Dr.

Medha Wadhwa
 An adverse event is defined as an injury
caused by medical management
[commission] rather than by the
underlying disease or condition of the
patient.”
 Patient Safety definition: “An adverse
event results in unintended harm to the
patient by an act of commission or
omission rather than by the underlying
disease or condition of the patient.”
 Patient safety is a discipline in the
health care sector that applies safety
science methods toward the goal of
achieving a trustworthy system of
health care delivery. Patient safety is
also an attribute of health care systems;
it minimizes the incidence and impact
of, and maximizes recovery from,
adverse events (Emanuel, L., Berwick, D., Conway, J., Combes, J., Hatlie, M.,
Leape, L., Reason, J., Schyve, P., Vincent, C., & Walton, M. (2008). What exactly is patient safety?
Advances in Patient Safety, Vol. 1: Assessment. Retrieved from
http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=aps2v1&part=advances-emanuel-berwick_110)
 Person Approach: Old system (remedial measures
directed primarily at the error-maker: naming, blaming,
shaming and retraining)
 Systems Approach: New System (Why and how:
strategies might include: education, new protocols and new
systems)
 patient factors
 provider factors
 task factors
 technology and tool factors
 team factors
 environmental factors
 organizational factors
Domain Sources
Surgery Wrong site surgery
Surgery on wrong patient
Wrong surgical procedure performed on patient
Foreign object left in a patient after surgery
or other procedure
Intraoperative or immediately post-operative
Death in an ASA Class I patient (NQF)
Anesthesia-related event (JCAHO)
Death or near death for anesthesia and
cardiac procedures (NJ)
[Intraoperative or Post-operative complication
Surgical repair or damage resulted from planned
surgical procedure where damage was not
disclosed or documented to the patient
Domain Sources
Product Death or serious disability from use of
or contaminated drugs, devices, or biologics
Device by facility
Events
Aspiration in non-intubated patient related
to conscious/moderate sedation
Death or serious disability from use or
function of a device in patient care, when
other than intended (NQF)
Medical equipment-related event (JCAHO)
Intravascular catheter related events (TN)
Death or serious disability from
intravascular air embolism during care at a
facility
Ventilator death or injury
Care Death or serious disability from medication error (e.g. wrong drug,
Manage- dose, patient, time, rate, preparation, or route (NQF)
ment Medication error (JCAHO)
Events
Patient death or serious disability associated with a hemolytic reaction
due to the administration of ABO-incompatible blood or blood
products (NQF)
Transfusion error (JCAHO)
Maternal death or serious disability associated with labor or delivery
in a low- risk pregnancy while being cared for in a healthcare facility
(NQF)
Maternal death (JCAHO)
Hysterectomy in a pregnant woman, ruptured uterus (TN)
Birth injury (RI)
Patient death or serious disability associated with hypoglycemia, the
onset of which occurs while the patient is being cared for in
a healthcare facility
Death or serious disability (kernicterus) associated with failure to
identify and treat hyperbilirubinimia in neonates
Perinatal death or loss of function
Stage 3 or 4 pressure ulcers acquired after
admission to a healthcare facility
Patient death or serious disability due to spinal manipulative therapy
Delay in treatment
Infestation by parasites or vectors (CA)
Death due to malnutrition, dehydration, or sepsis (PA)
 Environmental Events: Falls, Burns, Fire, Electric
shock, Restraint malfunction, etc.
 Criminal Events: Impersonation, Physical assault,
Poisoning, Accident, Abuse, Negligence, etc.
 Site-specific Outcomes: Brain injury, spinal cord
injuries, Fracture/dislocation of bones, Incident
involving sight or hearing impairment, etc.
 General Outcomes: Death arising from
unexplained cause/suspicious circumstances, death
due to unnatural causes, treatment for adverse
incident, transfer required due to adverse incidents,
serious injury, impairment, death or further
treatment due to adverse incidents, etc.
 Serious Events
Death/Severe Harm

Near Miss
Unwanted consequence
prevented because of recovery

No Harm Events
 The Swiss cheese model by James Reason of
accident causation illustrates that, although
many layers of defense lie between hazards
and accidents, there are flaws in each layer
that, if aligned, can allow the accident to
occur.
 The failure domains can be: organizational
influences, supervision, preconditions and
specific acts.
Some holes due
to active failures Hazards

Other holes due

Losses to
latent conditions

Successive layers of defences, barriers and safeguards

System defences
VA NCPS
o preoccupation with failure
o commitment to resilience
o sensitivity to operations
o a culture of safety
o maintain a powerful and uniform culture of safety
o use optimal structures and procedures
o provide intensive and continuing training of
individuals and teams
o conduct thorough organizational learning and safety
management
Although health care is different from other
industries (e.g. people are not airplanes) we can
learn:

from their successes:

o What factors make them work so well?

from their failures:

o How do disasters occur even in typically high reliability settings?
 Priority Areas

Care Coordination- Cross cutting

Self management/Health literacy- Cross Cutting
Asthma
Cancer Screening, esp. cervical and colorectal
Children with special healthcare needs (Chronic physical,
developmental, behavioral or emotional)
End of life with advanced organ system failure: CHF and COPD
Frailty associated with old age - preventing falls, pressure ulcers,
maximizing function and developing advanced care plans
Hypertension- appropriate management of early disease
Immunization children and adults
Ischemic Heart Disease - prevention, reduction of recurrence,
optimization of functional capacity
Major Depression- screening and treatment
 Medication Management - preventing medication errors and
overuse of antibiotics
 Healthcare acquired Infection - prevention and surveillance
 Pain control in advanced cancer
 Pregnancy and childbirth- appropriate prenatal and
intrapartum care
 Severe and persistent mental illness- focus on treatment in
public sector
 Stroke- early intervention and rehabilitation
 Tobacco dependence treatment in adults
 Obesity (emerging priority)
 Access,
Access,admission,
admission,transfer,
transfer,discharge
discharge Implementation and ongoing
 Clinical
Clinicalassessment
assessment(incl.
(incl.diagnosis,
diagnosis, monitoring/review
tests, assessments)
tests, assessments) Infrastructure (including staffing, facilities,
 Consent,
Consent,communication,
communication, environment)
confidentiality
confidentiality
Medical device, equipment
 Disruptive,
Disruptive,aggressive
aggressivebehaviour
behaviour
Documentation Medication

Documentation(including
(includingrecords,
records,
identification)
identification) Patient abuse
 Infection
Infectioncontrol
control Patient accident
Self harming behaviour
Treatment, procedure
Other
 Entry
Entrypoint
point

Patient Safety Domain

Patient Safety Domain

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