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Nama : Muhammad Satya Arrif Z

Topik : Patients safety in hospital


(Woolf, 2004)

These errors in addressing extant risks arguably are more threatening to health than lapses in
safety. Although “To Err Is Human” (1) suggested that 44 000 to 98 000 Americans die each
year because of medical errors, more careful analyses suggest that only a fraction of these deaths,
perhaps fewer than 5%, are causally linked to errors (18-20). Only a subset of adverse drug
events, the first concern of the patient safety movement, causes serious harm (21). A cohort
study of Medicare beneficiaries noted 5 life-threatening or fatal preventable adverse drug events
for every 1000 person-years of observation (22).

(Streimelweger et al., 2015)

Human errors are one main source for accidents in any industry including health care. According
to Reason,
particularly important is the identification of cognitive processes common to a wide variety of
human error types. These errors are differentiated into variable and constant6 errors and are
classified as active and latent failures.

(Erickson, 2014)

(Miake-Lye et al., 2013)

The rate of falls in acute care hospitals ranges from approximately 1 to 9 per 1000 bed-days
High-quality evidence shows that multicomponent interventions can reduce risk for in-hospital
falls by as much as 30%.


(Emanuel et al., 2008)

Patient safety is a discipline in the health care sector that applies safety science methods toward
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. This definition acknowledges that patient safety is both a way of
doing things and an emergent discipline. It seeks to identify essential features of patient safety.

Patient safety in five areas: (Donaldson et al., 2014)

-efforts to create and enforce new safety standards through regulation and accreditation;
-weaknesses in how health systems track and report errors; the disappointing uptake of
promising information technology (IT) tools that promote patient safety;
-the lack of progress in reforming the U.S. medical malpractice landscape and fostering
increased accountability among health care providers
-the paucity of physician and nurse engagement in patient safety efforts

Patients safety indicator

(McDonald et al., 2002)
Function / Objective

(Wong, 2017)

-Improve the accuracy of patient identification.

-Improve the effectiveness of communication among caregivers.
-Improve the safety of using medications.
-Reduce the harm associated with clinical alarm systems.
-Reduce the risk of health care–associated infections.
-The hospital identifies safety risks inherent in its patient population.

Example and application

(Gillespie et al., 2014)

checklists are associated with a reduction in overall complications in surgical patients. Surgical
safety checklists provide a means to safeguard patients and minimize risk through increased team
cohesion and coordination. Importantly checklists should be used to augment, and not replace,
other initiatives that contribute to a safety culture
Penggunaan ceklis pada pasien dengan tindakan bedah secara umum akan menurunkan
komplikasi. Ceklis keselamatan operasi menyediakan keselamatan pasiendan meminimalisasikan
resiko dengan meningkatkan keterpaduan dan koordinasi antar team

(Weaver et al., 2013)

Promotion of patient safety culture can best be conceptualized as a constellation of interventions

rooted in principles of leadership, teamwork, and behavior change, rather than a specific process,
team, or technology. Strategies to promote a culture of patient safety may include a single
intervention or several interventions combined into a multifaceted approach or series. They may
also include system-level changes, such as those in governance or reporting structure. For
example, team training, interdisciplinary rounding or executive walk rounds, and unit-based
strategies that include a series of interventions have all been labeled as interventions to promote
a culture of safety. Team training refers to a set of structured methods for optimizing teamwork
processes, such as communication, cooperation, collaboration, and leadership

(Winters et al., 2013)

Rapid-response systems (RRSs) were created to improve recognition of and response to

deterioration of patients on general hospital wards, with the goal of reducing the incidence of
cardiorespiratory arrest and hospital mortality. An RRS generally has 3 components.
1) Criteria and a system for notifying and activating the response team (known as an “afferent
limb,” the mechanism by which team responses are triggered). Activation criteria usually
include vital signs (single-trigger criteria vs. aggregate and weighted early warning scoring) or
general concern expressed by a clinician or family member. The afferent limb defines the
variables that indicate deterioration and democratizes that knowledge to all clinicians. It also
empowers bedside clinicians to trigger the response team (or “efferent limb,” the team of
clinicians that respond to an event) when the clinician has a suspicion that a patient is
deteriorating (2). As such, most RRSs rely on clinicians to proactively identify deteriorating
patients rather than solely on continuous monitoring technology, which is common in the
intensive care unit (ICU).

2) The response team (efferent limb). The response team most frequently comprises ICU-trained
personnel and equipment. Team composition varies on the basis of local needs and resources but
generally uses one of the following models: medical emergency teams (METs), which include a
physician; rapid-response teams, which do not include a physician; and critical care outreach
teams, which follow up on patients discharged from an ICU but also respond to all ward patients.

3) An administrative and quality improvement component. This team collects and analyzes event
data and provides feedback, coordinates resources, and ensures improvement or maintenance
over time.

(Kim et al., 2013)

Essential specimen handling steps. Blue items are physician-specific responsibilities; pink items
are nursing staffespecific responsibilities.
(Kim et al., 2015)

The most logical process to improve patient safety in health care systems is proposed below:
1.Identify current issues regarding patient safety

2.Revise systems, education, and training to address known patient safety issues

3.Educate health care professionals about the importance of patient safety concepts. Establish a
system of checks and balances to reduce medical errors. Ensure practical application of patient
safety concepts (training)
4.Enhance patient interaction to reduce errors

Repeat the process to address errors that persist.

Major Actions To Improve Patient Safety
(Pittet and Donaldson, 2005)
•Hand hygiene
1. Strengthen high-level commitment within countries to implement national strategies to
promote hand hygiene
2. Test implementation of the WHO Guidelines on Hand Hygiene in Health Care (advanced
draft) in several districts worldwide

•Blood safety
1. Promotion of optimal hand hygiene associated with procedures for collection, processing, and
use of blood products
2. Promotion of donor skin antisepsis to prevent blood contamination
3. In-service education and training on safe transfusion practices at the bedside

•Injection practices and immunization

1. Promotion of optimal hand hygiene at time of intravenous injection and immunization
2. Strengthen high-level commitment within countries to use autodisable syringes for
immunization services
3. Actions around ensuring safe disposal of sharps as part of an integrated management of waste
within health care facilities

•Water, basic sanitation, and waste management

1. Actions to ensure access and quality of water to support hygiene and hand hygiene in
particular, at a health care facility level
2. Actions to ensure safe disposal of sharps

•Clinical procedures
1. Specific education programs promoting safety in surgical procedures, tailored to the major
needs of the countries
2. Surgical hand preparation using either antimicrobial soap and water or alcohol-based handrub
to reduce infections associated
with surgical procedures
3. Access to safe emergency surgical care: availability and actual usage of procedures and
equipment for a specific set of clinical procedures

Health Information Technology for patient Safety

(Middleton et al., 2013)
Fourteen usability principles for the design of electronic medical records
1. Consistency—Design consistency and standards utilization
2. Visibility—System state visibility
3. Match—System and world match
4. Minimalism—Minimalist design
5. Memory—Memory load minimization
6. Feedback—Informative feedback
7. Flexibility—Flexible and customizable system
8. Message—Useful error messages
9. Error—Use error prevention
10. Closure—Clear closure
11. Reversibility—Reversible actions
12. Language—User language utilization
13. Control—User control
14. Documentation—Help and Documentation

(Singh and Sittig, 2016)

(Salinas et al., 2013)

The rate of patient registration errors depended on patient origin and registration modality.
Electronic requesting resulted in a smaller number of errors. Even when the test request was
done electronically, there was a great variability between centers. This emphasizes the fact
that human intervention is still clue despite the advantages of the new technologies and
highlights the role of the laboratory professional to detect the errors in order to plan the
appropriate barriers.
SEIPS model of work system and patient safety
(Carayon et al., 2014)

Key characteristics of the SEIPS (Systems Engineering Initiative for Patient Safety) model
(1) description of the work system and its interacting elements
(2) incorporation of the well-known quality of care model developed by Donabedian (1978)
(3) identification of care processes being influenced by the work system and contributing to
(4) integration of patient outcomes and organizational/employee outcomes
(5) feedback loops between the processes and outcomes, and the work system (see Fig. 1).

Patient Safety in Undergraduate Medical Education

(Kiesewetter et al., 2016)
The Learning Objective Catalogue is subdivided into three chapters:
1. Basics (ca 10-15%)
2. Recognizing Causes as Foundation for Proactive Behavior
(ca 40%)
3. Approaches for Solutions (ca 45-60%)
The percentages are intended to set the scale for the fraction of time and content for the chapter
in relation to the entire curriculum.

It would be desirable that the Learning Objective Catalogue for Patient Safety in Undergraduate
Medical Education serves as a foundation for constructive, professional deliberation with the
topic at the individual faculties and initiates numerous curricular structures.
improve team communication may be the next major advance in improving patient
(Weller et al., 2014)
With increasing complexity and even more specialisation of skills, the current healthcare
environment demands effective communication and teamwork to reliably deliver best patient

(Brock et al., 2013)

The relationship between team communication and patient safety4 has increased the emphasis
placed on training future health professionals to work within teams.7–9 However, few studies
have sought to demonstrate that prepractice interprofessional team training is effective in
building the foundations for later practice within healthcare teams

Brock, D., Abu-Rish, E., Chiu, C.-R., Hammer, D., Wilson, S., Vorvick, L., Blondon, K.,
Schaad, D., Liner, D., Zierler, B., 2013. Interprofessional education in team
communication: working together to improve patient safety. BMJ Qual Saf 22, 414–423.
Carayon, P., Wetterneck, T.B., Rivera-Rodriguez, A.J., Hundt, A.S., Hoonakker, P., Holden, R.,
Gurses, A.P., 2014. Human factors systems approach to healthcare quality and patient
safety. Appl. Ergon. 45, 14–25. doi:10.1016/j.apergo.2013.04.023
Donaldson, L.J., Panesar, S.S., Darzi, A., 2014. Patient-Safety-Related Hospital Deaths in
England: Thematic Analysis of Incidents Reported to a National Database, 2010–2012.
PLOS Med. 11, e1001667. doi:10.1371/journal.pmed.1001667
Emanuel, L., Berwick, D., Conway, J., Combes, J., Hatlie, M., Leape, L., Reason, J., Schyve, P.,
Vincent, C., Walton, M., 2008. What Exactly Is Patient Safety?, in: Henriksen, K.,
Battles, J.B., Keyes, M.A., Grady, M.L. (Eds.), Advances in Patient Safety: New
Directions and Alternative Approaches (Vol. 1: Assessment), Advances in Patient Safety.
Agency for Healthcare Research and Quality, Rockville (MD).
Erickson, A.K., 2014. Safety first: The latest updates from the Joint Commission. Pharm. Today
20, 6–7. doi:10.1016/S1042-0991(15)30760-X
Gillespie, B.M., Chaboyer, W., Thalib, L., John, M., Fairweather, N., Slater, K., 2014. Effect of
Using a Safety Checklist on Patient Complications after SurgeryA Systematic Review
and Meta-analysis. Anesthesiol. J. Am. Soc. Anesthesiol. 120, 1380–1389.
Kiesewetter, J., Gutmann, J., Drossard, S., Gurrea Salas, D., Prodinger, W., Mc Dermott, F.,
Urban, B., Staender, S., Baschnegger, H., Hoffmann, G., Hübsch, G., Scholz, C., Meier,
A., Wegscheider, M., Hoffmann, N., Ohlenbusch-Harke, T., Keil, S., Schirlo, C., Kühne-
Eversmann, L., Heitzmann, N., Busemann, A., Koechel, A., Manser, T., Welbergen, L.,
Kiesewetter, I., 2016. The Learning Objective Catalogue for Patient Safety in
Undergraduate Medical Education – A Position Statement of the Committee for Patient
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Miake-Lye, I.M., Hempel, S., Ganz, D.A., Shekelle, P.G., 2013. Inpatient Fall Prevention
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Middleton, B., Bloomrosen, M., Dente, M.A., Hashmat, B., Koppel, R., Overhage, J.M., Payne,
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Salinas, M., López-Garrigós, M., Lillo, R., Gutiérrez, M., Lugo, J., Leiva-Salinas, C., 2013.
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