Institutional Magnitude Of Harm in Health Care

Hospital Share patient safety concepts

Departemenital Factors Outline Discuss nature and types of harm

Work Environment Josie King Story

System Factors Impact Safety
Team Factors Science of Safety

Individual Provider Diagnostic Error of delay in diagnosis

Task Factors
Treatment Error in the performance of an operation
Types of
Patient Characteristics Errors
Prevenative Failure to provide prohylactic treatment
Nurse borrows medication from another
patient
Other Failure of Communication, equipment Failure

Fax system for ordering medications is

broken
Patient Safety: The avoidance, prevention and
Tube system for obtaining medications is National Patient Safety Foundation amelioration of adverse outcomes or injuries
broken Medication Error Story stemming from the processes of health care

Patient receives a medication to which he is

allergic
Definitions Patient Safety: Freedom from accidental injury

IOM- To Err is Human Medical Errors can be defined as the failure of a

ICU Nurse Staffing planned action to be completed as intended or the use
of a wrong plan to achieve an aim.
Patient arrests and dies

Patient Safety -
Concepts and Science
Adverse dong events (wrong medications)
Create culture of safety

Improper transfusions
identify key processes

Reduce complexity
Develop reliable processes
Create independent checks for key processes
Surgical injuries
Focus on the System - Processes To prevent mistakes Wrong site surgery
improve key processes
Growing Burden of Unsafe Patient
Care Globally Restraint related injuries

Patient Falls
Automate
Pressure Ulcers- Bed Sores

Mistaken patient identities

Recognize that harm is the result of a cascade Healthcare associated infections

of broken Systems

Design safe systems

Coach people to make safe choices Injury, disability and death

Science of
Speak up when you heave n concern
Safety Societal costs
Implications of providing unsafe care
Focus on interpersonal communication
Loss of trust in realthcare systems, providers
Listen when others do

Accept responsibility for the system in which Rework and unnecessary waste
you work