Dr.Nikhil Datar

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This presentation is by Dr.Nikhil Datar at the Putting Patients First Conference on 20th Oct,10. Topic "Promoting Patient Safety". HELP is the world's largest the worlds largest free patient education library - www.healthlibrary.com

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  • Introduction: mother’s story…
  • Dr.Nikhil Datar

    1. 1. Patient safety -- Learning from Commonwealth fellowship Dr Nikhil Datar ( At WHO )
    2. 2. 1991, Harvard medical practice study 1999, IOM :” To err is human” Studies from Australia and other countries Patient safety Dr Lucian Leap
    3. 3. “Many people in the healthcare profession and in the general public still believe that mistakes in medical care are episodes of individual failure and that most errors occur as a result of someone not doing his or her job.” ---Don Burwick (Achieving safe and reliable health care)
    4. 4. Inferences: •Out of the 3.7% cases, the acts which could be called as “negligence” were only 1%. •50% of these are preventable. •The majority of them were not individual failures but the system failures. It was a defective system which was just waiting to fail.
    5. 5. With Sir James Reason 57 per 100000 deaths happen due to unintended injuries.. It is the 9th cause of mortality in the world.
    6. 6. “Swiss cheese” model of errors Sir James Reason
    7. 7. Medicine is complex • Harvard Venuguard query: – 250 primary problems+ 900 secondary problems+300 medicines+ 100 diagnostic tests+40 procedures – In ICU settings , 179 procedures per day .. Which can prove dangerous.
    8. 8. Philosophy of errors • Ignorance • Ineptitude – Samuel Gorovitz ( journal of medicine and philosophy, 1970) • Situational Awareness
    9. 9. Test your awareness
    10. 10. How reliable is health care? 1000010010 1000 1million 10million100000 hazardous Ultra-safe Bungee jumping Mountain climbing Chemical manufacturing Scheduled airlines European rail Nuclear power health
    11. 11. Learning from Aviation industry • Team work and communication • Incidence reporting system • Protocols and check lists

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