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Patient safety
- 1. Anup Shrestha Department ofSurgery Pokhara Academy of Health Sciences.
- 5. .The paediatricianordered injection of vitamin K. The nurse gave the baby injection. Her parents realized she was no longer breathing after sometimes. They rushed her back to the clinic. The baby girl died later that afternoon.
- 6. Patient a sciencethat promotes the use of evidence-based medicine and commonsense improvements in an attempt to minimize the impact of human error on the routine delivery of health services. Our main aim is “First, Do No Harm”
- 7. Autonomy Beneficence Non-Maleficence Justice
- 8. S –Sense the error A – Act to prevent it F – Follow Safety Guidelines E – Enquire into accidents/Deaths T – Take appropriate measure Y – Your responsibility
- 9. An AdverseEvent A near miss A no harm Negligence
- 10. Around 1in 10 hospitalized patients experience harm, with at least 50% preventability The number of death attributed to medical error = one jumbo jet crash per day. Approximately 43 million patient safety incidences occur every year Medication errors cost an estimated 42 billion USD annually
- 11. Human factor Inadequatepatient assessment Failure to interpret appropriate test Error in treatment or operation Inadequate monitoring Deficiencies in training Fatigue Personal or psychological factor Lack of recognition of the dangers of errors
- 12. Poor communication Inadequate staff level Disconnected reporting system Lack of proper handovers Environment design Equipment failures Cost-cutting measures Inadequate system to report incidents
- 13.
- 14. All organizationsoperating in potentially harmful environment tends to build up defenses against potential damage and that these defenses can be broken down by active failures and latent condition.
- 16. S :Software H: Hardware E: Environment L: Liveware
- 17. International Level:By WHO “Clean care in safer care” , “Safe surgery save lives” “Patient safety alerts”. Institution and Hospital Level: Team working and Training Using information Technology Redesigning systems and processes
- 18. Good communication Professional behavior and maintaining fitness to practice Reporting adverse events and near misses Staff communication and the work environment Practices to reduce fatigue and stress.
- 19. Every yearalmost 7000 patients die due to bad handwritten medical prescription by doctors
- 21. Lean isa set of operating philosophies and methods that help create a maximum value for patients by reducing waste and waits
- 23. Surgery performedon the wrong patient or side or site The wrong procedure performed Failure to communicate changes in the patient’s condition. Disagreements about proceeding Retained instruments or swab Wrong surgical count
- 24. The surgicalsafety checklist identifies specific checks to be carried out at three obligatory time points
- 25. Cognitive errorsof judgment Procedural Executional
- 26. misinterpretation, misuseof instrumentation missed iatrogenic injury
- 27. Case example InOR a nursing student notices that the surgeon is closing the wound and there is still a pack inside the patient. The student is not sure if the surgeon is aware of the pack and is wondering whether to speak up. Create an effective learning environment Safe and supportive learning environments
- 28. The five“whys” Statement: The nurse gave the wrong drug. Why? Statement: because she misheard the name of the drug ordered by the doctor. Why? Statement: because the doctor was tired and it was the middle of the night and the nurse did not want to ask him to repeat the name. Why? Statement: because she knew that he has a temper and would shout at her. Why? Statement: because he was very tired and had been operating for the last 16 hours. Why? Because...
- 29. Healthcare workersmay experience a range of emotions including distress, shame, guilt, fear and depression Leads to physical and psychological disturbances. Hamper the care of other patients.
- 30. Schwartz’s Principleof Surgery. Bailey and Love’s Short practice of Surgery. World Health Organization’s Patient Safety Manual. Lawal AK, Rotter T, Kinsman L, et al. Lean management in health care: definition, concepts, methodology and effects reported (systematic review protocol). Systematic Reviews. 2014;3:103. doi:10.1186/2046-4053- 3-103.
Editor's Notes
- #3 Hospital in India
- #5 The surgeon was over confident and he didn’t checked the imaging reports before the surgery
- #6 A couple took their two-week-old baby girl for a routine check-up. Later they found that the injection injected to the baby was injection epinephrine instead of injection vitamin k. and the nurse who injected the medicine was confused because the colour of vials for both medicine was same
- #7 Patient safety is a fundamental principle of health care
- #8 1 respect for the patient's right to self-determination 2the duty to 'do good‘ the duty to 'not do bad‘ 4– to treat all people equally and equitably.
- #10 1. An incident which results in harm to the patient 2. an incident that could have resulted in unwanted consequences but did not. 3. An incident that occurs and reaches the patient but results in no injury to the patient. 4 . Care that fails below a recognized standard of care.
- #11 The number of death attributed to medical error is the aviation equivalent of one jumbo crash per day. A jumbo can carry maixmum 660 passengers . After reporting this data interest in patient safety research and programs increased significantly
- #12 1 delay or error in daignosis 4 foloow up of the patient 5 experience 6 , due to overload, time pressure 7 eg depression and drug abuse
- #13 1 Between health care providers 3 over reliance on automated system 6 due to lack or parts or skilled operators
- #14 1931 Unsafe acts or near misses lead to minor injuries and over time to a major injury. It also assess the risk of near misses Not only by reducing the number of mistakes but increasing the number of defenses set up against the consequences of mistakes, near misses are the best data about the relaibility of safety system. Important to report near misses and adverse events
- #15 Reason Hypothesized that Active failures .. Errors at the ground level 2 latent condition .. Created by the decision taken by higher level or administration. When a adverse event occurs ..not only individual is to be blamed .. Whole system and administration should also be blamed because they are also responsible for creating these loop holes.
- #16 Each slice of the cheese is an oppurtunity to prevent an accident .. More the slice fewers the hole .. And there is lees chance of accident to occur.
- #17 The centre of the model is human factor ….it is the most flexible factor but it is also the most unpredictable factors because different person have different skill personality attitude . Hardware the device and equipment we use while working. Soft ware means non physical aspect of the system the manuals checklist and computer porgrams 4 the flow of the information to the patient and to the colleagues should not be interrruptted and identical
- #19 1Poor communication is a common reason for patients taking legal actions. 4 smooth communication between the staff and healthy environment should be created Organizations and individuals should manage Practices to reduce fatigue and stress
- #20 A doctor many think the pharmacist will understand his regular prescription. But patients may go to another pharmacy and end up with wrong medication.
- #21 Prescription are Important in childrens and in patients while prescribing narcotics and anti pshycotic drugs
- #22 Based on the Toyota model, Reduce waste and how to maximize the potential of the available manpower We cant change the human condition but we can change the condition in which we are working. Serive in affordable cost
- #26 1 failure or late conversion of a difficult laparoscopic procedure into an open one. 2 When we take a step in a surgery for granted and skip it 3 when too much force is used.
- #27 1 which is unique to minimal access surgery :misreading of a two-dimensional image 2 , such as with energised dissection modalities, for example, diathermy 3 either at the time of surgery or diagnosed late
- #28 All the discussion leads to a question ? At every level of the medical education patient safety is important
- #30 Sometimes the media think that we medical persons are machines not human being. Not only the media but the person at the higher level also think we are machines.