multi annual
planning process over the course of the Strategy’s lifetime.
c) Through the National Patient Safety Program we will monitor the implementation plans for the
prioritized patient safety initiatives and the attainment of patient safety improvements.
d) We will constantly monitor and review patient safety risks and will prioritize other patient safety
and improvement initiatives where this is required.
e) We will include patient safety as a key objective in any current or newly established programme,
strategy, policy or project across health and social care services.
f) We will align current specialist resources at national level within the HSE to support the priorities
set out in the Strategy.
Commitment 5: Using Information to Improve Patient Safety
We will use information from various sources to provide intelligence that will help us recognize when
things go wrong, learn from and support good practice and measure, monitor and recognize
improvements in patient safety
Rationale
The measurement of patient safety is complex. To make health and social care safer, organizations must
be transparent and open, continually measuring harm and reliability, recognizing and learning from good
practice, assessing standards of care and targeting programmes of improvement. They must also remain
alert to problems and changes as they occur and be adept at responding to and managing potential threats
to safety.
Patient Safety Principle
There is an ability to learn and improve across the whole health and social care service. Patients, careers,
families, health service leaders and staff will know that services are safe based on reliable information.
They will know too that incidents will be quickly identified and responded to, ensuring continuous
learning and improvement in safety.
Commitment 5: Using Information to Improve Patient Safety
Actions

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 a) We will further develop and enhance local and national suites of key patient safety indicators
which will be used as part of the health and social care services’ performance and accountability
process.
b) We will measure and monitor safety to evaluate the effects of safety improvement initiatives and
to inform further emerging priorities.
c) We will develop, consolidate and continuously improve patient safety surveillance and reporting
systems at every level of the health and social care service.
d) We will use a range of information sources and methods of presenting data, including incident
and risk data, quality and safety metrics for clinical services, assessments against national
standards, patient engagement, staff engagement, claims, complaints, incident reviews, clinical
audit, regulatory reports, Coroner’s reports, mortality reviews and research to support these
patient safety surveillance and reporting systems.
e) We will publish reports in relation to our performance in patient safety and we will recognize and
highlight achievements in patient safety improvement.
f) We will measure compliance with the National Standards for Safer, Better Healthcare and report
on implementation.
g) We will support patient safety research and publish and act on the results.
h) We will further develop and enhance technology solutions, including eHealth, to improve access
to and reliability of information to measure and improve patient safety.

Commitment 6: Leadership and Governance to Improve Patient Safety

We will embed a culture of patient safety improvement at every level of the health and social care service
through effective leadership and governance.
Rationale
Effective leadership and governance, adequate supports for patient safety, appropriate infrastructure,
skills, team-working, knowledge, values and behaviors are critical to patient safety. Leadership is
fundamental to shaping an organizational culture with safe, person-centered and compassionate care at its
core. Effective governance provides the necessary structures, processes, standards and oversight at every
level of the organization to ensure that services are safe.
Patient Safety Principle
Leaders, managers and clinicians across health and social care services will be visible and active in
influencing the safety of care by shaping culture and building resilience within the organization, setting
direction, providing support to the workforce, implementing a systems approach to safety improvement
and monitoring progress and improvement in safety performance.
Commitment 6: Leadership and Governance to Improve Patient Safety
Actions
a) The HSE Board will demonstrate its commitment to patient safety by endorsing this Strategy and
by monitoring its implementation.
b) Patient safety, including safety performance and improvement and anticipating and managing
risk, will be a priority at all levels of the organization.
c) We will put in place a National Patient Safety Programme to support the implementation of
actions set out in this Strategy.
d) The National Patient Safety Programme will prepare an overall implementation plan for the
Strategy, progress against which will be publicly reported.

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 e) Patient Safety actions to implement this Strategy will be included in the HSE’s National Service
Plan and in each service level Operational Plan.
f) We will strengthen clinician leadership for patient safety at local and national level to provide
support and advice and to lead the integration of national efforts to improve patient safety.
g) An investment strategy for patient safety will be developed for approval by the HSE Board to
address risk-prioritized patient safety issues both at national and service level.
h) We will support appropriate governance arrangements for patient safety (including appropriate
clinical governance structures) in line with the requirements of Sláintecare. There will be defined
responsibilities for Boards, management, staff and relevant multidisciplinary quality and safety
committees.
i) We will work with staff and relevant training bodies to support the development of leadership
(including clinical leadership) for patient safety across health and social care services. This
leadership will seek to adopt and embed in our health and social care services behaviors that
promote teamwork, collective decision making and trust.
j) We will align staff skilled in quality and patient safety with patient safety initiatives to support
the achievement of the objectives of this Strategy.
k) We will develop a comprehensive communications program and supporting awareness campaign
to engage support for patient safety amongst the public and health and social care staff and to
disseminate learning and good practices.

References
1) Building a better health service patient safety strategy 2019-2024
2) World Health Organization (WHO) (2007) Patient Safety Solutions. Vincent, C (2006), Patient
Safety, Churchill Livingstone (Publisher)
3) World Health Organization (WHO) (2016), Transitions of Care: Technical Series on Safer
Primary Care.
4) Health Information and Quality Authority (HIQA) (2018), Guidance on data quality framework
for health and social care
5) Global Patient Safety Action Plan 2021–2030 Towards eliminating avoidable harm in health care

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