PATIENT

SAFETY

Created by: B20 Students

OBJECTIVES
Definition of patient safety and its
history.
The goal of patient safety.
The role of patient safety in
minimizing the incidence of
adverse events.
Difference between system failures,
violations, and errors.
The harm caused by healthcare
errors and system failure.
Models of Patient Safety.
DEFINITION
Patient safety is defined as:
“the absence of preventable
harm to a patient and reduction
of risk of unnecessary harm
associated with health care to
an acceptable minimum."
HISTORY
GOALS:
1- Prevention and Reduction of
risks and errors that occur to the
patient during the medical
procedure/intervention.
2- Learning-based improvement
from errors and adverse events.
Achievable by:
• Safety Strategies
• Clear Policies
• Skilled Health Care Provider
• Effective involvement of
patients in their care
THE ROLE OF
PATIENT SAFETY
DIFFERENCES
BETWEEN
SYSTEM
FAILURES,
VIOLATIONS,
AND ERRORS
SYSTEM FAILURE
System failure : is defined as a failure
due to a flaw or flaws in a system.
System failure in medicine are
predictable but not always accurately
and timely, can occur again if the
flaws are not identified and rectified.
ERRORS

Failure to carry out a planned

action as intended or
application of an incorrect
plan.
There is a non-deliberate
deviation from what was
intended.
 ERRORS

SKILL- BASED MISTAKES

ATTENTIONAL LAPSES RULE-BASED KNOWLEDGE-

SLIPS OF OF MISTAKES BASED MISTAKES
ACTION MEMORY
VIOLATIONS
Violations are errors caused by
deliberate deviation by an individual
from an accepted protocol or
standard of care.

● There are three types of violations:

1- Routine
2- Optimizing
3- Exceptional
 EXAMPLES
● Routine violations: professionals
fail to practice hand hygiene.

● Optimizing violations: involve

violations in which a person is
motivated by personal goals, such
as greed or thrills from risk-taking.

● Exceptional violations: knowingly

skip important steps in
administering medications.
THE HARM CAUSED
BY HEALTH-CARE
ERRORS AND
SYSTEM FAILURES.
HARM CAUSED
BY HEALTH-CARE
ERRORS
1- Medication errors e.g. (Giving the wrong medication or dose or
Dispensing the right medicine in the wrong form).
Impact : Physically it can cause worsening of health, Emotionally it can
cause fear of having any other medication, Financially it will cause the
patient to buy more drugs.
HARM CAUSED BY
HEALTH-CARE
ERRORS
2- Misdiagnosis e.g. (Mistaking a cold for a severe illness).
Impact : Physically delaying of the right diagnosis will cause
adverse effects, Emotionally uncertainty of health, Financially
high expenses will be paid due to the prolonged treatment
HARM CAUSED
BY HEALTH-CARE
ERRORS
3- Surgical mistakes e.g. (Operating on the wrong body part or
Leaving tools inside a patient).
Impact : Physically big scars in unwanted places and extended recovery
time, Emotionally Severe emotional trauma, Financially Increased medical
bills due to additional surgeries and hospital stays.
HARM CAUSED BY SYSTEM FAILURES
• Communication Breakdown: insufficient communication between
healthcare teams will cause crucial information to be left out and therefore
causing harm to the patient.

• Inadequate Training and Education: inadequate training programs or lack

of education for healthcare professionals can contribute to errors.

• Resource Constraints: limited availability for medical equipments which

may be a problem when hospitals become overcrowded.
 TAKE HOME MESSAGE

Healthcare errors and system failures destroy patient trust, compromise

safety, and raise unnecessary suffering.

Fixing these issues is not just about preventing mistakes it is about

building a system that values safety and follows a better care for
everyone.
MODELS OF
PATIENT SAFETY
 WHAT ARE THE MODELS
OF PATIENT SAFETY
Safety management models are conceptual diagrams that include and
address the unit of analysis, the concepts and means needed to develop
safety.
 WHAT IS THE PURPOSE
OF THE MODELS OF
SAFETY
•Understanding the system of health care

•Recognizing the differences of performances

•Providing methods for improvement of the services

•Better understanding of the people who work in the system

 THE SWISS CHEESE
MODEL
• James Reason proposed the image of "Swiss
cheese" to explain the occurrence of system failures

• Each slice may have many holes, each representing weaknesses

• A single mishap or is unlikely to result in an adverse event.

• Failures in successive layers can result in an adverse event

 THE CYCLE OF PATIENT
SAFETY
● The patient, clinician, and practice staff member are linked together

● The model also reflects that primary care practice does not exist in
isolation

● Part of a broad, complex health care system

● It is associated with culture, community, and external environment.

 CONCEPT OF THE “CYCLE OF
SAFETY”
• Partnership: refers to the relationships between the patient, provider,
and practice staff within the primary care practice.
• Teamwork: Strategies to improve teamwork and inclusion of the
patient and family as part of the health care team.
• Community: community influences, including practice location,
sociodemographic characteristics of the patients, and community-based
resources
• Health care environment: strongly influenced by external forces,
including policy, health reform, and practice transformation efforts.
THANK YOU