Patient Safety

&
Health-care Associated
Infection
Outline

 Patient Safety and its significance.

 Burden of harm and its impact on patient safety.
 Types of error and harm.
 Swiss cheese model for analyzing safety errors.
 Difference between Old Paradigm and New Paradigm.
 Health Care Associated Infection (HAIs).
 The types of Health Care Associated Infections.
 Interventions for the Prevention of Health Care Associated Infection.
Patient Safety?
 Patient Safety is a health care discipline that emerged with the evolving
complexity in health care systems and the resulting rise of patient harm in
health care facilities.

 It aims to prevent and reduce risks, errors and harm that occur to patients
during provision of health care. A cornerstone of the discipline is continuous
improvement based on learning from errors and adverse events.

 Patient safety is fundamental to delivering quality essential health

services.

 Ensure successful implementation of patient safety strategies; clear policies,

leadership capacity, data to drive safety improvements, skilled health care
professionals and effective involvement of patients in their care, are all
needed.
 Why patient safety?
 The occurrence of adverse events due to unsafe care is likely one of the 10 leading causes of
death and disability in the world.

 In high-income countries, it is estimated that one in every 10 patients is harmed while receiving
hospital care . The harm can be caused by a range of adverse events, with nearly 50% of them
being preventable.

 Each year, 134 million adverse events occur in hospitals in low- and middle-income countries
(LMICs), due to unsafe care, resulting in 2.6 million deaths .

 Globally, as many as 4 in 10 patients are harmed in primary and outpatient health care. Up to 80%
of harm is preventable. The most detrimental errors are related to diagnosis, prescription and the
use of medicines.

 Investments in reducing patient harm can lead to significant financial savings, and more
importantly better patient outcomes. An example of prevention is engaging patients, if done
well, it can reduce the burden of harm by up to 15%.
 The burden of harm:
Every year, millions of patients suffer injuries or die because of unsafe and
poor-quality health care. Below are some of the patient safety situations
causing most concern.

 Medication errors are a leading cause of injury and avoidable harm in

health care systems: globally, the cost associated with medication
errors has been estimated at US$ 42 billion annually.
 Health care-associated infections occur in 7 and 10 out of every 100
hospitalized patients in high-income countries and low- and middle-
income countries respectively (11).
 Unsafe surgical care procedures cause complications in up to 25% of
patients. Almost 7 million surgical patients suffer significant
complications annually, 1 million of whom die during or immediately
following surgery (12).
The burden of harm:
 Unsafe injections practices in health care settings can transmit
infections, including HIV and hepatitis B and C, and pose direct
danger to patients and health care workers;

 Diagnostic errors occur in about 5% of adults in outpatient care

settings, more than half of which have the potential to cause severe
harm. Most people will suffer a diagnostic error in their lifetime.

 Sepsis is frequently not diagnosed early enough to save a patient’s

life. Because these infections are often resistant to antibiotics, they
can rapidly lead to deteriorating clinical conditions, affecting an
estimated 31 million people worldwide and causing over 5 million
deaths per year.
Human Factors – Error Types
Lapses Errors in performance of
Unintended Actions
(Right idea, wrongly
a skill based behaviour,
actioned) typically occur when
attention is diverted
Slips

Rule & knowledge based

Unsafe errors arise when a
actions Mistakes situation is
(wrong idea) misinterpreted or a rule
is misapplied
Intended
Actions
Errors resulting from
Violation intended deviation from
(rule breaking) accepted standards,
procedure and rules
Latent Conditions
 Latent conditions are problems intrinsic to the system.

 Circumstances that can create conditions for active failures to occur.

 Latent conditions also predispose to the occurrence of many active failures

(slips, lapses, mistakes and violations) that result in patient harm.

 Latent conditions are failures waiting to be triggered by an active error.

 Prevention of latent conditions requires corrective actions once an active failure

has been identified.
 THE SWISS CHEESE MODEL FOR ANALYSING SAFETY ERRORS

True Swiss cheese is called

Emmental. The bubbles are
caused during processing.
 Just Culture / Culture Of
Accountability
Punitive Culture Blame-Free Culture Just Culture
• Before the 1990s •By the mid 1990s • NEW
• Frontline • Recognize that humans
workers were •Supported a "no-
are imperfect so errors
afraid to report blame" response
will and can happen to
their own errors to errors anyone
or those of a
colleague •Unsafe acts were the • Staff are encouraged
• Missed result of mental slips (even rewarded) for
enormous or lapses, or honest reporting errors
opportunities to
learn mistakes • There is a well-
about Errors •Fails to tackle established system of
• Little insight into individuals who accountability
System-based • High insight into
causes make unsafe /
System-based causes
reckless behavioral
choices
1436-05 Just / Accountabillity Culture
Changing the Safety Paradigm
Healthcare Associated Infections
(HAIs)

-
HAIs
 Infection developing in patients after admission to the hospital, which
was neither present nor in the incubation period at the time of
hospitalization
 They may become evident during patient’s stay or after their
discharge
 Hospital acquired infections

 Hospital associated infections

 Hospital infections
Where do the microbes come from?

 Patient's own flora

 Cross infection from medical personnel
 Cross infection from patient to patient
 Hospital environment (inanimate objects):
 Air
 Water
 Dust
 IV fluids & catheters
 Bedpans
 Endoscopes
 Ventilators & respiratory equipment
Sources of Infection
 Endogenous:
 Patients own flora may invade patient’s tissue during some surgical
operations or instrumental manipulations
 Normal commensals of the skin, respiratory, GI, UG tract

 Exogenous:
 From another patient / staff member / environment in the hospital
 Environmental sources: Inanimate objects, air, water, food
 Cross infection from: other patients, hospital staff (suffering from
infections or asymptomatic carriers)
Microorganisms
 Any pathogen , on occasion, can cause HAI
 Those that are able to survive in hospital environment & develop
resistance to antibiotics & disinfectants: major cause
 Commensal bacteria: found in the normal flora of healthy people.
significant protective role by preventing colonization by pathogenic
microorganisms.
 Some commensal bacteria may cause infection if the host is
compromised.
 Eg: Staphylococcus epidermidis (cause of i.v. infections),
 Escherichia coli (cause of urinary infections).
 Pathogenic bacteria: they have greater virulence, and cause
infections (sporadic or epidemic) regardless of host status.
Bacteria
Gram positive bacteria:
• Staphylococus aureus:
bacteria that colonize the skin, nose and throat of patients and hospital
staff. They cause a wide variety of lung, bone, heart and bloodstream
infections and are frequently resistant to antibiotics.

• In hospitals commonly 40-50% of S. aureus isolates are MRSA.

• Staph epidermidis & Group D Streptococci

• Streptococci: Streptococcus hemolyticus,

Streptococcus Pyogenes

• Clostridium tetani spores: survive in dust for very long time

Gram negative bacteria:
• In recent decades, enteric Gram negative bacilli → most important group of
hospital pathogens

• Enterobacteriaceae:
(E. coli, Proteus, Klebsiella, Enterobacter, Serratia) may colonize sites when
the host defences are compromised. They may also be highly antibiotic
resistant.

• Pseudomonas spp:
-often isolated in water and damp areas. They may colonize the digestive
tract of hospitalized patients.
- Ability to survive & multiply at low temp
- Resistance towards antibiotics & disinfectants
Viruses:
• HIV and Hepatitis B & C viruses: transmitted through
blood & blood products
• Viral diarrhea & Chickenpox can be spread in hospitals
• Cytomegalovirus, Herpes virus, Influenza, Enteroviruses &
Arenaviruses can cause HAI

Fungi:
• Candida albicans, Aspergillus, Mucor

Protozoa:
• Entamoeba histolytica, Plasmodia, Toxoplasma gondii, Pneumocystis
carinii
Multidrug resistant Staphylococcus aureus (MRSA):
colonize hospitals & cause Nosocomial infections.
Thus, known as ‘Hospital Staphylococci’
 Modes of Transmission
1. Contact:
Most common route of transmission

Hands or Clothing:
- Hands of staff: important vehicle of spread
- Contact of hands & clothing of attendants
Eg: Staphylococcus aureus, Streptococcus pyrogenes

Inanimate objects:
- Improper disinfection of Instruments: endoscope, bronchoscope,
cystoscope
Eg: Pseudomonas aeruginosa
2. Airborne:

Droplets:
- Droplets of Respiratory infections: transmitted by inhalation

Dust:
- Dust from bedding, floors, wound exudates & skin Eg: Pseudomonas
aeruginosa, Staphylococcus aureus

Aerosols:
- Aerosols from nebulizers, humidifiers & AC
Eg: Legionella pneumophila
3. Oral Route:
- Hospital food may contain Antibiotic-resistant bacteria → may colonize
intestine → can cause infections

4. Parenteral route:
- Disposable syringes & needles
- Certain infections may be transmitted by blood transfusion, tissue donation,
contaminated blood products
Eg: Hepatitis B, HIV
 Common HAI
UTI:
o Most common HAI (40% of HAI)
o Usually associated with catheterization or instrumentation of
urethra, bladder or kidneys
o Eg: E. coli, Klebsiella, Proteus, Serratia, Pseudomonas, Candida albicans

Pneumonia (Respiratory Infections):

o Leading cause of mortality in patients suffering from HAI
o During aspiration in unconscious patients & pulmonary ventilation
o Eg: Staph. aureus, Klebsiella, Enterobacter, Serratia, Proteus,
Pseudomonas, Acinetobacter, Legionella, E. coli
 Wound & skin sepsis:
o Follow surgical procedure where causative agents are introduced
into the tissue during operations
o Higher in elderly patients
o Manifest within a week of surgery
o Non-surgical wounds due to burns, bed sores.
o Eg: Staph aureus, Pseudomonas aeruginosa, E. coli, Proteus, Enterococci

 Gastrointestinal infections:
o Food poisoning due to Salmonella, Shigella sonnei
o Enterotoxic manifestation due to Staphylococcal contamination of
cooked food
 Bacteremia & Septicemia:
o Bacterial invasion of bloodstream in various HAIs
o Mostly caused by infected intravenous cannulae
o Gram negative bacilli: common pathogens

 Tetanus:
o Inadequate attention to aseptic precautions during surgery
o Use of contaminated dressings or improperly sterilized dressings
o Improper disinfection of site of intramuscular injection
o Inadequate care while cutting umbilical cord of new-born
 Diagnosis

 HAIs may occur sporadically or as an outbreak

 Diagnosis by routine bacteriological methods:
o Direct smear examination
o Culture
o Sensitivity testing
 Identification & elimination requires sampling from possible sources of
infections such as hospital personnel, inanimate objects, water, air or food
 Prevention
 Administration of antibiotic therapy to the carrier staff or source patients to
destroy the pathogenic agents
 Proper sterilization & disinfection of inanimate objects. This helps to control
the source of infection
 Disinfection of excreta & infected material is necessary to control the exit
point of infection
 Transmission can be controlled by regular washing of hands, disinfection
of equipments & change of working cloths
 Use of sterile dressings, surgical gloves & face-masks further contribute
in control of nosocomial infection
 Pre-operative disinfection of patient’s skin
 Proper investigation of HAI & treatment of such cases
Hospital Infection Control Committee /
Department

 Every hospital must have an effective Hospital-acquired

Infection Control Committee / Department
 Responsible for the control of HAIs
Functions:
 To formulate & update policies on matters related to hospital
infections
 Review and approve surveillance and infection prevention
program, emergence of drug resistance
 Use of different antimicrobial agents
 Proper sterilization & disinfection procedures
 To assess and promote improved practice at all levels of health
facility.
 To Obtain and manage critical bacteriological data and
information, including surveillance data
 To ensure appropriate staff training
 Safety management
 Development of policies for the prevention and control of
infection
 To develop its own infection control manual
 Monitor and evaluate the performance of program
 To recognize and investigating outbreaks of infections in the
hospital and community
Hospital Infection
Control
• Reduce patient exposure to pathogens
• Reduce the number & virulence of nosocomial pathogens
• Use of aseptic technique during patient care
• Hand washing
• Proper isolation of patients known or suspected of harboring
infectious diseases
• Whenever possible, avoid crowding wards
• Use gloves when necessary
• Wash hands immediately after glove removal and between patients
• Masks, Eye protection, Gown: Wear during activities likely to generate
splashes or sprays
• Gowns: Protect skin and soiling of clothing
Sharps:
• Avoid recapping of needles
• Avoid removing needles from syringes by hand
• Place used sharps in puncture-resistant containers

Ensure clean environment:

• Establish policies and procedures to prevent food and water contamination
• Establish a regular schedule of hospital cleaning with appropriate disinfectants
in, for example, wards, operating theaters, and laundry
• Dispose of medical waste safely
• Needles and syringes should be incinerated
• Other infected waste can be incinerated or autoclaved for landfill disposal
Your Hands can be Dangerous…

Wash them with Soap & Water

to keep bacteria away
 Hand Hygiene is the single most
effective intervention to reduce the
cross transmission of HAI
Handwashing:
• Must be "bacteriologically effective"
• Wash hands before any procedure in which gloves and forceps are
necessary
• After contact with infected patient or one colonised with multi-
resistant bacteria
• After touching infective material
• Use soap and water (preferably disinfectant soap)
 Standard safety measures to minimise the infection

• Assume that all specimens/ patients

are potentially infectious for
pathogens
• All blood specimens or body fluids

 must be placed in leak-proof impervious bags or

Container for transportation to the laboratory
• Use gloves while handling blood & body fluid specimens
& other objects exposed to them
• If there are chances of spattering, use face
masks and glasses
• Wear laboratory coat or gowns while
working in the laboratory. These should not
be taken outside
• Never pipette by mouth.
Mechanical pipetting devices
should be used
• Decontaminate laboratory work
surfaces with appropriate disinfectant after
the spillage of blood or other body fluids
• Limit use of needles & syringes to situations for
which there are no other alternatives

• Biological safety hoods should be used for

laboratory work

• All potentially contaminated materials of

laboratory should be decontaminated before
disposal or reprocessing

• Always wash hands after completing laboratory

work

• Remove all protective clothings before

leaving the laboratory