Objective

The role of a safety committee is to establish and maintain a progressive patient safety program to provide safe environment to the patient, visitors and employees.

Scope

Applicable to all the members in the safety committee.

Constitution of committee

1. Nursing superintendent
2. Fire & Safety Officer
3. Sr. Lab Incharge
4. CT Scan Technician
5. Sr. OT Incharge
6. A/C Manager
7. Bio-Medical Engineer
8. Maintenance In-charge
9. Housekeeping Supervisor.
10. MRD in-charge
11. Sr. Security Officer.
12. RSO
13. Executive – Medical Service & Operation.
14. Manager – Quality & Operations

The chairman shall have the authority to invite any non-member to attend the meeting if it is deemed fit in relation to any matter being/ or to be deliberated by the committee.

Quorum

The minimum quorum for passing any resolution in the committee should be 50% of the members present in the committee with chairperson being mandatory.

Frequency of meeting

Members of the committee meet once in two months.

Selection of members

1. Chairperson – Selected by the chairman of Apex Committee
2. Secretary – Selected by the chairperson, he or she is also a member of the committee
3. Members – Selected by the chairperson

Responsibilities

To oversee, guide and ensure the following aspects of safety in the hospital

1. Environment/facility safety
2. Emergency management

• Promote a culture of safety throughout the hospital through staff education programmes and training
• Display patient education materials for educating patients and families on their role in ensuring safety at the hospital.
• Conduct a thorough facility safety inspection of the campus once a year in a non-patient care area and twice in a year inpatient care area; to map potential safety risks to patients and employees. The documented findings of the safety inspection will be submitted to the quality department with suitable recommendations for actions
• Conduct root-cause analysis for major safety-related incidents and ensure appropriate corrective and preventive actions
• Analyze all reported sentinel events (safety-related) and plan and ensure corrective and preventive actions
• Review and update the list of sentinel events (safety-related) periodically based on the emerging studies published in international journals, information databases of organizations like NABH and JCAHO.
• Compile performance statistics for safety-related indicators and analyze the same for trends.
• To promote a culture of ‘Do no harm’ and report any ‘Near Misses’ to ensure higher safety for the patients and personnel.
• The committee is responsible for implementing a systematic process of identifying the factors within the hospital that contribute to posing risk to a patient, visitor or staff member of the Hospital. This also encompasses the collection and aggregation of adverse event reports from all the sources.
• To guide, advise, oversee, and monitor the capability and capacity of the organization to track and institute corrective measures to deal with ‘Sentinel Events’ including investigation and consequent response.
• To review incident reporting analysis
• To take immediate steps to address, resolve, and track the issues, which are brought to notice through safety rounds and/or other channels
• To monitor and initiate actions for appropriate storage and safety practices with regard to all hazardous and dangerous materials including waste management.

Role of Chairperson

• Acts as a liaison between the safety committee members and the hospital administration.
• Receives all the safety audit reports and information pertaining to hospital safety, initiate necessary action based on the reports.
• Initiate surveillance programmes in the hospital.
• Keep oneself abreast with the recent developments in the field

Role of secretary (Member secretary)

• Prepare the agenda for the next meeting
• Submission for approval of agenda by the chairperson
• Inform the committee members regarding the next meeting at least 2 days before the meeting
• The minutes of the meeting shall be prepared by the secretary
• Get the approval of minutes by the chairperson
• Circulate the agenda approved by the chairperson to the members and the concerned persons
• To maintain all records ( as per list) related to the committee
• Submission of a copy of the agenda and the minutes of the meeting to the quality department after getting a signature from all the concerned members

Agenda

Agendas for the meeting shall be prepared by the secretary in consultation with the chairperson and signed by the chair. Then it is sent to all committee members and other experts. The agenda shall be sent to all at least 2 days before the scheduled meeting.

A meeting shall be called even by an oral / telephone communication in case of an emergency meeting. A justification for the emergency meeting has to be given.

Minutes

• Shall be prepared by the secretary.
• MoM is sent to the chairperson for the approval within three days of the meeting.
• After the approval of the minutes by the chairperson, the approved minutes are circulated within 2 days of the meeting to all the committee members and the person concerned for implementation.
• A copy of the agenda and minutes of every meeting shall be sent to the quality manager by the member secretary

Decision making

• A thorough discussion of the agenda shall be done by the committee members and based on their suggestion and recommendations the issue shall be weighed. Also as and when needed any kind of trial study may be performed and based on the outcome of it the committee will decide on that issue.
• The decision of the committee will be finally taken by a majority vote and that shall be implemented.

Records to be maintained

1. List and details of all members
2. The TOR of the committee
3. Copy of all agendas, minutes of all meeting
4. Attendance sheet
5. Copy of any other correspondence to the committee members or non-members
6. Copy of any study conducted for the sake of the committee