Introduction to Patient Safety

Safety rules are your best tools

Syeda Rida Shahid

Safety?

 S _ Sense The Error

 A_ Act to prevent it
 F_ Follow the Safety Guideline
 E_ Enquire into incidents / Death
 T_ Take Appropriate Action
 Y_ Your Responsibility
 What is Patient safety?

 According to WHO, Patient Safety is a health care

discipline that emerged with the evolving complexity
of healthcare systems and the resulting rise of patient
harm in healthcare facilities. It aims to prevent and
reduce risks, errors, and harm that occur to patients
during the provision of health care.
We define patient safety as a discipline in the health care professions
that applies safety science methods toward the goal of achieving a
trustworthy system of health care delivery

We also define patient safety as an attribute of health care systems

that minimizes the incidence and impact of adverse events and
maximizes recovery from such events.
To Err is Human
➢The Institute of Medicine’s To Err Is Human, published in 1999,
represented a watershed moment for the US healthcare system.

➢At least 44,000 people, and perhaps as many as 98,000 people, die in
hospitals each year as a result of medical errors that could have been
prevented.

➢Talks about the concept of “First, do no harm.” - More commonly,

errors are caused by faulty systems, processes, and conditions that lead
people to make mistakes or fail to prevent them.

Institute of Medicine (IOM) USA, 1999

 Why Patient
❖ Recognizing that healthcare errors impact 1 in
every 10 patients around the world, the World Safety?
Health Organization calls patient safety an
endemic concern.
7 Medical Error
The failure of a planned action to be completed as intended or the
use of a wrong plan to achieve an aim.
❖ Adverse drug events
❖ Improper transfusions,
❖ Medication Error
❖ Surgical injuries and wrong-site surgery,
❖ Restraint-related injuries or death,
❖ Falls,
❖ burns, phlebitis and pressure ulcers,
❖ Mistaken patient identities
Causes for Errors

 1.Individual made: errors due to human factor in the process (

wrong calculations of drugs, not following the 5 rights of
medications)

 2. System made: holes in the system that allows to slip through

( no clear & detailed policy & procedures, no double-
checking systems)

 3. Environmental made: the dangers that come from the

setting of the hospital & the material & equipments used ( no
fire exit doors, worn out power cables )
Activity (Identify Errors)
Individual Made
Reading the wrong gauge
Environment Made
Poor Infrastructure
No clear & detailed policies & procedures System Made

Forgetting to carry out a step in a procedure Individual Made

No double-checking systems System Made
Poor Infrastructure Environment Made
No clear & detailed policies & procedures System Made
Forgetting to carry out a step in a procedure
Individual Made
No double-checking systems
System Made
Identification of a patient through
bed number Individual Made

Inadequate Resources Environmental Made

No fire exit doors​ Environmental Made

Worn out power cables Environmental Made

 Human Error

 “To err is human ”

❖ Human beings make mistakes because the systems, tasks &
processes always have room for improvement.

❖ Every error has a root cause & every cause has a solution.

❖ Errors can be prevented with every one’s initiative in the system

Here comes the role of the Patient Safety Department

Its Not Important Who Caused the Accident but What
Caused It

We cannot change the human condition, but

we can change the conditions under which
humans work
13
 Identify the Case Scenario

IPSG 3- Improve the Safety of High Alert Medication

15 Identify the Case Scenario

A physician called in an order for “15 mg” of hydralazine to

be given IV every 2 hours. The nurse, thinking that he had
said “50 mg,” administered an overdose to the patient who
developed tachycardia and had a significant drop in blood
pressure.

IPSG 2- Improve Effective Communication-

Read Back
 Identify the Case Scenario
16

 An old age patient named Saima, admitted for elective laparoscopic

cholecystectomy. Her pre-operative anesthesia assessment was done and she was kept
NPO from midnight. The consent was signed by resident of general surgery.
 On the day of procedure patient was shifted to OT waiting room. Patient was waiting in
the waiting area, when trainee technician called patient Samiya name. Due to
misunderstanding patient Saima, went to Cath Lab staff. The trainee technician without
verifying patient’s identification from ID band for complete name and MR number, took
the patient inside Cath lab.
 The procedure was started. Patient’s angiography was performed and patient was
shifted to ward. The event was identified when post procedure patient was informed
about findings of anigiography. Then patient verbalized that she had come for the
surgery of gall stones.
Journey of Culture
Punitive Culture Blame-Free Culture
• Before the 1990s • By the mid 1990s
• Frontline workers were • Supported a "no-
afraid to report their blame" response to
own errors or those of
errors
a colleague
• Missed enormous • Unsafe acts were the
opportunities to learn result of mental slips or
about Errors lapses, or honest
• Little insight into mistakes
System-based causes
• Fails to tackle
individuals who make
unsafe / reckless
behavioral choices
Just Culture
• NEW
• Recognize that humans
are imperfect so errors
will and can happen to
anyone
• Staff are encouraged
(even rewarded) for
reporting errors
• There is a well-
established system of
accountability
• High insight into
System-based causes
1436-05 Just / Accountabillity Culture
 Patient Safety Culture

❖ A safety culture is the combination of attitudes and behaviors toward patient safety that are conveyed
when walking into a health facility.

❖ The three key elements of a safety culture are the following (Joint Commission "The Essential Role of
Leadership"):
• Fair and just culture
• Reporting culture
• Learning culture

❖ Safety culture is generally measured by surveys of providers at all levels. Available validated surveys include
AHRQ's Surveys on Patient Safety Culture™ (SOPS®) and the Safety Attitudes Questionnaire

❖ Hospitals to assess staff perceptions of an organization's safety culture and to pinpoint areas of concern. The
survey also helps identify differences in perception about the organization's safety culture among staff and
among care units.

❖ Safety culture surveys can be conducted periodically—preferably, every two years—to track changes and
improvements over time.
Just Culture

 A just culture focuses on identifying and addressing

systems issues that lead individuals to engage in unsafe
behaviors, while maintaining individual accountability by
establishing zero tolerance for reckless behavior.

 It distinguishes between human error (eg, slips), at-risk

behavior (eg, taking shortcuts), and reckless behavior
(eg, ignoring required safety steps), in contrast to an
overarching "no-blame" approach still favored by some.
The Three Behaviors
Human Error At-Risk Behavior Reckless Behavior
Product of Our Current A Choice: Risk Believed Conscious Disregard of
System Design and Insignificant or Justified Substantial and
Behavioral Choices Unjustifiable Risk

Manage through Manage through: Manage through:

changes in: • Removing incentives • Remedial action
• Processes for at-risk behaviors • Punitive action
• Procedures • Creating incentives
• Training for healthy behaviors
• Design • Increasing situational
• Environment awareness

Console Coach Discipline

The Model for Safety Culture

Pathologica • It does not matter what we do, as long

l as we do not get caught.

Reactive • Safety occurs in response to an incident

Bureaucrati
• Safety is driven by management systems
c/Calculati and imposed on the workforce
ve
• We continue to work on problems that
Proactive we identify

• The ideal, where safety is an integral

Generative part of everyday life in all staff
 ➢ Risk management for healthcare entities can be
defined as an organized effort to identify, assess, and
reduce, where appropriate, risk to patients, visitors, staff,
and organizational assets.
➢ Risk management in its best form may be to use it in a
proactive manner in identifying and managing the risks.
➢ Once a risk has been identified, healthcare staff
What Is Risk members can develop a means of addressing and
Management managing it.

in Healthcare? ➢ Healthcare risk management acknowledges that the

dangers of the risk are still there, but with preparation
and strong policies, the scope of those threats can be
reduced.
➢ Collecting feedback from patients and incident reports,
 23
Incident
An incident may be defined as
‘any event that has caused harm,
or has the potential to harm a
patient, visitor or staff member,
or any event which involves
malfunction, damage or loss of
equipment or property, and any
event which might lead to a
complaint.
Sentinel event
It is an unexpected occurrence
involving death or serious
physical or psychological injury,
loss of limb or function, or the
risk thereof.
Root Cause Analysis
(RCA)
Process for identifying the basic
or causal factor(s) that underlies
variation in performance,
including the occurrence or
possible occurrence of a sentinel
event.
Identify Incidents/Sentinel Events/Near Miss

1. Wrong Patient surgery

2. Wrong Medicine dispense
3. Fetal Abduction
4. Wrong Medicine dispense, but patient did not received
it due to timely intervention of a nurse
5. Patient developed bedsore
6. Wrong blood transfusion leads to patient’s death
7. Nurse placed B.P Cuff on hand at fistula side, patient
intervene timely