Patient Safety

WHO Curriculum
Marshell Tendean. MD. DPCP
Departement of Internal Medicine
UKRIDA Faculty of Medicine
Jakarta Indonesia
Objective :

• To describe the importance of patient safety approach

• Focus on the following issues :

• Infection control

• Perioperative procedure and assesment

• Risk of fall and Hospital Patient Safety indicator

Background :
•Element of Care

•Supportin
•Physician •Patients
g staff
Background
• There is now overwhelming evidence that significant numbers of patients are
harmed from their health care either resulting in permanent injury, increased
length of stay (LOS) in hospitals and even death
• When so many people and different types of health-care providers (doctors,
nurses, pharmacists, social workers, dieticians and others) are involved this
makes it very difficult to ensure safe care, unless the system of care is
designed to facilitate timely and complete information and understanding by
all the health professionals.
Emanuel and other patient safety leaders defined
patient safety as follows:
• “A discipline in the health-care sector that applies safety science
methods towards the goal of achieving a trustworthy system of
health-care delivery. Patient safety is also an attribute of health-care
systems; it minimizes the incidence and impact of, and maximizes
recovery from adverse events [49].”
This model shares fifty similar features with other
models of quality design including:

• Understanding the system of health care.

• Recognizing that performance varies across services.

• The methods for improvement including how to implement and

measure a change.

• Understanding the people who work in the system and their

relationships with one another and the organization.
Case Ilustration :
• This case shows how easy it is to inadvertently reuse a syringe.
• Sam, a 42-year-old man, was booked for an endoscopy at a local clinic. Prior to the procedure he
was injected with sedatives, but after several minutes the nurse noticed Sam seemed
uncomfortable and required additional sedation. She used the same syringe, dipped it in the open
sedative vial and re-injected him. The procedure continued as normal.
• Several months later, Sam, suffering from swelling of the liver, stomach pain, fatigue and jaundice,
was diagnosed with Hepatitis C. The Centers for Disease Control was contacted, as 84 other cases
of liver disease were linked to the clinic. It was believed that the sedative vial may have been
contaminated from the backflow into the syringe and that the virus may have been passed on
from the contaminated vial.
Infection Control
Main types of infections

• Infectious diseases are caused by pathogenic micro-organisms such as

bacteria, viruses, parasites or fungi; the diseases can be spread,
directly or indirectly, from one person to another.

• Zoonotic diseases are infectious diseases of animals that can cause

disease when transmitted to humans.
Health care-associated infections causes :
• person–person via hands of health-care providers patients and
visitors;
• personal equipment (e.g. stethoscopes, computers) and clothing;
• environmental contamination;
• airborne transmission;
• carriers on the hospital staff;
• rare common-source outbreaks.
Burden of Infection
• Between 5% and 10% of patients admitted to modern hospitals in the
developed world acquire one or more infections.
• The risk of health care-associated infection in developing countries is from
2 to 20 times higher than in developed countries. In some developing
countries, the proportion of patients affected by a health care-acquired
infection can exceed 25%.
• In the United States, 1 out of every 136 hospital patients becomes seriously
ill as a result of acquiring an infection in hospital; this is equivalent to two
million cases and about 80 000 deaths a year.
Infection control

• Infection control practices can be grouped in two categories :

1. Standard precautions

2. Additional (transmission-based) precautions

Standard precautions
• Treating all patients in the health care facility with the same basic
level of “standard” precautions involves work practices that are
essential to provide a high level of protection to patients, health care
workers and visitors.
These include the following:
• Hand washing and antisepsis (hand hygiene);
• Use of personal protective equipment when handling blood, body
substances, excretions and secretions;
• Appropriate handling of patient care equipment and soiled linen;
• Prevention of needlestick/sharp injuries;
• Environmental cleaning and spills-management; and
• Appropriate handling of waste.
WHO Recommendation on Hand hygiene
The 5 moment of hand washing :
 Gloves
• There are two main indicators for wearing gloves in the clinical
setting:
• to protect the hands from contamination with organic matter and micro-
organisms;
• to reduce the risk of transmitting micro organisms to both patients and staff
Cough ethics :
Health care facilities should :
Place acute febrile respiratory symptomatic patients at least 1 metre (3 feet)
away from others in common wait- ing areas, if possible.
Post visual alerts at the entrance to health-care facili- ties instructing persons
with respiratory symptoms to practise respiratory hygiene/cough etiquette.
Consider making hand hygiene resources, tissues and masks available in
common areas and areas used for the evaluation of patients with respiratory
illnesse
Guidelines for wearing apron and mask
• Wear disposable plastic aprons when in close contact with the patient, material or
equipment or when there is a risk that clothing may become contaminated;

• Dispose of plastic aprons after each episode of care or procedure. Non-disposable

protective clothing should be sent for laundering;

• Wear full-body, fluid-repellent gowns when there is a risk of extensive splashing of

blood, bodily fluids, secretions or excretions with the exception of perspiration.
• Face masks and eye protection should be worn when there is a risk of blood,
bodily fluids, secretions and excretions splashing into the face and eyes.

• Respiratory protective equipment is to be worn when caring for patients with

respiratory infections transmitted by airborne particles.
Waste disposal

Ensure safe waste management.

Treat waste contaminated with blood, body uids, secretions and excretions as
clinical waste, in accord- ance with local regulations.
Human tissues and laboratory waste that is directly associated with specimen
processing should also be treated as clinical waste.
Discard single use items properly.
Safe Injections
Who Recommendation for save injections
INJECTION DEVICE SECURITY

• In curative and preventive services, ensuring injection device security implies

appropriate forecasting, nancing, procurement and supply management so that the
following items are available in adequate quantities:
• Injectable products (AD/RUP/SIP);
• Appropriate single dose diluents;
• Single use injection devices for injection and reconstitution;
• Safety bxoxes.
Recommendation :
Students should know what to do if exposed :

• If a student is inadvertently exposed or becomes infected they should

immediately:
• Notify the appropriate staff in the hospital or clinic as well as a supervisor. It is
important that students receive appropriate medical attention as soon as
possible.

• Immunizised with hepatitis B vaccine.

Save Surgery
Case ilustration
• A 42 yo woman, with symptoms of chronic kidney disease come with a chief
complaint of fatigue
• She has a previous history of parathyroid adenoma and underwent unilateral
parathyroidectomy 2 years ago
• Her present PTH is 3000 u/ml (15-40 u/mL) and her current lumbal x ray showed
diffuse calcifications and osteoporosis.
• The procedure instead shall be started with locating the functional nodul prior to
surgery with sestamibi nuclear scanning which has not done in the patient.
The Safe Surgery Saves Lives programme aims to improve surgical safety and reduce
the number of surgical deaths and complications in four ways:

(1) By giving clinicians, hospital administrators and public health officials

information on the role and patterns of surgical safety in public health;
(2) By defining a minimum set of uniform measures or ‘surgical vital
statistics’, for national and international surveillance of surgical care;
(3) By identifying a simple set of surgical safety standards that can be used in
all countries and settings and are compiled in a ‘surgical safety check-list’ for
use in operating rooms; and
(4) By testing the checklist and surveillance tools at pilot sites in all WHO
regions and then disseminating the checklist to hospitals worldwide.
The Australian Commission on Safety and Quality in Healthcare uses a
five-step process similar to the Universal Protocol to prevent wrong site
surgery:

• Step 1: Check that the consent form or procedure request form is

correct.
• Step 2: Mark the site for the surgery or other invasive procedure.
• Step 3: Confirm identification with the patient.
• Step 4: Take a ‘team time out’ in the operating theatre, treatment or
examination area.
• Step 5: Ensure appropriate and available diagnostic images.
Who Reccomendations for safety procedure
Surgical infection prevention
• The Study on the Efficacy of Nosocomial Infection Control (SENIC) showed that about 6% of all nosocomial infections
can be prevented with minimum intervention.
• Reduced preoperative hospitalization;
• Evaluation and treatment of remote infections;
• Weight reduction (for obese patients);
• Cessation of tobacco use;
• Control of hyperglycaemia;
• Restoration of host defences;
• Decreased endogenous bacterial contamination;
• Appropriate methods of hair removal;
• Administration of appropriate and prophylaxis;
• Confirmation of proper asepsis and antisepsis of skin and instruments;
• Maintenance of meticulous surgical technique and minimization of tissue trauma;
• Shortened operating time;
• Effective wound surveillance.
Patient Safety Indicator and The
Risk of Falls
Risk of Falls :
• Most falls are caused by the interaction of multiple risk factors.
Timed and go test
• Directions: Patients wear their regular footwear and can use a walking aid if
needed. Begin by having the patient sit back in a standard arm chair and
identify a line 3 meters or 10 feet away on the oor
• Instructions to the patient: When I say “Go,” I want you to:
• Stand up from the chair
• Walk to the line on the oor at your normal pace
• Turn Walk back to the chair at your normal pace
• Sit down again
• Stop timing after patient has sat back down and record.
• Time: _________ seconds
• An older adult who takes ≥12 seconds to complete the TUG is at high risk for falling.
Prevention of falls :
• Assess FIRST on these modi able risk factors:
• Lower body weakness
• Diffculties with gait and balance
• Use of psychoactive medications
• Postural dizziness
• Poor vision
• Problems with feet and/or shoes
• Home hazards