2. Understanding patient safety
■ Errors can be viewed from a person-
centred or system approach
■ The majority of near misses or adverse
events are due to system factors
■ Understanding why these errors occur
and applying the lessons learnt will
prevent future injuries to patients
3. ■ It is important to report all near
misses or adverse events so that we
can constantly learn from mistakes
■ Error models can help us
understand the factors that cause
near misses and adverse events and
also direct us to where our defences
against harm need to be improved
4. Strategies for patient safety
■ The WHO has established a
number of international initiatives
for patient safety
■ Various national approaches are
being undertaken by countries in
the developed world
5. ■ In developing countries patient
safety issues are more acute due to
a lack of resource, and face
different challenges
6. ■ Hospitals or institutions that will
offer the greatest patient safety
systems in the future will include
those that foster team working,
maximise the use of information
technology and are prepared to
realign their systems and processes
7. Patient safety at the coalface
requires
■ Communicating well with patients
and their carers
■ Professionalism, as another
essential component of patient
safety
8. ■ Clinical risk management and patient
advocacy and their roles in adverse
events and patient complaints
■ Team working and information flow as
well as managing the work
environment
■ Recognising the pitfalls to safe
prescribing
9. Surgeons can be committed during
the care of their patients and
include:
• diagnostic and management errors;
• resuscitation errors;
• prophylaxis errors;
11. Well recognised and potential
errors include
• the wrong patient in the operating
room;
• surgery performed on the wrong
side or site;
• the wrong procedure performed;
12. • failure to communicate changes in
the patient’s condition;
• disagreements about proceeding;
• retained instruments or swabs
13. All these events are catastrophic for
the patient and almost invariably
occur through a lack of
communication.
