MULTIDISCIPLINARY CONFERENCE

PATIENT SAFETY
Key Learning Points
The department that discussed regarding Patient Safety is the department of Anesthesiology. It is known
to be among the leading disciplines with regard to patient safety.

Methods to promote patient safety

 Swiss cheese
o Before hazards become accidents, there are multiple layers to prevent them. To err is
human, hence, one person trying to prevent accidents from happening can still have
loopholes hence it is a collective responsibility and effort to prevent hazards from
turning to accidents. What one cannot see may be prevented by another. These layers
of defenses can then be seen as multiple layers of cheese with holes, hence the name.
 Parmesan Cheese
o Rather than layers of defense, this illustration focuses more on how or WHY these
accidents happen. Imagine that a certain accident is symbolized by a whole parmesan
cheese. There are multiple reasons as to why this accident happened. We have fatigue
of the worker, limits of the facilities, limits of the patient’s knowledge. Little by little, we
are breaking down the parmesan, or in other words ‘grating’ the cheese. This is usable
retrospectively so that through these factors, we can learn to prevent the accidents.

Health care today is now safer due to advances in pharmacology, technology, and more
stringent practice standards. However, also due to the advances, people who are able to survive
increase, along with the complexities that simpler medical technology hasn’t been or been used to
facing yet. Thus, the difficulties also arise. The change in patterns of monitoring and the ever increasing
pressure to achieve targets also make it difficult to achieve patient safety. Nevertheless, these factors,
once resolved, will surely enable us to better protect the patients.

Few good practices to achieve patient care is through monitoring, identification, and record
keeping. Making sure that each patient is identified and recorded, while nurses taking care of them
verifies each patient and monitors them all throughout, especially when being given medicine that can
greatly affect them.

One good practice that has been starting to rise especially due to the advances in technology is
patient simulation. Due to this, healthcare workers can now mimic a better fraction of how patients
respond to certain managements, thus they can be more mentally and physically prepared once faced
with real life cases.

The department with this wonderful slogan and I truly believe in this and its significance towards
patient safety, “ To err is human, to cover up is unforgiveable, and to fail to learn is inexcusable.”