Patient Safety
Presenter : Dr. Dipendra Bhusal
Moderator: Dr. Sunil Jwarchan
Department of General Surgery
Pokhara Academy of Health Sciences
Introduction
• Increased life expectancy >25years in
over last semicentennial.
The Nature Journal
Law of supply and demand applied to health
services.
• 2 big challenges in proving
safe and effective service,
• greater demand and larger options ,
• increasing complexity in healthcare
• "First, do no harm" is a fundamental healthcare principle prioritizing
patient safety.
• Global evidence indicates a significant burden of avoidable patient
harm across healthcare systems.
• Avoidable patient harm has major implications, including human,
moral, and ethical consequences.
• The prevalence of harm challenges established healthcare principles
and ethics.
• Financial implications accompany the human toll, affecting healthcare
systems globally.
• Defined as “the absence of preventable harm to a patient and
reduction of risk of unnecessary harm associated with health care to
an acceptable minimum”
• to prevent harm to patients,
caused by the process of
health care itself.
Origin of patient safety concept
• 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
Improving patient safety means reducing patient harm
CURRENT ENVIRONMENT
• Errors and system failures repeated
• Action on known risk is very slow
• Detection systems in their infancy
• Many events not reported
• Understanding of causes limited
• Blame culture alive and well
• Defensiveness and secrecy
Prevalence of adverse health care event
• WHO estimates that, even in advanced hospital settings, one in ten
patients receiving healthcare will suffer preventable harm
• The report “To Err is Human: building a safer health system” by IOM
of the national academy of health system drew widespread attention
to the alarming statistics that there were between 44000 and 98000
preventable deaths , 7000 related to medication error only.
• If medical error was a disease then it would be 3rd leading cause of
death in USA after heart issues and cancer
Why ERROR?
• Usually not willful negligence, but systemic flaws,
-inadequate communication and wide spread process variation and
patient ignorance.
Patient safety incidents
• An Adverse event: An incident which results in harm to the patient.
• A near miss: An incident that could have resulted in unwanted
consequences but did not either by chance or through a timely
intervention preventing the event from reaching the patient.
• A no harm event: An incident that occurs and reaches the patient but
results in no injury to the patient. Harm is avoided by chance or due
to mitigating circumstances
Common causes of adverse health events
• Preventable Events
• Of these, inadequate communication ranks highest in frequency
4. Law of supply and demand applied to health
services.
• 2 big challenges in proving
safe and effective service,
• greater demand and larger options ,
• increasing complexity in healthcare
5. • "First, do no harm" is a fundamental healthcare principle prioritizing
patient safety.
• Global evidence indicates a significant burden of avoidable patient
harm across healthcare systems.
• Avoidable patient harm has major implications, including human,
moral, and ethical consequences.
• The prevalence of harm challenges established healthcare principles
and ethics.
• Financial implications accompany the human toll, affecting healthcare
systems globally.
6. • Defined as “the absence of preventable harm to a patient and
reduction of risk of unnecessary harm associated with health care to
an acceptable minimum”
• to prevent harm to patients,
caused by the process of
health care itself.
7. Origin of patient safety concept
• 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
Improving patient safety means reducing patient harm
8. CURRENT ENVIRONMENT
• Errors and system failures repeated
• Action on known risk is very slow
• Detection systems in their infancy
• Many events not reported
• Understanding of causes limited
• Blame culture alive and well
• Defensiveness and secrecy
9. Prevalence of adverse health care event
• WHO estimates that, even in advanced hospital settings, one in ten
patients receiving healthcare will suffer preventable harm
• The report “To Err is Human: building a safer health system” by IOM
of the national academy of health system drew widespread attention
to the alarming statisitics that there were between 44000 and 98000
preventable deaths , 7000 related to medication error only.
• If medical error was a disease then it would be 3rd leading cause of
death in USA after heart issues and cancer
10. Why ERROR?
• Usually not willful negligence, but systemic flaws,
-inadequate communication and wide spread process variation and
patient ignorance.
11. Patient safety incidents
• An Adverse event: An incident which results in harm to the patient.
• A near miss: An incident that could have resulted in unwanted
consequences but did not either by chance or through a timely
intervention preventing the event from reaching the patient.
• A no harm event: An incident that occurs and reaches the patient but
results in no injury to the patient. Harm is avoided by chance or due
to mitigating circumstances
21. Live were and software interaction
• Non physical aspect of system: Computer programs
• Good interface: makes it difficult to commit mistake
22. Live ware and Environment interface
• Include stressor in the physical environment that have to be coped
with such as noise, poor acoustics and over crowding
23. Second live ware and Human interface
operator
• Interface of interpersonal communication
• Embraces concept of team coordination,
conflict resolution, continuity of
information flow( handover)
24. SHELL Model
• Edges are not smooth
• Independent components are constantly changing.
• Interaction of live ware is constantly changing
• Reduces the mismatch by understanding
human factor and take steps to reduce
effect
25. Patient safety
• Intent teaching : Do NO Harm
• Still error do occur
• Indicator of inadequate system
• Fill the inadequacies
• Do research and offer solution
26. Understanding patient safety incidents
• Help to anticipate situations
• Ways to solve Problem:
1. Person approach
2. System approach
27. Person approach
• Humans make mistake
• Due to Error of communication, omission, error of execution leading
to adverse event
• By understanding reason , steps can be taken to prevent
• Problem of this approach: Blaming and Restrict learning
28. System approach
• Adverse event rarely occurs due to single isolated cause
• If there is Error, There is failure of the system
• 2 models to understand it.
I. Henrich’s Safety Pyramid
II. Swiss cheese Model
29. Heinrich's Safety Pyramid is a graphical representation of the relationship between
workplace incidents, injuries, and near misses
30. 2. Swiss Cheese Model
• Reason’s theory: Accident causation
• Active failure: Error done by individual in coal face( Reality/ground)
• Latent Condition: created by decisions of organization eg: less staffs in
hospital
• On their own : not responsible for error
• On combination leads to patient safety event
31.
32. Strategies of patient safety
• WHO in strong leadership role to address patient safety challenges
• Global initiatives
• Campaign:
1. WHO save lives: Clean your hand campaign
2. WHO guideline for safe surgery 2009: surgical checklist
36. Regional Initiatives:
Resource Rich countries:
• government and national organization: take up strategies aim at delivering
safety and quality improvement
• regulate and license physician and healthcare institution: uniformity across
nation
• Develop and adopt policies
• Provide patient safety education program
• National level clinical audits
• Report and learn from adverse events
• set up agencies to resolve concerns about practice of doctor by providing
case and incident management servies
37. Resource limited countries:
• Aspiration and challenges are same but issues are different
• Probability of patient safety issue is much more.
• Infection In post operative period is 20X more
• Instruments/ equipment :around 50% do not work
• Some places: reusable syringe and needle
38. Institutional/Hospital Level
• Team Work: Organize team training programs: Aim: Improve Human
factors
• Simulator base workshops
• Classroom Courses
39. • The International Patient Safety Goals (IPSG) were developed in
2006 by the Joint Commission International (JCI). The goals were
adapted from the JCAHO's National Patient Safety Goals.
• The Joint Commission has updated the IPSGs over time:
40. Patient Safety at Coal face
• Communicating openly with patients and their carers and obtaining
consent
• It improves treatment outcome, decrease errors and decrease legal
actions.
• Patient has right to choose: to help make good decision by patient ;
need to communicate treatment options, procedure and risk and
complication.
41. Informed consent
• Details and uncertainty of diagnosis
• The propose and details of the proposed surgery
• Known possible side effects and potential complication
• The likely prognosis
• Other options for treatment, including the option not to treat
• Explanation of the likely benefits and probablities of success for each
option
• The name of the doctor who will hae overall responsibility
• A reminder that patient can change his or her mind at any time
42. If any adverse event occurs?
• Be honest and communicate
• Patient deserves full explanation of what happened, potential
consequences, can it be fixed
• Taking care of patient after treatment
• Ensuring it is not repeated
• Appropriate apologies
43. Professional Behavior and maintaining fitness
to practice
• Embraces those attitude and behaviors that serve the patients best
interests above and beyond other considerations.
• Maintaining Competence, skills.
• Credentials: good way to update skills
• Responsible: Individual , Employer, Professional organization
44. Reporting of adverse events or near miss
• Mostly goes unreported
• Because of fear of blame and potential for litigation
• Establish clinical risk assessment and management system for specific
task
• Based on information , risk identification , analyze and control
1. Should be done on blame free environment
2. All the data should be collected not only in institutional level
but at national level which can later be used to educate doctor and
prevent events.
45. Safety Reporting system
• It is a paper based incident reporting and management system to
submit, refine, analyze and communicate important information
where it focus on identify and preventing system failure.
• Any healthcare provider can report an incident
• Safety reporting system promotes just culture.
46. Just culture
• a culture of trust that changes the individual blaming for being
forgetful, inattentive, unmotivated, careless or even neglect to a
system approach.
• It acknowledge that dangerous error can occur and tries to mitigate
their effect when they do happen rather than blaming and shaming
people
• So human error is a consequence but not a cause
• It is step one of safety improvement.
47. Caring for the second victim
• 1st victim of an adverse event is the patient and their family
• Doctor purposely do not set out to injure patient but when it does happen,
he/she may experience a range of emotions including distress, shame, guilt
, fear and depression to the extent they can be regarded as second victim.
• The wound to second victim may at times be profound; this distress can
lead to further deficits in patient care.
• Coping with the impact of error cab be challenging and second victim
requires management.
• Dysfunctional coping strategies include denial,blaming other or refusal to
discuss the issue
48. • There are 2 strategies
1. Problem focused strategy: Includes accepting responsibility for the
mistake or disclosing the error and apologizing to the patient
2. Emotion focused strategy: Takes in attempts to deal with the
negative emotions aroused by the problem. Second victim has to
open up lines of communication and it is equally important that
professional colleague show compassion and empathy by sensing
difficulty or poor coping, providing a sounding board and by
offering advice and support.
49. References:
• Bailey and Love’s Short Practice of Surgery 26th Edition
• https://www.who.int/news-room/fact-sheets/detail/patient-safety
• https://ourworldindata.org/life-expectancy
• https://www.jointcommissioninternational.org/what-we-offer/advisory-services/quality-management-and-patient-
safety/?utm_source=Google&utm_medium=cpcjci&utm_campaign=jcic_gaqualitymgmt&gad_source=1&gclid=EAIaIQobChMIlIbF-
rSlgwMVOqNmAh0lVg_3EAAYASAAEgKf4PD_BwE
Editor's Notes
In 1900, the average life expectancy of anewborn was 32 years. By 2021 this had more than doubled to 71years
Large number of old population
Large demand for health care
2 big challenges in proving safe and effective service, greater demand and larger options . Making it more complex
So as doctors our job of providing effective and safe healhcare is not being done in good manner
The discipline of patient safety is the coordinated efforts to prevent harm to patients, caused by the process of health care itself
Errors donot only occour in resourch limited but in resource rich too
Why
Financial burden of unsafe care is huge, prolongs hospitalization, increases loss of income to pt, ligitation (cost to health care system)
In most cases fault is not willful negligence, but systemic flaws, inadequate communication and wide spread process variation and patient ignorance.
People responsible are the doctors, nurses, pharmacists , technicians and patient
Of these, inadequate communication between healthcare staff, or between meical staff and their patient or family members ranks highest in frequency
Understaning human factor enhances performance by better understaning effect OF human factor on team work, task, work space and culture
Understand by shell model
Helps to understand human factor,
L: centre of shell model
Affected by many things so
Most flexible and most unpreedable in shell model
Own personality, motivation, different thresshold for stress intolerance, skill and knowlede about subject and attitue to healthcare
To over come the limitation of human operator –good interface with other component of the shell to prevent error
To over come the limitation of human operator
Have good interface with other component of shell in order to prevent error and to have good performance
There are Ergonomic design of the tools and medical devices
Made to make things easy for surgeon to do the job
Makes it difficult to commit mistake
Ergonomic design of the tools and medical devices
Made to make things easy for surgeon to do the job
Makes it difficult to commit mistake
Human factor training in healcare enhances clinical performance by understanding the effects of team work,task, equipments, workshops
Works on cognatie and interpersonal skills to effectively manage a team based high risk activities.
Crew resource management training
That are likely to lead to error or highlit areas where preventive measures can be taken
Ransons
The pyramid suggests a ratio between the number of incidents at each level. Heinrich proposed that for every major injury, there are a certain number of minor injuries, and a larger number of near misses.
Heinrich's theory emphasizes that by addressing and preventing the lower-level incidents (near misses and minor injuries), organizations can reduce the likelihood of major injuries and fatalities.
Active failure and latent condition break the defense system
Health care worker are at the end of the pathway
So more vigilent to detect the loop holes
To take action to prevent error
Adopted in 18000 health facilities across 176 countries
Fitness to work
Credentialing is one way that is used to ensure that clinicians are adequately prepared to safely treat patients with particular problems or to undertake defined procedures.
