This document discusses patient safety and medical errors. It notes that medical errors impact about 1 in 10 patients worldwide according to the WHO. The rates of death from medical errors in healthcare exceed those of other high-risk industries like commercial airlines or nuclear power. The document outlines some of the common causes of medical errors, including systemic flaws, communication issues, and patient ignorance. It emphasizes that a culture of safety and teamwork is needed to effectively address patient safety issues and prevent future errors.

1. Dr. Shailendra.V.L.
MBBS, DA, MD
Specialist Anesthesiologist
Director Patient Safety
Al Bukariya general hospital

2.  Patient safety is a new healthcare discipline
that emphasizes the reporting, analysis, and
prevention of medical error that often leads
to adverse patient outcomes.
 Recognizing that healthcare errors impact 1
in every 10 patients around the world, the
World Health Organization calls patient
safety an endemic concern.
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3.  Less than one death per 1,00,000 encounters
 Commercial airlines
 Nuclear power generation
 Off shore oil rigs
 One death in 1,000 – 1,00,000 encounters:
 Motor vehicle driving
 Chemical manufacturing
 More than one death per 1,000 encounters
 Bungee jumping
 Mountain climbing
 Health care
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4.  Hospital is a people intensive place.
 Provides services to sick people round the
clock – 24 hours a day & 365 days a year.
 People have a free access to enter the
hospital any time for advice & treatment.
 Hospital atmosphere is filled with emotions,
excitement, happiness, death & sorrow.
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5.  Institute of Medicine, USA found in a study:
 Medical error injures 1 in 25 hospital patients
 Kills about 44,000 to 98,000 every year
 Medical errors costs USA billions of dollors each
year.
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6. 1. Not willful negligence but systemic flaws.
2. Inadequate communication.
3. Wide-spread process variation.
4. Patient ignorance.
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7. 1. Individual made: errors due to human
factor in the process ( wrong calculations
of drugs, not following the 5 rights of
medications)
2. System made: holes in the system that
allows to slip through ( no clear & detailed
policy & procedures, no double checking
systems )
3. Environmental made: the dangers that
come from the setting of the hospital & the
material & equipments used ( no fire exit
doors, worn out power cables )
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8. “ To err is humane ”
 Human beings make mistakes because the
systems, tasks & processes always have room
for improvement.
 Every error has a root cause & every cause
has a solution.
 Errors can be prevented with every one’s
initiative in the system.
Here comes the role of the patient
safety department
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9. “We cannot change the human
condition, but we can change the
conditions under which humans
work ”
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10. …………………is our job
Individual accountability &
Vigilance is important, but its
not enough!!!!!
To build a culture of safety, we
have to work as a team.
TEAM WORK
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11. 1. Sentinel event:
1. Unexpected incident involving death or serious
physical or psychological injury or the risk
thereof.
2. Near miss:
1. An event or situation that could have resulted
in an accident, injury or illness but did not,
either by chance or timely intervention.
3. Adverse health care event:
1. Any variation in the processes leading to unsafe
situations in everyday working life.
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12. 1. Errors & system failures repeated.
2. Action of known risks is very low.
3. Detection system is in their infancy.
4. Many events are not reported.
5. Blame culture is alive & active.
6. Defensiveness & secrecy
7. Few examples of successful improvements.
8. Very low awareness of patient & staff
safety.
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14.  Dr.Shailendra.V.L.
 Director Patient Safety
 Pager # 140
 Dr.Taimoor Raja
 Assistant Director Patient Safety
 Mrs. Manar Mehamood
 Patient Safety Co-odinator
 Pager # 188

15. 1. Detection of safety issues.
2. Preventive & corrective actions.
3. Processes to reduce risks.
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16. 1. OVR / self reporting.
2. Safety oriented Leadership Walk Rounds.
3. Communication / education.
4. MOH – Patient safety standards monitoring.
5. Promoting patient safety culture.

17.  It is an atmosphere of mutual trust in which
all the staff members can talk freely about
safety problems & how to solve them,
without fear of blame or punishment.
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18. 1. Support team work & respect others.
2. Share lessons learnt.
3. Encourage use of communication.
4. Take a proactive approach to error.
5. Study & learn from our mistakes.
6. Share information about safety with others.
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20.  Voluntary reporting of process variation by
all health care workers
 Non punitive (no disciplinary action taken)
 To improve the quality of services
 To prevent recurrence of same errors
 Used to plan strategies to prevent same error
repeating again


22. 

24.  This is a multi disciplinary team that takes a
proactive approach to patient safety.
 It provides coordination & oversight to
advance an organizations safety program &
implement safety-related policies &
procedures.
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