introductiontopatientsafetydepartmentHHH

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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