P ATIENT SAFETY

Dr. Imran Siddiq

HOD- Quality Management Department – Shalamar Hospital
LEARNING OBJECTIVE

Understand the discipline of patient safety and its

role in minimizing the incidence and impact of
adverse events, and maximizing recovery from them
WHAT IS PATIENT SAFETY?

 Patient safety is a new healthcare discipline that

emphasizes the reporting, analysis, and
prevention of medical error that often leads to
adverse patient outcomes.

 Recognizing that healthcare errors impact 1 in

every 10 patients around the world, the World
Health Organization calls patient safety an
endemic concern.
WHAT SAFETY IN HOSPITAL?

 Hospital is a people intensive place.

 Provides services to sick people round the clock – 24 hours

a day & 365 days a year.

 People have a free access to enter the hospital any time for
advice & treatment.

 Hospital atmosphere is filled with emotions, excitement,

happiness, death & sorrow.
MEDICAL ERRORS

Institute of Medicine, USA found in a study:

Medical error injures 1 in 25 hospital patients

Kills about 44,000 to 98,000 every year

Medical errors costs USA billions of dollors each

year.
WHY ERRORS

1. Not willful negligence but systemic flaws.

2. Inadequate communication.

3. Wide-spread process variation.

4. Patient ignorance.
 CAUSES FOR ERRORS

1. Individual made: errors due to human factor in the

process ( wrong calculations of drugs, not following the 5 rights of medications)

2. System made: holes in the system that allows to slip

through ( no clear & detailed policy & procedures, no double checking systems )

3. Environmental made: the dangers that come from the

setting of the hospital & the material & equipments
used ( no fire exit doors, worn out power cables )
 HUMAN FACTOR

1. Human beings make mistakes because the systems, tasks

& processes always have room for improvement.

2. Every error has a root cause & every cause has a solution.

3. Errors can be prevented with every one’s initiative in the

system. Here comes the role of the patient safety
department
 ITS NOT IMPORTANT WHO CAUSED
ACCIDENT BUT WHAT CAUSED IT

“We cannot change the human condition, but we can change

the conditions under which humans work ”
IMPORTANCE IN HEALTH CARE?

Importance of human factors has been recognized for long time in:
• aviation

• nuclear power
• only recently been acknowledged as an essential part of
patient safety

• A major contributor to adverse events in health care

• all health-care workers need to have a basic understanding

of human factors principles
 EXAMPLES

• order medications electronically

• hand off information

• move patients

If all of these tasks become easier for the health-care

provider, then patient safety can improve.
AVOIDABLE CONFUSION IS EVERYWHERE…

US Department of Veteran affairs

Health care is increasingly
complex

Gaba
TRAPS IN HEALTH CARE?

• look-alike and sound-alike pharmaceuticals

• equipment design
○ e.g. infusion pumps
 Look at the chart
Say the colour of the word, not the word itself

Why is it hard?
SITUATIONS ASSOCIATED WITH
AN INCREASED RISK OF ERROR
• unfamiliarity with the task*
• inexperience*
• shortage of time
• inadequate checking
• poor procedures
• poor human equipment interface

* Especially if combined with lack of supervision

INDIVIDUAL FACTORS THAT
PREDISPOSE TO ERROR
•limited memory capacity
•further reduced by:
○fatigue
○stress
○hunger
○illness
○language or cultural factors
○hazardous attitudes
 APPLY HUMAN FACTORS
THINKING TO YOUR WORK
ENVIRONMENT

1. Avoid reliance on memory

2. Make things visible
3. Review and simplify processes
4. Standardize common processes and procedures
5. Routinely use checklists
6. Decrease the reliance on vigilance
SUMMARY: HUMAN FACTORS

• Errors are inevitable - even for doctors!

• there are situations that can increase the likelihood

of error recognize them for your patient’s sake - and
yours!

• attention to human factors principles can lead to a

reduction in error or its consequences
INTERNATIONAL PATIENT SAFETY
GOALS
IPSG

1.IDENTIFICATIONS
2.COMMUNICATIONS
3.HIGH ALERT MEDICATIONS
4.SAFE SURGERY
5.PREVENTION OF INFCTIONS
6.RISKS OF FALL.
INTERNATIONAL PATIENT SAFETY
GOALS
 Two unique patient identifiers i.e. Full Name and
unique Medical Record Number.
Goal 1  Id wrist band, addressograph & Patient bed side tagging
Patient
Identification  No Bed number/room number should be used for
 
identification
 

 Discourage verbal/ telephonic orders.

 In case where verbal orders become necessary then it should
Goal 2 be followed by “READ BACK”.
Effective  Patient shifting/ handover should be done properly &
Communication documented
 No illegible hand writing
 Read back critical lab values
 Independent double check for illegible handwriting or in case
of any confusions regarding physician orders.
INTERNATIONAL PATIENT SAFETY
GOALS
 All staff should be educated about high risk and LASA
Goal 3 medications
High Alert  Don’t keep high risk medication in easy access.
Medication
 
 High risk medication should be kept in lock
 Crash cart should be maintained orderly and kept locked.
 Dual verification before IV, high alert & LASA medication
 
 

 Patient family education should be done prior to

Goal 4
surgery or any medical intervention
Ensure Safe  Informed consent should be taken prior to any medical
Surgery intervention.
 
 Properly fill in the Surgical Safety Checklist
 “Time out” should be performed immediate before
incision & documented
INTERNATIONAL PATIENT SAFETY
GOALS
Goal 5  Ensure 5 moments of hand hygiene
Reduce the risk  Implementations of hospital ICP policies & procedures
of Health care  Ensure the usage of PPE’s as required
associated  Ensure the implementation of hospital waste
infections management policies & procedures
 
 

 Ensure Fall risk assessment during hospital stay

 Moderate & high risk of fall patients should be identified.
Goal 6
 Always keep side rails up
Fall Risk
 Never leave patient unattended
Assessment
   Post-op and high risk patient should kept close to nursing
station.
 Ensure functioning of Nursing Call system.
 
Any QUESTIONS? ?
STUDENTS SHOULD:

 understand the multiple factors involved in failures

 avoid blaming
 practise evidenced-based care
 maintain continuity of care for patients
 be aware of the importance of self-care
 act ethically everyday