1.
D R . A N J A L A T C H I M U T H U K U M A R A N
V I C E P R I N C I P A L
E R A C O L L E G E O F N U R S I N G
S A R F R A Z G A N J , E R A U N I V E R S I T Y
L U C K N O W - 2 2 6 0 0 3
PATIENT AND STAFF SAFETY
MANAGEMENT SYSTEM

2.
Introduction

3.
Key facts about patient safety by WHO
report
 The occurrence of adverse events due to unsafe care is likely one of the 10 leading
causes of death and disability in the world (1).
 In high-income countries, it is estimated that one in every 10 patients is harmed
while receiving hospital care (2). The harm can be caused by a range of adverse
events, with nearly 50% of them being preventable (3).
 Each year, 134 million adverse events occur in hospitals in low- and middle-income
countries (LMICs), due to unsafe care, resulting in 2.6 million deaths (4).
 Another study has estimated that around two-thirds of all adverse events resulting
from unsafe care, and the years lost to disability and death (known as disability
adjusted life years, or DALYs) occur in LMICs (5).
 Globally, as many as 4 in 10 patients are harmed in primary and outpatient health
care. Up to 80% of harm is preventable. The most detrimental errors are related to
diagnosis, prescription and the use of medicines (6).
 In OECD countries, 15% of total hospital activity and expenditure is a direct result of
adverse events (2).
 Investments in reducing patient harm can lead to significant financial savings, and
more importantly better patient outcomes (2). An example of prevention is engaging
patients, if done well, it can reduce the burden of harm by up to 15% (6).

4.
Definition
“ The reduction and mitigation of unsafe
acts within the health-care system, as well as
through the use of best practices shown to
lead to optimal patient outcomes.”
• Essentially, patient safety is about
constantly working to avoid, manage and
treat unsafe acts within the health care
system.

5.
What is patient safety

6.
Definition
 Patient safety practice is a type of process or
structure whose application reduces the probability
of adverse events resulting from exposure to
healthcare system.
 Mistake-proofing is the use of process or design
features to prevent errors or the negative impact of
errors.

7.
Concept of patient safety

8.
PATIENT SAFETY
Evolving Issues
 Taxonomy – how we categorize and group
different patient safety events.
 Nomenclature – using a common and universally
accepted language Patient Safety

9.
Patient Safety Terms
 Adverse Event - Identifying risks and processes
before they happen
 Medical Error -Bad outcome from care
 Sentinel event -Major and enduring loss of
function
 Near Miss -An examination of past event
 Retrospective Analysis - Deficient process of
care
 Prospective Analysis -Could have resulted in loss,
injury or illness, but did not

10.
Patient Safety: Challenges and Concerns
 Difficulty recognizing errors
 Lack of information systems to identify errors
 Relationship of trust with providers
 Shortages of clinical professionals
 Concern about liability
 Limited capacity on how to use quality improvement
tools such as PDSA
 Culture of patient safety is lacking

11.
Some Reasons Why Errors Occur
System Factors
 Complexity of healthcare processes
 Complexity of health care work environments
 Lack of consistent administration practices
 Deferred maintenance
 Clumsy technology
Human Factors
 Limited knowledge
 Poor application of knowledge
 Fatigue
 Sub-optimal teamwork
 Attention distraction
 Inadequate training
 Reliance on memory
 Poor handwriting

12.
Not Who caused the accident but What
caused the accident?
 “ We cannot change the human condition, but we
can change the conditions under which human
works.” (Reason 2000)
 Adoption of this paradigm by leaders is the
beginning for culture change

13.
Trigger s DEFENSES

14.
Swiss chees theory

15.
Example of swiss model

16.
Patient Safety
Active Failures
 highly visible errors with immediate consequences
Latent Failures
 may be hidden for years and generally rooted in
organizational culture
 takes the right set of circumstances for the error to
become visible or known

17.
The Anatomy of Errors in Healthcare
Blunt End of the System
 Organizational Factors - culture, policies,
procedures, regulations
 Environmental Factors - equipment, staffing,
resources, constraints
Sharp end of the System
 Human Factors - clinical competency,
communication skills, problem solving skills

18.
Culture of Safety
 Indicate the extent to which you agree with following
statements.
 Scoring: strongly disagree, neutral, agree, strongly agree.
 A. Senior management provides a climate that promotes
patient safety
 B. If people find out that I made a mistake, I will be
disciplined.
 C. My supervisor/manager says a good word when
he/she sees a job done according to established patient
safety procedures
 D. Discussion around major events focuses mainly on
systems-related issues, rather than focusing on the
individual(s) most responsible for the event.

19.
Important issues facing healthcare
organizations.
 Establishing culture of patient safety and just
culture.
 Identifying organizational champions.
 Deploying patient safety strategies.
 Adoption of safety-related technologies.

20.
Just culture
 Balancing safety and accountability.
 The single greatest impediment to error prevention
in the medical industry “that we punish people for
the medical mistakes”.

21.
3 basics features of just culture
 1. It doesn’t reduce the personal accountability and
discipline. It emphasizes the learning from the errors
and near misses to reduce errors in the future.
 2. The greatest error not to report a mistake. Thereby
prevent learning.
 3. All in the organization to serve as safety
advocates. Both providers and consumers will feel
safe and supported when they report medical errors,
near misses and voice concerns about patient safety.
It has zero tolerance for reckless behavior.

22.
Behaviors
Human error – inadvertent action: doing other than what
should have been done. Manage through change in
processes, procedures and training.
At risk behavior: behavioral choice that increase risk where
risk is not recognized or is believed to be justified. Manage
through increase awareness, and providing incentives for
healthy behaviors and disincentives for risky behaviors.
Reckless behavior: consciously disregard substantial and
unjustifiable risk. Manage through Remedial and punitive
action.

23.
Red rules
 cannot be broken
 few in number
 easy to remember
 associated only with processes that can cause serious
harm to employees, customers, or the product line.
 must be followed exactly as specified except in rare
or urgent situations.
 Every worker, regardless of rank or experience in
the company, is expected to stop the work or
production line if the red rule is violated.

24.
Learning Organization
 A learning healthcare system “is designed to
generate and apply the best evidence for the
collaborative healthcare choices of each patient and
provider;
 to drive the process of discovery as a natural
outgrowth of patient care;
 and to ensure innovation, Quality, Safety, and value
in healthcare”
( IOM Roundtable on EBM)

25.
Patient Safety
Highly Reliable Organizations
 Risk auditing: monitoring of activities to identify
both expected and unexpected risks
 Appropriate reward systems that encourage safety-
related behavior
 System quality standards
 Acknowledgment of risk to learn from error
 Flexible management model to promote teamwork
and communication

26.
Responsibilities of governing bodies of
organization
 Zone safety
 Work around interruptions
 Deviation from policy
 Deviation from best practices
 Standard :
 policies and practices
 Procedure
 Standard of care
 SOP guidelines
 Routine practice of guidelines

27.
Responsibilities of Governing body to
enhance patient safety
 Getting data
 Establishing and monitoring system-level measures.
 Setting aims
 Change the environment, policies and cultures.
 Learning- Establish executive accountability.

28.
More Definitions
 Never events: As defined by the National Quality
Forum, these are preventable events considered so
harmful that they should never occur. Also called
serious reportable events (SREs), they include
most medication errors as well as instances of
performing surgery on the wrong body part or the
wrong patient.
 Complications of care: Healthcare-associated
complications, including infections that patients
develop while in the hospital, are thought to be
largely preventable.

29.
Patient Safety
 Communication and Teamwork Challenges
 Healthcare is traditionally hierarchical
 Personal communication styles of staff
 Lack of common language – led to development of
SBAR
 Addressed with other patient safety initiatives
Simulation training
 Rapid Response Teams (RRT)
 Walk rounds
 Patients participating on committees/RCAs

30.
Patient Safety
 Miscommunication:
 Breakdowns in communication can result in the
wrong treatment, a lack of treatment, or incorrect
self-care by the patient. Miscommunication can be
the result of faulty systems (poor methods of
reporting critical test results, for example);
 lack of attention to the health literacy of patients; or
a lack of cultural competency on the part of the
healthcare team.

31.
Disclosure
 Implement a formal (transparent) policy and process
of disclosure of adverse events to patients/families,
including support mechanisms for patients, family,
and care/service providers

32.
Reasons to Disclose
Disclosure
 Right thing to do
 Patients expect it
 Professional responsibility
 Earn trust/possibly forgiveness of patient
 Supports patient safety initiatives
 Required by The Joint Commission for
unanticipated outcomes

33.
Personnel Barriers to Disclosure
 Fear of legal liability
 Fear of loss of credibility and reputation
 Fear of loss of licensure
 Fear of punishment by organization or loss of job
 Feelings of vulnerability
 Difficulty in accepting role in error

34.
System Barriers to Disclosure
 We’ve always done it this way
 Hierarchical structure of medicine
 Profession demands perfection
 Struggle with accepting even most well trained and
competent can make mistakes
 Conflict of Interest

35.
patient safety :Michael Woods 4R’s
 Recognition
 Regret
 Responsibility
 Remedy

36.
Patient Safety: Mistake Proofing
 Knowledge in the Head
 Knowledge in the Environment

37.
Patient Safety - Technology to Improve
Patient Safety
 CPOE
 Barcoding
 Robotics
 Electronic medical records

38.
International Patient Safety Goals
International Patient Safety Goals
Goal 1 Identify Patients Correctly
Goal 2 Improve Effective Communication
Goal 3 Improve the Safety of High-Alert Medications
Goal 4 Ensure Correct-Site, Correct- Procedure,
Correct-Patient Surgery
Goal 5 Reduce the Risk of Health Care- Associated
Infections
Goal 6 Reduce the Risk of Patient Harm Resulting from
Falls

39.
The burden of harm
 Every year, millions of patients suffer injuries or die because of unsafe and poor-
quality health care. Many medical practices and risks associated with health care are
emerging as major challenges for patient safety and contribute significantly to the
burden of harm due to unsafe care. Below are some of the patient safety situations
causing most concern.
 Medication errors are a leading cause of injury and avoidable harm in health care
systems: globally, the cost associated with medication errors has been estimated at
US$ 42 billion annually (10).
 Health care-associated infections occur in 7 and 10 out of every 100
hospitalized patients in high-income countries and low- and middle-income
countries respectively (11).
 Unsafe surgical care procedures cause complications in up to 25% of patients.
Almost 7 million surgical patients suffer significant complications annually, 1
million of whom die during or immediately following surgery (12).
 Unsafe injections practices in health care settings can transmit infections,
including HIV and hepatitis B and C, and pose direct danger to patients and health
care workers; they account for a burden of harm estimated at 9.2 million years of
life lost to disability and death worldwide (known as Disability Adjusted Life Years
(DALYs)) (5).

40.
Continued
 Diagnostic errors occur in about 5% of adults in outpatient care settings, more
than half of which have the potential to cause severe harm. Most people will suffer a
diagnostic error in their lifetime (13).
 Unsafe transfusion practices expose patients to the risk of adverse transfusion
reactions and the transmission of infections (14). Data on adverse transfusion
reactions from a group of 21 countries show an average incidence of 8.7 serious
reactions per 100 000 distributed blood components (15).
 Radiation errors involve overexposure to radiation and cases of wrong-patient
and wrong-site identification (16). A review of 30 years of published data on safety
in radiotherapy estimates that the overall incidence of errors is around 15 per 10
000 treatment courses (17).
 Sepsis is frequently not diagnosed early enough to save a patient’s life. Because
these infections are often resistant to antibiotics, they can rapidly lead to
deteriorating clinical conditions, affecting an estimated 31 million people worldwide
and causing over 5 million deaths per year (18).
 Venous thromboembolism (blood clots) is one of the most common and
preventable causes of patient harm, contributing to one third of the complications
attributed to hospitalization. Annually, there are an estimated 3.9 million cases in
high-income countries and 6 million cases in low- and middle-income
countries (19).

41.
Goal 1: Identify Patients Correctly
Rationale:
Wrong-patient errors occur in virtually all aspects of
diagnosis & treatment. The intent for this goal is two-
fold:
First, to reliably identify the individual as the person
for whom the service or treatment is intended;
Second, to match the service or treatment to that
individual.

42.
Requirement
 Prior to the start of any invasive procedure, conduct
a final verification process, (such as a “time out”) to
confirm the correct patient, procedure and
communication techniques.
 Problems associated with surgical safety in
developed countries account for half of the avoidable
adverse events that result in death or disability

43.
Requirement
Use at least two patient identifiers whenever collecting
laboratory samples or administrating medications or
blood products.
Acceptable identifiers may be the individual’s name,
an assigned identification number, telephone number,
photograph or other person-specific identifier. (e.g.
birth date)

44.
Goal 2: Improve Effective Communication
Rationale:
Ineffective communication is the most frequent
cited category of root causes of sentinel events.
Effective communication, which is timely, accurate,
complete, unambiguous, and understood by the
recipient, reduces error and results in improved
patient/client/resident safety.

45.
Requirement
Simply repeating back the order or test result is not
sufficient. Whenever possible, the receiver of the order or
test result enter it into a computer, then read it back, and
receive confirmation from the individual who gave the
order or test result.
Requirement
“Critical test results” are defined by the individual health
care organization and will typically include “stat” test,
“panic value” reports, and other diagnostic test results that
require urgent response.

46.
Requirement o Requirement:
Standardize a list of abbreviations, acronyms, symbols,
and dose designations that are not be used throughout
the organization.
Requirement
Implement a standardized approach to “hand off”
communications, including an opportunity to ask and
respond to questions.
Requirement
Measure, assess, and if appropriate, take action to
improve the timeliness of reporting, and the timeliness of
receipt by the responsible licensed caregiver, of critical
tests and critical results and values.

47.
Communication in Patient Care
 Is not:
 - Yelling
 - Accusatory (angry)
 - Being respectful of authority
 Is:
 - Focused on patient
 - Nothing your perceptions
 - Persistently raising concerns, intended to move
toward desired action

48.
SBAR
 A structured communication technique designed to
convey a great deal of information in an organized &
brief manner.
 This is important as we all have different styles of
communicating, varying by profession, culture, and
gender.

49.
SBAR description
 Situation
 A concise statement of the problem What is going on now
 Background
 Pertinent and brief information related to the situation
What has happened
 Assessment
 Analysis and considerations of options What you
found/think is going on
 Recommendation
 Request/recommend action What you want done S B A R

50.
SBAR Situation
 A concise statement of the problem What is going on
now Background Pertinent and brief information
related to the situation What has happened
Assessment Analysis and considerations of options
What you found/think is going on Recommendation
Request/recommend action What you want done S B
A R

51.
Example SBAR briefing
 55 YO Man with HTN, admitted for GI Bleed –
received 2 units, last hematocrite
 VS: BP 90/50, Pulse 120
 Looking pale, sweaty
 Feels confused and weak, some problem with heavy
chest

52.
Example SBAR briefing Situation:
Situation :
 Dr. Jones, I have a 55 Y/O Man who looks pale, sweaty
and is complaining of chest pressure.
Background: He has a history of HTN, admitted for GI
Bleed received 2 units, last crit two hours ago was 31 vital
signs are: BP 90/50, Pulse 120
Assessment: I think he’s got an active bleed and we can’t
rule out an MI but we don’t have a troponin or a recent
H&H.
Recommendation:
I’d like to get an EKG and labs and I need for you to
evaluate him in right away.

53.
Goal 3: Improve the Safety of High- Alert
Medications Implementation
 Expectation Remove concentrated electrolytes
(including, but not limited to, potassium chloride,
potassium phosphate, Nacl~0.9%) from patient care
units. Standardize & limit the number of drug
concentrations available in the organization

54.
Requirement
 Identify and, at a minimum, annually review a list of
look-alike/sound-alike drugs used by the
organization, and take action to prevent errors
involving the interchange of these drugs.
 Label all medications, medication containers (for
example, syringes, medicine cups, basins) or other
solutions on and off the sterile field.

55.
Goal 4: Ensure Correct-Site, Correct- Procedure,
Correct-Patient Surgery
 Rationale
 Wrong-site, wrong-patient, wrong-procedure
surgery can be prevented if appropriate processes are
in place.
 The intent is to establish and implement processes to
always identify the correct site, correct person and
correct procedure.

56.
Goal 5: Reduce the Risk of Health Care-
Associated Infections
 Rationale
 At any given time, 1.4 million people worldwide
suffer from infections acquired in hospitals. The risk
of health care-associated infection in some
developing countries is as much as 20 times higher
than in developed countries.
 Compliance with the CDC hand hygiene guidelines
will reduce the transmission of infectious agents by
staff to patients/clients/residents thereby decreasing
the incidence of healthcare associated infections.

57.
Goal 6: Reduce the Risk of Patient Harm
Resulting from Falls
 Rationale
 Falls account for a significant portion of injuries in
hospitalized patients, long-term care residents, and
home care recipients.
 In the context of the population it serves, the services
it provides, and its environment of care, the
organization should assess,
 its patient risk for falls and take action to reduce the
risk of falling and to reduce the risk of injury, if a fall
occur.

58.
 Implementation Expectation As appropriate to the
population served, the services provided, and the
environment of care, a fall reduction program may
include risk assessment and periodic re-assessment
of individual patients or of the environment of care.
 59. Implementation Expectation The program
should include risk reduction strategies involving
patients/families in education and environment of
care redesign. The program should also include
development and implementation of transfer
protocols (e.g., bed-to-chair), when relevant.

59.
Question
 The most important procedure to prevent hospital
acquired infection is :
 1 . Using gloves
 2 . Hand washing
 3 . Wearing protective gowns
 4 . All of the above
 5 . None of the above

60.
question
 For inpatient identification all of the following Can
be used except for :
 1 . Patient room number
 2 . Patient medical ID
 3 . Patient full name
 4 . Patient national ID
 5 . None of the above

61.
Thank you so much for your patience for
listening

62.
Refernces
 References
 1. Jha AK. Presentation at the “Patient Safety – A Grand Challenge for Healthcare
Professionals and Policymakers Alike” a Roundtable at the Grand Challenges
Meeting of the Bill & Melinda Gates Foundation, 18 October 2018
(https://globalhealth.harvard.edu/qualitypowerpoint, accessed 23 July 2019).
 2. Slawomirski L, Auraaen A, Klazinga N. The economics of patient safety:
strengthening a value-based approach to reducing patient harm at national level.
Paris: OECD; 2017 (http://www.oecd.org/els/health-systems/The-economics-of-
patient-safety-March-2017.pdf, accessed 26 July 2019).
 3. de Vries EN, Ramrattan MA, Smorenburg SM, Gouma DJ, Boermeester MA. The
incidence and nature of in-hospital adverse events: a systematic review. Qual Saf
Health Care. 2008;17(3):216–23. http://doi.org/10.1136/qshc.2007.023622
https://www.ncbi.nlm.nih.gov/pubmed/18519629
 4.National Academies of Sciences, Engineering, and Medicine. Crossing the global
quality chasm: Improving health care worldwide. Washington (DC): The National
Academies Press; 2018 (https://www.nap.edu/catalog/25152/crossing-the-global-
quality-chasm-improving-health-care-worldwide, accessed 26 July 2019).