Patient safety concepts are important to understand at the beginning of work @ a new facility.

1. Introduction to Patient Safety
Dr. Shailendra.V.L.
Patient Safety Department
Al Bukeriya general hospital

2. Outline
• Introduction to the concept of Patient Safety
• Occurrence Variance Report (OVR)
– Adverse Events
– Near Miss
– Sentinel Events
• International Patient Safety Goals

3. SECTION-I
INTRODUCTION TO THE CONCEPT
OF
PATIENT SAFETY

4. Patients and Medical Errors
• Healthcare errors impact 1 in every 10
patients around the world (WHO)
• Institute of Medicine, USA found in a study:-
– Medical errors injure 1 in 25 hospital patients
– Kills about 44,000 to 98,000 every year
– Medical errors costs USA billions of dollars each
year

5. Risk Comparison
• Less than one death per 100,000 encounters
– Commercial airlines
– Nuclear power generation
– Off shore oil rigs
• One death in 1,000 – 100,000 encounters:
– Motor vehicle driving
– Chemical manufacturing
• More than one death per 1,000 encounters
– Bungee jumping
– Mountain climbing
– Health care

6. Why Errors?
“To err is human”
• Not always willful negligence but systemic flaws
• Inadequate communication
• Wide-spread process variation
• Patient ignorance
Every error has a root cause
Every cause has a solution
Errors can be prevented with every one’s participation in the system
Here comes the role of the patient safety department

7. Patient Safety
• Patient safety is a new healthcare discipline
that emphasizes on
– Reporting
– analysis, and
– prevention of
medical errors that may leads to adverse patient
outcomes

8. Patient Safety
• Goals of Patient Safety
– Detection of safety issues
– Preventive & corrective actions
– Processes to reduce risks
• Broad Strategies
– Self reporting (OVR)
– Safety oriented Leadership Walk Rounds
– Communication / education
– MOH – Patient safety standards monitoring
– Promoting patient safety culture

9. SECTION-II
OCCURRENCE VARIANCE REPORT (OVR)

10. Sources of Errors
1. Individual made: Errors due to human factor in
the process e.g. wrong calculations of dosage
2. System made: Holes in the system that allow to
slip through e.g. no clear, detailed policy, no
double checking systems
3. Environment made: Hazards that come from
the environment of the hospital e.g. emotions,
dangerous medicines, radiation hazards

11. How to Make it Safer
• Acceptance, not denial
• Identifying the causes of the medical errors
and patient harm
• Finding solutions
• Improving systems

12. Identifying the Causes
• Significant patient harm
• Patient complaints
• Colleagues reporting
• Management trying to detect
• Self Reporting i.e. OVR

13. Occurrence Variance Report (OVR)
• Self Reporting – corner stone of improvement
– Voluntary reporting of process variation by all
health care workers
– Non punitive – no punishments
– To improve the quality of services
– To prevent recurrence of same errors
– To target system, not individuals

14. Types of Events
1. Adverse Event: Any variation in the
processes leading to unsafe situations in
everyday working life
2. Near Miss: An event or situation that could
have resulted in patient harm but did not,
either by chance or timely intervention
3. Sentinel Event: Unexpected incident
involving death or serious physical or
psychological injury or the risk thereof

15. Example
• An inpatient received 2 (two) unit of the
incorrect type of blood at the time. The
patient’s blood was drawn for a type/cross
match, the sample was mislabeled with
another patient's name. The transfusion was
given to the patient whose name appeared on
the type/cross match lab report, not the
patient whose blood was in the lab specimen
vial.

16. Examples of Reportable Events
• Eclampsia in booked patient
• APGAR score less than 7 at 5 minutes
• Unplanned blood transfusion
• Wrong implant or prosthesis
• Injury or unplanned repair or removal of an organ
• Complications post ERCP
• Complications post angiogram
• Retinopathy of prematurity (ROP) needing laser

17. SECTION-III
INTERNATIONAL PATIENT SAFETY GOALS

18. 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

19. Goal 1
• Identify Patients Correctly
– Wrong-patient errors occur in virtually all aspects
of diagnosis and treatment
– At least two patient identifiers
• File number
• Name
– Before
• Administering medications, blood, or blood products
• Taking blood and other specimens for clinical testing

20. Goal 2
• Improve Effective Communication
– Verbal and telephone order or test result is
• written down by the receiver
• then read back by the receiver, and
• confirmed by the giver
– Reporting back of critical test results and panic
values

21. Goal 3
• Improve the Safety of High-alert Medications
– Medicines with high risk of patient harm
– Policies to address the location, labeling, and
storage of concentrated electrolytes

22. Goal 4
• Ensure Correct-site, Correct-procedure,
Correct-patient Surgery
– Mark surgical site identification and involve the
patient in the marking process
– Use time-out procedure before starting a surgical
procedure

23. Goal 5
• Reduce the Risk of Health care–associated
Infections
– Implement an effective hand hygiene program
– Catheter associated infections

24. Goal 6
• Reduce the Risk of Patient Harm Resulting
from Falls
– Policies to reduce the risk of patient harm
resulting from falls
– Implement initial assessment of patients for fall
risk and reassessment when indicated
– Implement measures to reduce fall risk for those
assessed to be at risk

25. Conclusion
• Identification and prevention of patient harm
• Self reporting the events
• Adherence to the Six International Patient
Safety Goals

26. THANK YOU