Dr.

Ramkishor R Pandey
The most natural division of all offences is that of omission and commission

-Addison
GENERAL SAFETY RULES
 URGENCY SHOULD NOT BE USED AS AN EXCUSE TO
NEGLECT SAFETY
 WHEN IN DOUBT DON’T INDULGE IN GUESSWORK
 DO NOT HANDLE OR OPERATE MACHINERY WITHOUT
AUTHORIZATION
 REPORT IMMEDIATELY ANY FAULTY EQUIPMENT
 MAINTAIN PERSONAL HYGIENE
 FOLLOW ESTABLISHED PROCEDURES
 CO-OPERATE WITH H.I.C.C. TO PREVENT INFECTION SPREAD
 WEAR PROPER UNIFORM FOR THE JOB
 NEVER INDULGE IN PRACTICAL JOKES INVOLVING FIRE, ACID,
COMPRESSED AIR ETC…
 PAY DUE ATTENTION TO ALL WARNING BOARDS
 BE FAMILIAR WITH WORK PROCEDURES
 USE A GOOD LADDER FOR OVERHEAD OBJECTS
 ALWAYS REMEMBER TO USE HANDRAILS ON STAIRWAYS OR
RAMPS
PATIENT CARE SAFETY
 PREVENT FALL FROM BED ESP. FOR DISORIENTED AND
SEDATED PATIENTS
 MAKE INFIRM PATIENTS AT EASE
 PROVIDE FOR PATIENTS’ BELONGINGS TO BE KEPT WITHIN
EASY REACH
 USE BEDSIDE RAILS ON BOTH SIDES
 DOUBLE CHECK MEDICATIONS REGARDING INSTRUCTIONS,
LABELS AND PATIENT IDENTITY
 KNOW PROPER TECHNIQUES FOR LIFTING A PATIENT UP IN
BED, TURNING A PATIENT IN BED
 KEEP MEDICINE SUPPLY LOCKED
PREVENTION OF A FALL
 FLOOR MATS TO BE PROVIDED WHERE INDICATED
 PICK UP LITTLE THINGS ON FLOOR LIKE BANANA PEELS
 STAIR THREADS TO BE PROPERLY MAINTAINED
 CLEAN UP A LIQUID SPILL IMMEDIATELY
 HAND RAILS TO BE PROVIDED ON ALL STAIRCASES
 TAKE ONE STAIR AT A TIME
 VARIATIONS IN FLOOR LEVELS TO BE
PROPERLY ILLUMINATED
 BEWARE OF ELECTRICAL CORDS
 PROPER MAINTENANCE OF STEP LADDERS
 PROPER MAINTENANCE OF LIFTS AND
STAIRCASES
SAFETY IN TRAFFIC
 SECURE WHEELCHAIR OR STRETCHER BY LOCKING WHEEL
BRAKES BEFORE LOADING OR UNLOADING PATIENT
 PUSH STRETCHERS AND BEDS FROM THE END AND NOT ON
THE SIDES
 CONTROL STRETCHERS AND WHEELCHAIRS FROM THE
LOWER SIDE WHILE GOING UP OR DOWN THE RAMP
 SWINGING DOORS SHOULD HAVE VISION PANELS
 ALL STRETCHERS TO HAVE ATLEAST 2 ATTENDANTS
SAFETY IN ELECTRICAL GOODS
 PREVENT DAMPNESS NEAR SWITCHES, WIRINGS AND
APPLIANCES
 INSPECT CORDS, PLUGS, SWITCHES, SOCKETS FREQUENTLY
TO ENSURE THEY ARE NOT DAMAGED
 REPORT ELECTRICAL FAULTS IMMEDIATELY
 REPORT DEFECTIVE WIRING TO MAINTENANCE DEPT.
 BE SURE EQUIPMENT IS PROPERLY GROUNDED
 AVOID USING ADAPTER TO FIT 3-PINNED PLUG
IN A 2-PINNED OUTLET
 ALWAYS CONNECT AND DISCONNECT
IN THE “OFF” POSITION
 REPLACE BRASS ELECTRICAL SOCKETS BY NON-CONDUCTIVE
MATERIAL
 NEVER ATTACH DECORATIONS OF PAPER OR CLOTH TO
ELECTRICAL WIRES
 DON’T FASTEN EELECTRICAL CORDS BY NAILS OR STAPLES
 DON’T USE ANY PORTABLE ELECTRICAL APPLIANCE UNTIL ITS
SAFETY HAS BEEN CHECKED
WHO’S 9 PATIENT SAFETY SOLUTIONS
 Ensuring legibility of prescriptions,using pre-printed orders, or
electronic prescriptions;
 Providing opportunities for practitioners to ask questions during
handover of patients
 Involving the patients and their families in this process;
 Comparing the “home” list of all the drugs a patient is taking with the
admission, transfer, or discharge order when writing medication
orders
 Ensuring that the list is transferred to the next provider of care at
transition points;
 Prohibiting the reuse of needles at health care facilities
 Ensuring safe needle disposal practices;
 Making alcohol-based hand rubs available at all points of care
 Putting reminders of hand hygiene techniques in the workplace
“To Err is Human”

Distinction between two types of causes of errors in medicine:

Individuals and Systems.
 The Paradox

 HEALTH CARE
 LITERACY
 PATIENT SAFETY
Problem Analysis:

Error may be because:

1. staff not trained correctly.
2. policy procedure is outdated and doesn’t apply to current
equipment being used.
3. Training was inadequate and staff did not feel free to ask
questions.
4. First time procedure for caregivers.
5. unavailability of more knowledged persons to ask for.
6. Some other emergency might have come up and didn’t get time
to return and check the patient.
 ROLE OF ADMINISTRATOR

The administrator’s role is to engage others to:

 Design and operate systems based on evidence in safety science

 Develop and support people who provide care and services
 Build a culture of safety and continuous learning
 Focus and align resources to create greater safety
 Assure evidence based, patient centered and system centered work
The Antithesis
REMEMBER…

 Health care is a complex system and is inherently

risk prone where crisis are common so team work is
essential.
 People, no matter how competent and vigilant are
falliable when faced with multiple cognitive demands.
 People create safety by defending against risk,
intercepting error before it reaches the patient.
 Safety is a system and can post threats of failure and
risk prone professionals and organisational cultures
are often associated with faulty communications.