The document discusses patient safety, defining it as the prevention and reduction of adverse outcomes in healthcare settings. It highlights various types of medical errors, including medication and surgical errors, and emphasizes the importance of a safety culture in hospitals to mitigate these issues. Key recommendations for improving patient safety include enhancing incident reporting, conducting root cause analyses, and ensuring a well-trained workforce.

1. LOGO
Dr.D.VENODEN, MEDICAL ADMINISTRATOR, MoH, Sri Lanka

2. CONTENTS
Introduction to patient safety
Classification of hospital accidents
Evolution of patient safety culture
Elements of safety culture
Types of Medical errors
11/22/2017
2

3. WHAT IS PATIENT SAFETY?
Patient safety is defined as the prevention and
reduction of adverse outcomes (Alahmadi,2009)
11/22/2017
3
Learning from the
mistake is the key to
improve patient safety

4. PATIENT SAFETY – GLOBAL
SCENARIO
11/22/2017
4

5. PATIENT SAFETY – GLOBAL
SCENARIO
12.9% of admissions to public hospital in
New Zealand is associated with a hospital
adverse event.
10% of such admissions in UK
7.5% of such admissions in Canada
2.5 billion of Euros are spent yearly for
compensation due to mistakes in hospitals
in Italy
11/22/2017
5

6. 11/22/2017
6

7. ADVERSE EVENTS
ADVERSE EVENT
PREVENTABLE ADVERSE EVENT
An injury caused by medical management rather than the
underlying condition of the patient
An adverse event attributable to an error
11/22/2017
7

8. ERROR AND NEAR MISS
ERROR
NNEAR MISS
Failure of a planned action to be completed as intended (i.e., error of
execution) or the use of a wrong plan to achieve an aim (i.e. error of
planning)
An unplanned event that did not result in injury, illness, or damage – but had
the potential to do so. Only a fortunate break in the chain of events prevented
an injury, fatality or damage
11/22/2017
8

9. ERRORS AND ADVERSE EVENTS
11/22/2017
9

10. NEVER EVENTS AND NEGLIGENCE
NEVER EVENTS
Failure to meet standard practice of an average qualified physician
practicing in the specialty in question
NEGLIGENCE
Serious, largely preventable patient safety incidents that should not
occur if the available preventative measures have been implemented by
healthcare providers
11/22/2017
10

11. HOSPITAL ACCIDENTS
Active failure
It is related to errors of procedures or treatment at
the site of the action
Latent failure
It is related to design failure, building failure and
regulatory and procedure failures.
11/22/2017
11

12. Active vs. latent error
Active errors
 occur at the level of the frontline operator
 their effects are felt almost immediately
Latent errors
 Not under the direct control of the operator
 poor design, incorrect installation, faulty
maintenance, bad management decisions,
and poorly structured organizations
11/22/2017
12

13. LATENT FAILURE
SWISS CHEESE MODEL
11/22/2017
13

14. LATENT FAILURE
SWISS CHEESE MODEL
11/22/2017
14

15. 15
Multi-Causal Theory “Swiss Cheese”
diagram (Reason, 1991)
11/22/2017

16. STAGES IN THE DEVELOPMENT OF AN
ACCIDENT OR INCIDENT
11/22/2017
16

17. What is safety ‘culture’?
The safety culture of an organisation is the product
of individual and group values, attitudes,
perceptions, competencies and patterns of
behaviour that determine the commitment to, and
the style and proficiency of, an organisation’s
health and safety management.”
11/22/2017
17

18. All based on our
mental processes, beliefs, knowledge, and values
What we
think
Culture is learned,
not biologically inherited
What we do
What we produce
= the outcomes
Adapted from Reason
WHAT IS SAFETY CULTURE
11/22/2017
18

19. KEY CHARACTERISTICS OF SAFETY
CULTURE…
Mutual trust
Shared
perceptions
on the
importance of
safety
Confidence in
the efficacy of
preventive
measures
Safety culture
11/22/2017
19

20. EVOLUTION OF PATIENT SAFETY
CULTURE
11/22/2017
20

21. @SAFE_QI
The Model for Safety Culture
• No time for safety or investment into
improvementPathological
• Safety occurs in response to an incidentReactive
• Safety is driven by management systems and
imposed on the workforceBureaucratic
• There is value placed in safety with continually
improving systemsProactive
• The ideal, where safety is an integral part of
everyday life in all staffGenerative
Hudson P. Applying the lessons of high risk industries to health care
Qual Saf Health Care 2003
21

22. ELEMENTS OF SAFETY CULTURE
Element of safety
culture
Characteristics
Reporting culture  Staff have confidence in the local
incident reporting system and use it to
notify health care managers of incidents
that are occurring, including near misses.
Barriers of incident reporting should be
identified and removed:
- Staff are not blamed and punished when
they report incidents
-They receive constructive feedback after
an incident reporting
11/22/2017
22

23. ELEMENTS OF SAFETY CULTURE
Element of safety
culture
Characteristics
Informed culture  Those who manage and operate the
systems have current knowledge on the
factors that determine the safety of the
system
Open culture  Staff feel comfortable discussing
patient safety incidents and raising
safety issues with both colleagues and
senior managers
11/22/2017
23

24. ELEMENTS OF SAFETY CULTURE
Element of safety
culture
Characteristics
Just culture  Staff, patients and carers are treated
fairly, with empathy and consideration
when they have been involved in a
patient safety incident or have raised a
safety issue
Learning culture  The organization
-Is committed to learn safety lessons
- Communicates them to colleagues
- Remembers them over time
11/22/2017
24

25. TYPES OF ERRORS
SYSTEM ERRORS
(LATENT)
 Heavy work load/fatigue
 Incomplete/unwritten
policies
 Inadequate
training/supervision
 Inadequate maintenance
of equipment/department
 Communication
HUMAN
MISTAKES(ACTIVE)
 Action slips or
failures(e.g. picking up
the wrong syringe – due
to anxiety, fatigue etc)
 Cognitive failure(e.g.
memory lapses, mistakes
through misreading a
situation)
 Violations( deviations
from the standard
procedures)
11/22/2017
25

26. TYPES OF MEDICAL ERRORS
Medication errors: Errors which occur at any
point in the medication usage chain. It can occur
at ordering stage, transcribing stage, dispensing
stage or administering stage.
Surgical errors – specific to surgery-wrong site
surgery, retained sponges and instruments.
Diagnostic errors
Human factors and errors at the person-machine
interface
11/22/2017
26

27. TYPES OF MEDICAL ERRORS
Transition and hand off errors
Team work and communication errors
Hospital acquired infections
Other complications of health care
11/22/2017
27

28. SAFETY
S – Sense the error
A – Act to prevent it
F – Follow safety guidelines
E- Enquire into accidents/ deaths
T – Take appropriate remedial measure
Y – Your responsibility
11/22/2017
28

29. HOW TO PROMOTE PATIENT
SAFETY
Improve the system of incident and accident
reporting
Carrying out root cause analysis (RCA) and
Human failure mode effect analysis (HFMEA)
Creating safety culture in hospitals
Increase attention is to be paid to the importance
of a well trained, well-rested workforce to patient
safety
Availability and involvement of more supervisors
and efforts to encourage trainees to admit their
limitations and call for help.
11/22/2017
29

30. HUMAN FAILURE MODE EFFECT
ANALYSIS
30
11/22/2017

31. HOW TO PROMOTE PATIENT
SAFETY
Regulations and Accreditations are powerful
tools to promote patient safety
11/22/2017
31

32. LOGO