Introduction To Public Health

Lecture 13

Magda Khutsishvili, Pharm B, MPH

Lecturer in the University of Georgia
School of Health Sciences
magda.khutsishvili@ug.edu.ge
• Theme: Patient Safety
• Reading Materials: HEALTH SYSTEMS SCIENCE AMA Education Consortium
SECOND EDITION Editors-in-Chief: Susan E. Skochelak, MD chapter: 6
 Patient Safety
• Patient safety has received increasing focus over the past several decades as the
impact of medical errors in health care has drawn increasing attention from the
public and the medical community.
• The World Health Organization (WHO) defines patient safety as:
“The reduction of risk of unnecessary harm associated with health care to an
acceptable minimum.”
 Principles of Patient Safety [1]
• Adverse event is defined as: “harm
caused by medical treatment”
• Preventable adverse event is: “an
adverse event that is attributable
to error”
• Negligent adverse event: is when
the care provided to the patient do
not meet the standard of care an
average physician would provide.
• An error: is defined as “the failure
of a planned action to be
completed as intended or the use
of a wrong plan to achieve an aim.”
 Principles of Patient Safety [2]
• A slip occurs when an action does not
occur as planned.
• A lapse occurs when an action is
missed or a person forgets to do
something
• A violation occurs when a deliberate,
illegal, or otherwise unsanctioned
action is undertaken.
• Not all harms are the result of error.
Multiple harms exist in health care • A study of medication errors and near misses
related to the underlying condition of found that at least 78% of the issues were
a patient, known complications of a
therapy, or expected natural course of attributable to system issues, not human
a disease process. errors.
Types of Medical Errors
 Medication Errors [1]
• Causes of Medication Errors include:
1. Prescribing the wrong medicine or the
wrong dose, or failure to consider
interactions or contraindications
2. illegible handwriting of physicians, but
it’s frequency declined after most
medications are ordered electronically,
however there is another challenge
related to the inappropriate entry into
the electronic ordering system.
3. Patients may take medications
inappropriately due to insufficient or
incomplete instructions
Medication Errors [2]

1. Avoiding the use of abbreviations for

dose designations
2. Providing mandatory patient
education with improving access to
drug information
3. Using automated alerts
4. Implementing bar codes
5. Administrating and standardizing
prescribing and dispensing practices
Surgical/procedural errors
 Diagnostic Errors
• Diagnostic error is defined as: “the failure to establish an accurate and timely explanation of
the patient’s health problems or communicate that explanation to the patient.”

• Goals for reducing diagnostic errors include:

1. Facilitate more effective teamwork in the diagnostic process among health care professionals,
patients, and their families.
2. Enhance health care professional education and training in the diagnostic process.
3. Ensure that health information technologies support patients and health care professionals
in the diagnostic process.
4. Develop a reporting environment and medical liability system that facilitate improved
diagnosis through learning from diagnostic errors and near misses.
5. Design a payment and care delivery environment that supports the diagnostic process.
6. Provide dedicated funding for research on the diagnostic process and diagnostic errors
 Transitions of care errors
• Transitions of care: times when patients are moved from one setting of care or practitioner
to another, are high-risk times for errors to occur when information about a patient can be
lost or misinterpreted.
• To ensure information is not lost, experts recommend the use of a structured handoff
process or checklist.
• One such structured process, I-PASS, has been tested at multiple institutions and found to
improve communication and result in decreased preventable adverse events.
 Teamwork/communication errors
• Multiple obstacles can contribute to • Many health care systems use a tool called:
ineffective team performance, SBAR for communication during transitions
including: of care and critical events.

1. Frequent changes of team

membership
2. Time pressures
3. Varying communication styles
4. Fatigue
5. Inadequate information sharing
6. Lack of role clarity
7. Intensity and volume of workload
 Communication with patients after adverse events
due to medical errors
• When a patient has been harmed, health care
professionals, in consultation with the health system’s
department of quality, should approach the situation with
transparency and provide honest communication to
patients and families.
• Full disclosure of a medical error includes:
1. An explanation of why the error occurred
2. An apology
3. An explanation of how the impact on the patient’s health
will be minimized, including an explanation of anticipated
future care
4. A discussion regarding actions that will be taken to
minimize the chance for future occurrence of similar
injury to other patients.
 Error Reporting Systems
• Reporting is typically mandatory for serious events, including:
1. Death
2. Retained foreign object after surgery
3. Radiation overdose
4. Transfusion error

• Reporting systems are most effective when they are perceived as

designed to facilitate the improvement of patient safety.

• There are 2 types of Error reporting systems:

1. Voluntary reporting systems: receive error reports from clinicians who
are directly involved in the event
2. Mandatory reporting systems: receive error reports from a designated
person who often is not directly involved in the error, it includes both
 Patient safety improvement strategies
• There are two, the most common methodologies for prevention of errors:

1. Standardization:
The expectation of how a process is normally expected to occur is clearly defined, and all
team members are expected to meet the requirements without exception.
Care is taken to simplify processes, use technology or equipment to minimize human error,
and reduce the probability of cognitive errors.

2. Constraint:
It is a creation of limitations in a system,
It requires a person to slow down at a critical juncture and complete certain steps or goals to
proceed with the intended action.
Thank You For Your Attention!