The Hippocratic Oath

“I will prescribe regimens for the good

of my patients according to my ability
and my judgment and never do harm
to anyone
…In every house where I come I will enter
only for the good of my patients.”

--Excerpt from Hippocratic Oath, c. 300-400 BCE

Fr: Health Quality Advisors LLC
Quality & Patient Safety

1999: Institute of Medicine Report:

“To Err is Human”
 To do no Harm?

1999: Institute of DEATHS

Medicine Report: Medical Errors 98,000
“To Err is Human” Motor Vehicle Accidents 43,000
Breast Cancer 42,000
The first public AIDS 16,000
realization of the true
extent of patient harm Medication Errors 7,000
and safety in the Workplace injuries 6,000
healthcare setting
 More recent facts and figures . . .

Healthgrades Study (2002)

Patient Safety in American Hospitals (2000-2002)

Adverse events Over 1 million

Accidental deaths 195,000 / year

Extra healthcare costs $6B / year

 To do no Harm?
Health care associated deaths = 2 major plane crashes every 3 days!!!
Source of Medical Harm

Achieving Safe & Reliable Healthcare

Leonard, M, et al: 2004

5% Incompetent or poorly intended care

Conscientious
Conscientious competent
competent individuals
individuals
95%
95%
trying
trying hard
hard to achieve
achieve aa desired
desiredoutcome
outcome
Patient Safety: A New Way to Think

OLD NEW
WHO did it? WHAT allowed it?
Punishment Thanks for reporting
Errors are rare Errors are everywhere
MDs don’t participate Everyone participates
Add more complexity Simplify- Standardize
Calculate error rates No thresholds
Linking patient safety education with
traditional Medical Curriculum
• Traditional curricula for doctors and medical students
have focused on PURE CLINICAL SKILLS:
• diagnosis of illness, treatment of disease,
after-care and follow-up.

• TEAM WORKING, QUALITY IMPROVEMENT and

RISK MANAGEMENT have been overlooked.
These are the skills fundamental to patient safety.
Linking patient safety education with
traditional OB GYN SPECIALTY TRAINING
Patient Safety Committee

Enhancing Patient Safety:

IPSGs and TeamSTEPPS
“• The goals highlight problematic areas in healthcare &
describe evidence-, expert-based consensus solutions
to these problems.
• The goals generally focus on system-wide solutions,
wherever possible. ”
International Patient Safety Goals
 IDENTIFY Ensure CORRECT-
SITE, CORRECT-
patients PROCEDURE, CORRECT-
correctly PATIENT surgery

Improve Reduce the risk of

effective HEALTH-CARE
COMMUNICATION Associated INFECTIONS

Improve Safety of Reduce the Risk of Patient

HIGH-ALERT Harm resulting from
MEDICATIONS FALLS
 IDENTIFY GOAL
patients
correctly 1

IPSG.1:
The hospital develops & implements a
process to improve accuracy of patient
identification.
 IDENTIFY GOAL
patients
correctly 1
INTENT of IPSG.1
-To reliably identify the individual as the person for
whom the service or treatment is intended.
-To match the service or treatment to that
individual.
 IDENTIFY GOAL
patients
correctly 1
Hospital Patient Cannot be used for
Identification: identification:
Patient’s room number
Patient’s Name Patient’s location in the
ID / medical record number hospital
Birthdate
Bar-coded wristband
 IDENTIFY GOAL
patients
correctly 1
MEASURABLE ELEMENTS
• Patients are identified using 2 different identifiers
which should be UNIFORM throughout the hospital
• Patients are identified PRIOR TO
• Procedures: IV insertion, hemodialysis, blood extraction,
cardiac catheterization, diagnostic radiology
• Treatments: IV meds, blood transfusion, restricted diet
 Improve GOAL
effective
COMMUNICATION 2
The hospital develops & implements a process to improve the
effectiveness of VERBAL &/ TELEPHONE COMMUNICATION
among caregivers.
IPSG 2.1 Reporting critical results of diagnostic tests
IPSG 2.2 Handover communication.
 Improve GOAL
GOAL
effective 2
COMMUNICATION 2
Reporting of Critical Test Result
May indicate high-risk or life-threatening condition.
A formal reporting system which clearly identifies
how critical results are documented & communicated
The hospital must define:
What are critical values for all the diagnostic tests
Who is authorized to report/receive the critical values
What documentation is required in the medical record
Monitoring compliance
 Improve GOAL
GOAL
effective 2
COMMUNICATION 2
HANDOVER Communications (handoffs)
Who: physician-physician, physician-nurse, nurse-nurse
Between levels of care: wardCCU, EROR; staff family.
Handovers are STANDARDIZED & DOCUMENTED for the type
of handover occurring.
 Improve GOAL
GOAL
effective 2
COMMUNICATION 2
Most error-prone communications:
Patient care orders given
verbally in-person
over the telephone
 Improve GOAL
GOAL
effective 2
COMMUNICATION 2
SAFE PRACTICES:
Limiting verbal communication of prescription, medication orders
to urgent situations; disallowed when prescriber is present & chart
is available. Verbal orders restricted during a sterile procedure.

Develop guidelines for requesting & receiving test results on a

STAT basis, the identification & definition of critical tests & critical
values; to whom, by whom results are reported, and monitoring
compliance
 Improve GOAL
GOAL
effective 2
COMMUNICATION 2
SAFE PRACTICES:
Writing down complete order or test result by receiver
Receiver reading back & the sender confirming
Permissible alternatives in special circumstances (ER, OR, CCU).
 Improve GOAL
GOAL
effective 2
COMMUNICATION 2
SAFE PRACTICES:
Data from adverse events resulting from handover
communications are tracked and used to identify ways in which
handovers can be improved, and improvements are implemented.
 Improve Safety of GOAL
HIGH-ALERT
MEDICATIONS 3
• Safety of High Alert Medications (HAM).

• Manage the safe use of concentrated electrolytes.

 Improve Safety of GOAL
HIGH-ALERT
MEDICATIONS 3
HAM: Medications involved in a high percentage of
errors and/or sentinel events
Medications that carry a higher risk for
abuse or other adverse outcomes.

HAM cause harm more frequently, more serious, with significant

additional costs to care.
E.g. Look alike or Sound alike Medications
Illegible prescriptions
Misunderstanding during verbal orders
Similar packaging
 Improve Safety of GOAL
HIGH-ALERT
MEDICATIONS 3
Hospital needs to develop its own list(s) of high-alert
medications based on its
• Unique utilization patterns of medications
• Internal data about
• near misses,
• medication errors,
• sentinel events.
Hospital has a list of look-alike/sound-alike medications and
develops and implements a process for managing look-alike sound-
alike medications.
 Improve Safety of GOAL
HIGH-ALERT
MEDICATIONS 3
•The hospitalthe
Remove develops & implements
concentrated a process
electrolytes to manage
from the patient
thecare
safeunits
use to
ofthe
concentrated
pharmacy. electrolytes.
• Concentrated electrolytes are present only in patient
care units identified as clinically necessary in the
concentrated form.
• Concentrated electrolytes that are stored in patient care
units are clearly labeled and stored in a manner that
restricts access and promotes safe use
 Ensure CORRECT-SITE, GOAL
CORRECT-PROCEDURE,
CORRECT-PATIENT Surgery 4
The hospital develops & implements a process for
• Preoperative verification &
• Surgical / invasive procedure site-marking

The hospital develops & implements a process for

• Time-out - immediately prior to the start of procedure
• Sign-out - conducted after the procedure
 Ensure CORRECT-SITE, GOAL
CORRECT-PROCEDURE,
CORRECT-PATIENT Surgery 4
Preoperative Verification Process
• Verify the correct patient, procedure, and site
• Ensure all relevant documents, images, and studies
are available, properly labeled, and displayed
• Verify that any required blood products, special medical
equipment, and/or implants are present.
 Ensure CORRECT-SITE, GOAL
CORRECT-PROCEDURE,
CORRECT-PATIENT Surgery 4
Marking the Site
Instantly recognizable and unambiguous
Consistent throughout the hospital.
Patient involvement
All cases involving
• laterality,
• multiple structures ( fingers, toes, lesions), or
• multiple levels (spine).
 Ensure CORRECT-SITE, GOAL
CORRECT-PROCEDURE,
CORRECT-PATIENT Surgery 4

Time-Out
The team agrees on the following components:
• Correct patient identity
• Correct procedure to be done
• Correct surgical/invasive procedure site
 Ensure CORRECT-SITE, GOAL
CORRECT-PROCEDURE,
CORRECT-PATIENT Surgery 4
Sign-Out : WHO Surgical Safety Checklist
• Name of surgical/invasive procedure that was recorded
• Completion of instrument, sponge, & needle counts
• Labeling of specimens. Labels are read aloud,
including patient name)
• Any equipment problems to be addressed (as
applicable)
 Ensure CORRECT-SITE, GOAL
CORRECT-PROCEDURE,
CORRECT-PATIENT Surgery 4
Identify all areas within the hospital where surgical and
invasive procedures take place
cardiac catheterization lab
interventional radiology department
gastrointestinal lab
 Reduce the risk of GOAL
HEALTH-CARE Associated
INFECTIONS 5
The hospital adopts &
implements evidence-based
hand-hygiene guidelines
to reduce the risk of health
care-associated infections.
 Reduce the risk of GOAL
HEALTH-CARE Associated
INFECTIONS 5
Hospital adopts proper HAND HYGIENE
Guidelines posted in appropriate areas
Staff educated in hand washing & hand disinfection.
Soap, disinfectants, any means of drying are provided in
needed areas.
Hospital-wide implementation
 Reduce the Risk of Patient GOAL
Harm resulting from FALLS 6
Hospital develops & implements a process to reduce the
risk of patient harm resulting from FALLS for the
inpatient and outpatient population.
Reduce the Risk of Patient Harm GOAL
resulting from FALLS 6
FALLS: related to patient, the
situation, location.
FALL RISK CRITERIA identifies
those at high-risk & documentation
made to provide continuity of care.
FALL-RISK REDUCTION
Risk assessment (screening Qs),
Preventive measures,
Periodic assessment.
 IDENTIFY Ensure CORRECT-
SITE, CORRECT-
patients PROCEDURE, CORRECT-
correctly PATIENT surgery

Improve Reduce the risk of

effective HEALTH-CARE
COMMUNICATION Associated INFECTIONS

Improve Safety of Reduce the Risk of Patient

HIGH-ALERT Harm resulting from
MEDICATIONS FALLS
 Interventions to Improve Patient Safety

• Conduct team training

• Conduct drills for high risk events
- shoulder dystocia, emergency C-section, maternal
hemorrhage, neonatal resuscitation
• Review and apply guidelines
- ACOG, AWHONN, AAP
• Use standardized maternal-fetal record form
JCI Recommendations, 2004
Interventions to Improve Patient Safety

Ob-Gyns should prepare for emergencies by:

• Assessing potential emergencies that might occur
• Establishing early warning systems
• Designating specialized first responders
• Conducting emergency drills
• Debriefing staff after actual events
ACOG Committee on Patient
Safety . . . 2006
Patient Safety Committee

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