トピック10 患者安全と侵襲的処置 When Rabia first mentioned this conference to me in September 2007 I was impressed with her commitment, vision and energy for this international.

Presentation on theme: "トピック10 患者安全と侵襲的処置 When Rabia first mentioned this conference to me in September 2007 I was impressed with her commitment, vision and energy for this international."— Presentation transcript:

1 トピック10 患者安全と侵襲的処置 When Rabia first mentioned this conference to me in September I was impressed with her commitment, vision and energy for this international event. But frankly, I was a little nervous at how much work was needed to deliver such an ambitious programme in such a short time. It is an amazing testament to Rabia, Mustafa and other members of the organising committee and staff that this impressive programme has been realised here in this fantastic venue. I am delighted to be able to support this congress and the initiatives that are being shared to improve patient safety globally In my presentation I will draw on the global work on patients safety, reflecting on how patient safety affects us all how we should and can learn from error the work of the WHO World Alliance for Patient Safety and the personal experience of some clinicians, professionals, policy makers and patients in their efforts to make healthcare safer across the world I will be expending on this introduction in two interactive workshop sessions, one on Patients for Patient Safety and patient engagement and the other, a Learning from Error workshop 1 1

2 学習目標 以下を理解する 外科的及び侵襲的処置に伴う有害事象の主な原因
ガイドラインを遵守し，確認プロセスを実施し，チームワークを重視することによって，正しい患者に対して正しい時期に正しい場所で正しい治療を施行できるようになること 2 2

3 習得すべき知識 外科的及び侵襲的処置に関連した有害事象の主な種類 外科的及び侵襲的処置の安全を改善する確認プロセス 3
Launched in 2004 following the WHA Resolution which called for Member States to "pay the closest possible attention to the problem of patient safety" Promote awareness and political commitment Expert-led technical programmes to improve patient safety worldwide The Alliance will be publishing its Forward programme shortly. 3 3

4 習得すべき行動内容 患者間違い，手術部位間違い，手技間違いを回避するため の確認プロセス（術前チェックリスト）に従うことができる
リスクとエラーを減らすための技術を実践できる（タイムアウ ト，ブリーフィング，デブリーフィング，懸念の表明など） 死亡及び合併症について検討する教育プロセスに参加する チームの一員として積極的に取り組むことができる いかなる時も積極的に患者と向き合うことができる Launched in 2004 following the WHA Resolution which called for Member States to "pay the closest possible attention to the problem of patient safety" Promote awareness and political commitment Expert-led technical programmes to improve patient safety worldwide The Alliance will be publishing its Forward programme shortly. 4 4

5 侵襲的及び外科的処置に伴う 有害事象の主な原因
不良な感染管理 不十分な患者管理 処置の開始前，実施中及び終了後における医療提供者の コミュニケーションの失敗 Launched in 2004 following the WHA Resolution which called for Member States to "pay the closest possible attention to the problem of patient safety" Promote awareness and political commitment Expert-led technical programmes to improve patient safety worldwide The Alliance will be publishing its Forward programme shortly. 5 5

6 外科的処置 の質を改善 するための 確認プロセス
ガイドライン，プロトコル，チェッ クリストとは？ 外科的処置に関する ガイドラインとチェックリスト Launched in 2004 following the WHA Resolution which called for Member States to "pay the closest possible attention to the problem of patient safety" Promote awareness and political commitment Expert-led technical programmes to improve patient safety worldwide The Alliance will be publishing its Forward programme shortly. 6 6

7 リスク及びエラーを軽減するための 手術室での技術
チームのブリーフィング及びデブリーフィングに参加する 十分な情報を共有する 質問する 適切に自己主張する 意見を表明し，共有する 教育を行う 作業負荷を管理する Launched in 2004 following the WHA Resolution which called for Member States to "pay the closest possible attention to the problem of patient safety" Promote awareness and political commitment Expert-led technical programmes to improve patient safety worldwide The Alliance will be publishing its Forward programme shortly. 7 7

8 M&M検討会 そのような会議は開催されているか？ 教育と理解に重点が置かれているか？ 議論の目標が類似事象の再発防止に設定されているか？
その会議は中心的な活動とみされているか？ 全員が参加しているか？ 学生を含む若手も会議に出席するよう奨励されているか？ 死亡事例はどのように扱われているか？ 討論の要約が文書で管理されているか？ Launched in 2004 following the WHA Resolution which called for Member States to "pay the closest possible attention to the problem of patient safety" Promote awareness and political commitment Expert-led technical programmes to improve patient safety worldwide The Alliance will be publishing its Forward programme shortly. 8 8

9 要約 ガイドラインの価値 ガイドラインが用いられる理由を医療従事者が理解しておく 必要がある
プロトコルと確認ステップにより，患者間違いは最小限に減 らすことができる これらの技術を全員が用いれば，コミュニケーションを改善 し，エラーを最小限に減らすことが可能となる Launched in 2004 following the WHA Resolution which called for Member States to "pay the closest possible attention to the problem of patient safety" Promote awareness and political commitment Expert-led technical programmes to improve patient safety worldwide The Alliance will be publishing its Forward programme shortly. 9 9