Patient Safety

Fury Maulina
 Prescribing antibiotics without regard for the
patient’s underlying condition and whether
antibiotics will help the patient, or administering
multiple drugs  potential for adverse drug reactions
Many studies confirm  medical error is prevalent in our
health system and that the costs are substantial

• 18 000 unnecessary deaths/year

Australia • > 50 000 disabled patients/ year

• 44 000 (perhaps 98 000) unnecessary deaths/ year

US • 1 million excess injuries

Studies show  additional hospitalization, litigation costs,

infections acquired in hospitals, lost income, disability and
medical expenses have cost some countries between
US$ 6 billion and US$ 29 billion/year
• Many studies highlight that alongside the
enormous benefits of medical care 
significant risks for patients

• Managing these risks is a great challenge that

requires a culture of safety to be established
throughout medicine, from redesigning health
systems to training doctors competent in both
the clinical sciences and safety sciences.
 Why do medical students need to know
about patient safety?

• They need underpinning knowledge about

patient safety as well as know how to apply the
principles and concepts at the bedside
• They must be aware of the multiple factors
that influence healthcare outcomes and act to
reduce the opportunities for errors
• They need to know how the system of
healthcare operates and impacts on the
quality and safety of healthcare
• Patient safety  a complex topic which
includes new areas of knowledge such as
human factors, systems, root cause
analysis and risk reduction
The Australian Patient Safety Education
Framework (APSEF), published in 2005 
knowledge, skills and behaviours

WHO Patient Safety Curriculum Guide for

Medical Schools  was developed by a team
from the University of Sydney and Monash
University and assisted by an Expert Consensus
Working Group with representatives
from the six WHO regions  + APSEF
• Patient safety is the freedom for a patient from
unnecessary harm or potential harm
associated with healthcare  refocuses
learning on the patient and the multiple
interactions that can either heal or harm them

• Flexner, early 20th century  recognised

attributes such as ethical practice,
professionalism, population health,
compassion and integrity  equally important
 New framework

Ethical codes 
(perspective of
the doctor) complex
environment and
the needs of
Patient safety  patients
(perspective of
the patient)
 The significant number of studies 
most adverse events are preventable

28%: negligence
In a landmark of a health
study by Leape professional • Poor medical
et al. (1993): Management
> 2/3 adverse
events  • Substandard
preventable care
42%: other factors
not related to such
negligence
 Swiss Cheese Model

Source: Coombes ID et al. Why do interns make prescribing errors? A qualitative study, Medical
Journal of Australia, 2008, 188(2): 89–94. Adapted from Reason’s model of accident causation
 What need to do?

• Apply patient safety thinking in all clinical

activities
 Relationships with patients
• Understand the multiple factors involved in failures
 The five “whys”
• Avoid blaming when an error occurs
• Practise evidence-based care
• Maintain continuity of care for patients
• Student awareness of the importance of self-care
• Act ethically everyday
Multumesc!