This document discusses patient safety in healthcare. It defines patient safety as the absence of preventable harm during healthcare. It notes that most patient harm is due to systemic flaws rather than individual negligence. It then discusses various types of patient safety concerns like medical errors, adverse events, infections, and falls. International patient safety goals are also presented, such as properly identifying patients, improving communication, and reducing healthcare-associated infections. The document emphasizes that improving safety requires efforts across many areas to protect patients from harm.

1. PATIENT SAFETY

2. What is Patient Safety?
 Patient Safety is the absence of preventable harm
to a patient during the process of health care.
 Improving patient safety means reducing patient
harm.
 It emerged with the evolving complexity in health care
systems and the resulting rise of patient harm in
health care facilities.
 Most times, fault is not wilful negligence, but systemic
flaws, inadequate communication and wide-spread
process variation and patient ignorance.
 Patient safety is fundamental to delivering quality
essential health services.

3. Patient Safety Concerns
 Adverse Event: Bad outcome from care. Event or omission arising
during clinical care and causing physical or psychological injury to a
patient.
 Medical Errors: Major and enduring loss of function. Failure to
complete a planned action as intended, or the use of an incorrect plan
of action to achieve a given plan
 Medication Error: Any preventable event that may cause or lead to
inappropriate medication use or patient harm while the medication is
in the control of health professional, patient or consumer.
 Near Miss: Could have resulted in loss, injury or illness, but did not.
Situation in which an event or ommission arising during clinical care
fails to develop further, whether or not as the result of compensating
action, thus preventing injury.
Focus on near miss: no patient harm, therefore no blame; no guilt, no
fear of litigation, focus on future prevention
 Adverse Drug Reaction: Any response to a drug which is noxious

4.  Sentinel Event: Deficient process of care. Surgery on wrong body
part, surgery on wrong patient, patient administered wrong
medication.
 Hospital Acquired Infections: Nosocomial Infections. An infection
acquired in hospital by a patient who was admitted for a reason
other than that infection. An infection occurring in a patient in a
hospital or other health-care facility in whom the infection was not
present or incubating at the time of admission.
 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.
 Unsafe transfusion practices expose patients to the risk of
adverse transfusion reactions and the transmission of infections.
 Radiation errors involve overexposure to radiation and cases of
wrong-patient and wrong-site identification.
 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.
 Venous thromboembolism (blood clots) is one of the most

5. Burden of Harm
Every year, millions of patients suffer injuries or die because of
unsafe and poor-quality health care.
 The occurrence of adverse events due to unsafe care is 1 of the
10 leading causes of death and disability in the world.
 In high-income countries, it is estimated that 1 in every 10
patients is harmed while receiving hospital care. The harm can
be caused by a range of adverse events, with nearly 50% of
them being preventable.
 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.
 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.

6.  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.
 In OECD countries, 15% of total hospital activity and
expenditure is a direct result of adverse events.
 Investments in reducing patient harm can lead to significant
financial savings, and more importantly better patient
outcomes. An example of prevention is engaging patients, if
done well, it can reduce the burden of harm by up to 15% .
According to WHO (2005),
 On average, 8.7% of hospital patients suffer health care-
associated infections (HAI).
 In developed countries: 5-10%
 In developing countries: – Risk of HAI: 2-20 times higher –
HAI may affect more than 25% of patients
 At any one time, over 1.4 million people worldwide suffer
from infections acquired while in hospital.

7.  Globally, the cost associated with medication errors has been estimated at
US$ 42 billion annually .
 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.
 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.
 Unsafe injections practices 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)).
 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.
 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 .
 A review of 30 years of published data on safety in radiotherapy estimates that
the overall incidence of radiation errors is around 15 per 10 000 treatment
courses.
 Sepsis have affected an estimated 31 million people worldwide and causing

8. Principles of Patient Safety
 Proper identification of patient and matching to their care
elements
 Prevention of patient handover error and safety during
transition
 Assessing medical accuracy while giving care to a
patient
 Performance of correct procedure at a correct bodysite
 Take appropriate precautionary measures to avoid
infection
 Principle of Patient Safety:
 Right Drug
 Right Patient
 Right dose
 Right Route

9. 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

10. Goal 1: Identify Patients Correctly
 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)
 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.

11. Goal 2: Improve Effective
Communication
 Effective communication, which is timely, accurate, complete,
unambiguous, and understood by the recipient, reduces error and
results in improved patient/client/resident safety.
 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.
 Standardize a list of abbreviations, acronyms, symbols, and dose
designations that are not be used throughout the organization.
 Implement a standardized approach to “hand over” communications,
including an opportunity to ask and respond to questions.
 Measure, assess, and if appropriate, take action to improve the
timeliness of reporting, and the timeliness of receipt by the caregiver, of
critical tests and critical results.
 A complete list of the patient’s medications is communicated to the next
provider of service when a patient is referred or transferred to another
setting, service, practitioner or level of care within or outside the

12. Goal 3: Improve the Safety of High-
Alert Medications
 Remove concentrated electrolytes (like
potassium chloride, potassium phosphate) from
patient care units.
 Standardize & limit the number of drug
concentrations available in the organization.
 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.

13. Goal 4: Ensure Correct-Site, Correct-
Procedure, Correct-Patient Surgery
 Ensure Correct-Site, Correct- Procedure, Correct-
Patient
 Wrong-site, wrong-patient, wrong-procedure surgery
can be prevented if appropriate processes are in
place.
 “Preoperative verification process”: The checklist is
an example of one approach-the most common one.
 Ensure that all of the relevant documents are
available prior to the start of the procedure & that
they have been reviewed & consistent with each
other & with staffs’ understanding of the intended
site, patient, & procedure.

14. Goal 5: Reduce the Risk of Health
Care- Associated Infections
 Reduce the Risk of Health Care-Associated
Infections Rationale.
 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.

15. Goal 6: Reduce the Risk of Patient
Harm Resulting from Falls
 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.

16. TYPES OF PATIENT SAFETY
 ENVIRONMENTAL SAFETY
 MEDICAL SAFETY
 SURGICAL SAFETY
 EQUIPMENT INSTALLATION SAFETY
 ELECTRICAL SAFETY
 BLOOD SAFETY
 LABORATORY SAFETY
 INFECTION CONTROL
 SANITATION
 BMW DISPOSAL

17. ENVIRONMENTAL SAFETY
 There is a direct link between work environment
and patient safety.
 If we do not have a formal program in place
addressing work environment issues, little will
change.
 Creating healthy work environments requires
changing long-standing cultures, traditions and
hierarchies
 Therefore, though everyone must be involved in
the creation of healthy work environments, the
onus is on organizational, departmental and unit

18.  Adequate light
 Adequate ventilation, exhaust fan
 Stairs with hand rails
 Window-door-closer
 Slip preventing floors
 Fire extinguishers and fire alarms
 Prevent noise pollution
 Heavy and fixed beds
 Safe wheel chairs and trolleys
 No water logging in bathrooms
 Call bell system for patients
 Adequate no. of bed screens to maintain privacy of
the patient.

19. MEDICAL SAFETY
 Illegible Writing prescription by doctors.
 Wrong medicines or wrong does or wrong patient.
 Wrong injection, wrong does or wrong patient, wrong
route of administration.
 Drip sets: air bubbles, over hydration, drip speed.
 Oxygen flow: check empty gas cylinders.
 Clear, written medication guidelines.
 Identification of each patient with Similar patient
names
 Proper handing taking over during change of shift.
 Look alike and Sound Alike “LASA”

20. A- Medication orders should be written legibly in ink and should include:
 Patient’s name and location (ward, room No, and bed No) .
 Medication Generic Name.
 Dosage, frequency and route of administration.
 Signature of the physician.
 Date and hour the order was written.
B- Any abbreviations used in medication orders should be agreed to and
jointly adopted by the medical, nursing, pharmacy, and medical records staff
of the institution. Lately, in the interest of patient safety, “Do Not Abbreviate” Is
the new practice nowadays.
C- Before dispensing the drug: The pharmacist must receive the physician’s
original order or a direct copy of the order (except in emergency
situations).This permits the pharmacist to
 Resolve questions or problems with drug orders before the drug is
dispensed and administered.
 Eliminate errors which may arise when drug orders are transcribed into
another form for use by the pharmacy.
D- to check at least two patient identifiers before providing care, treatments or
services, likr Patient name and medical record number

21. Methods of sending the Physician’s orders to the
pharmacy are:
1. Self-copying order forms: This method provides the
pharmacist with a duplicate copy of the order and does not
require special equipment. There are two basic formats:
a. Orders for medications included among treatment
orders.
b. Medication orders separated from other treatment
orders on the order form.`
2. Electromechanical: Copying machines or similar devices
may be used to produce an exact copy of the physician’s
order. Provision should be made to transmit physicians’
orders to the pharmacy in the event of mechanical failure.
3. Computerized: Computer systems, in which the
physician enters orders into a computer which then stores
and prints out the orders in the pharmacy or elsewhere.

22. SURGICAL SAFETY
 Consent of the patient/ relative in writing
 Proper identification of patient: wrist band
 Proper identification mark of parts to be operated
 Pre- anesthetic check-up
 Anesthetic Safety
 Ensure no foreign body left inside
 Safety measures from ward to OT & coming back (Safety check list)
 Prevention of surgical wound infections
 Use of Surgical safety proforma in all operations
 Check Safety code if available
WHO SURGICAL SAFETY CHECKLIST
 The primary benefit of the checklist may be to engage the medical
team.
 By using the checklist, we may be gaining the ability to open
communication by the medical team, to encourage teamwork

23. EQUIPMENT INSTALLATION
SAFETY
 Regular checking of equipments
 Proper earthling to avoid shock
 Regular maintenance & repair
 Training of nurses & technical staff
 How do you control hazards?: Preventing inadvertent
harm to patients requires use of human factors
engineering principles.
 The “hierarchy of hazard control:”
 Eliminate hazard
 Guard against hazard
 Train to avoid hazards
 Warn against hazards

24. ELECTRICAL SAFETY
 Safety fuses with each equipment
 No loose wires or connection
 Properly plugged and fixed
 If short circuit call electrician
 Electricity back up battery/ generator
 Use of CVT/UPS

25. FIRE SAFETY
 Use Fire proof material for construction
 Have Fire Exit in all Buildings.
 Smoke detectors and water sprinklers on the roof
of all Floors.
 Fire Extinguishers in all areas.
 Fire Hydrants in all buildings.
 Training in Fire management
 Mock drills

26. BLOOD SAFETY
 Proper grouping & cross matching
 Tests of HIV, Inf. hepatitis & VDRL
 Proper labeling of group, name of the patient
 Standard operating procedure
 Screening against HIV, Hepatitis. VD, Malaria.
 Control blood transfusion reactions

27. SANITATION- INFECTION
CONTROL- BMW DISPOSAL
 Proper segregation & transportation of biomedical
wastes
 Sanitation & hygiene of different parts of hospital
to avoid infection
 Use of sterile procedures
 Safety in use of incinerator, autoclave, shredder,
needle destroyers and proper disposal of
biomedical waste.
 Formation of hospital infection control committee
 Investigation of all hospital infections
 Use of proper antibiotics in right doses in right
time

28. LABORATORY SAFETY
 Avoid needle stick injuries & spilling of blood
 Safety measures in Radiology & Radiotherapy
departments
 Safety norm guide lines for different areas of
hospitals.
 Regular pest control measures
 Care in handling acids, reagents, inflammable
substances.
 BMW segregation and disposal

29. PRACTICE OF PATIENT SAFETY (
WHO )
 Be aware of Look-Alike, Sound-Alike Medication
Names.
 Proper Patient Identification.
 Explain in Detail During Patient Hand/Take- Overs.
 Performance of Correct Procedure at Correct Body
Site.
 Careful About Electrolyte Imbalance.
 Assuring Proper Treatment During Shifting.
 Avoid Catheter and Tubing, Wrong Connections .
 Single Use of Injection Syringes.
 Improved Hand Hygiene to Prevent Health Care-
Associated Infections
 Proper Disposal of BMW and Good House Keeping.
 Practice Surgical Safety Guide Lines.

30. TIPS FOR IMPROVING PATIENT
SAFETY
 Constitution of Patient Safety Committee.
 Develop clear policies and protocols for patient safety.
 Discuss regularly patient safety initiative within
hospital staff.
 Orientation, Re-orientation hospital staff on patient
safety
 Encourage transparency in the regular death review.
 Incident reporting by staff.
 Each department to devise their own patient safety
protocols.
 Investigate each accident/ incident reported and take
remedial measures.

31. MEDICAL ERRORS

32. Errors can involve:
Medicine
Surgery
Diagnosis
Equipment
Lab reports
Radiology reports
Dietary dept

33. What are these errors
Errors: Failure of planned action to be completed as
intended (error of execution) or use of wrong plan to
achieve an aim (error of planning); accumulation of
errors result in accidents.
Active Errors: An error that occurs at the level of front
line operator and whose effects are felt almost
immediately. At point of human interface with complex
system.
Latent Errors: Errors in design, organisation, training
or maintenance that lead to operator errors and
whose effects typically lie dormant in system for
lengthy period of time. (system design)

34. Classification
Human errors
 Error of omission
 Error of commission
 Interpretation/evaluation
System Errors
 Inadequate staffing or untrained staff
 Poor communication between providers, facility and pharmacy
 Poor coordination between pharmacy and facility for drug
ordering and delivery
 Poor documentation and reporting system of patient specific
concerns and human errors

35. Process framework for a safer health care
Core elements
 Identify risk
 Measuring the identified risk in terms of magnitude and
frequency of occurrence
 Prioritizing and controlling the risk
 Constantly monitoring the effectiveness of control
measures

36. RISK MANAGEMENT

37. Steps
Step 1: Identify risk
Step 2: Determining the Cause
Step 3: Considering the consequences
Step 4: Assessing the likelihood of an adverse incident
Step 5: Determining the risk
Step 6: Identifying and reviewing controls
Step 7: Action Plan