Patient Safety is a health care discipline that emerged with the evolving complexity in health care systems and the resulting rise of patient harm in health care facilities. It aims to prevent and reduce risks, errors and harm that occur to patients during provision of health care.
Simple and Safe Approaches Towards Patient SafetyEhi Iden
A conference presentation on simple approaches and steps in achieving and managing patient safety in health. It talks about team approach, mutual support, just system, leadership commitment, complications of blame game and case study of the popular Kimberly Hiatt story.
Patient safety is the absence of preventable harm to a patient during the process of health care and reduction of risk of unnecessary harm associated with health.
Simple and Safe Approaches Towards Patient SafetyEhi Iden
A conference presentation on simple approaches and steps in achieving and managing patient safety in health. It talks about team approach, mutual support, just system, leadership commitment, complications of blame game and case study of the popular Kimberly Hiatt story.
Patient safety is the absence of preventable harm to a patient during the process of health care and reduction of risk of unnecessary harm associated with health.
Patient safety in Healthcare; Developing Patient Safety Culture by reporting ...VENODEN DHARMARAJAN
A guide and stimulant for the Medical Professionals on Patient Safety.
Patient safety is defined as the prevention and reduction of adverse outcomes (Alahmadi,2009). Learning from the mistake is the key to improve patient safety.
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
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.
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
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.”
Medical errors are ubiquitous and the costs (human and financial) are substantial. The top priority must be to redesign systems geared to prevent, detect and minimise effects of undesirable combinations of design, performance, and circumstance.
Patient safety in Healthcare; Developing Patient Safety Culture by reporting ...VENODEN DHARMARAJAN
A guide and stimulant for the Medical Professionals on Patient Safety.
Patient safety is defined as the prevention and reduction of adverse outcomes (Alahmadi,2009). Learning from the mistake is the key to improve patient safety.
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
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.
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
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.”
Medical errors are ubiquitous and the costs (human and financial) are substantial. The top priority must be to redesign systems geared to prevent, detect and minimise effects of undesirable combinations of design, performance, and circumstance.
November 1999I N S T I T U T E O F M E D I C I N E S.docxIlonaThornburg83
November 1999
I N S T I T U T E O F M E D I C I N E
Shaping the Future for Health
TO ERR IS HUMAN:
BUILDING A SAFER HEALTH SYSTEM
Health care in the United States is not as safe as it should be--and can be. At least 44,000 people, and perhaps as many as 98,000 people, die in hospitals each year as a result of medical errors that could have
been prevented, according to estimates from two major studies. Even using
the lower estimate, preventable medical errors in hospitals exceed attributable
deaths to such feared threats as motor-vehicle wrecks, breast cancer, and
AIDS.
Medical errors can be defined as the failure of a planned action to be
completed as intended or the use of a wrong plan to achieve an aim. Among
the problems that commonly occur during the course of providing health care
are adverse drug events and improper transfusions, surgical injuries and
wrong-site surgery, suicides, restraint-related injuries or death, falls, burns,
pressure ulcers, and mistaken patient identities. High error rates with serious
consequences are most likely to occur in intensive care units, operating rooms,
and emergency departments.
Beyond their cost in human lives, preventable medical errors exact
other significant tolls. They have been estimated to result in total costs (in
cluding the expense of additional care necessitated by the errors, lost income
and household productivity, and disability) of between $17 billion and $29
billion per year in hospitals nationwide. Errors also are costly in terms of loss
of trust in the health care system by patients and diminished satisfaction by
both patients and health professionals. Patients who experience a long hospi
tal stay or disability as a result of errors pay with physical and psychological
discomfort. Health professionals pay with loss of morale and frustration at
not being able to provide the best care possible. Society bears the cost of er
rors as well, in terms of lost worker productivity, reduced school attendance
by children, and lower levels of population health status.
A variety of factors have contributed to the nation’s epidemic of medi
cal errors. One oft-cited problem arises from the decentralized and frag
mented nature of the health care delivery system--or “nonsystem,” to some
observers. When patients see multiple providers in different settings, none of
whom has access to complete information, it becomes easier for things to go
Errors…are costly
in terms of loss of
trust in the health
care system by pa
tients and dimin
ished satisfaction
by both patients
and health profes
sionals.
Types of Errors
Diagnostic
Error or delay in diagnosis
Failure to employ indicated tests
Use of outmoded tests or therapy
Failure to act on results of monitoring or testing
Treatment
Error in the performance of an operation, procedure, or test
Error in administering the treatment
Error in the dose or method of using a drug
Avoidable delay in treatmen.
10Patient Safety Culture in hospitals.Student’s NameCoBenitoSumpter862
10
Patient Safety Culture in hospitals.
Student’s Name
Course
Instructor’s name.
Institutional Affiliation
September 24, 2021.
Patient Safety Culture in hospitals.
Introduction.
Patient safety is an issue of global public health concern. It refers to preventing patients from harm by implementing a care system that contains errors and learns from medical errors to build a safety culture involving healthcare workers, patients, and healthcare organizations. The safety of patients is critical in care quality. Many patients worldwide have suffered injuries, disabilities, and death due to medical errors or unsafe care. Patient safety culture can be defined as healthcare organizations' values about what is essential and how to operate to protect patients. To achieve a safe culture, organizations and their members must understand the values, norms, and beliefs about essential and attitudes and behaviors related to patient safety (Ali et al., 2018).
To achieve a culture of safety, organizations should emphasize addressing disparities in the quality of care because the current challenges may worsen the efforts to narrow the gap. The key issues in establishing and providing accessible, responsive, and effective health systems are quality and safety. Poor quality and unsafe patient care increase mortality and morbidity rates throughout the world. About 75% of the healthcare delivery gaps are preventable, and approximately 10% of inpatient admission result from preventable patient harm (Amiri et al., 2018).
Patient safety cultures with strong collaboration and leadership drive and prioritize safety (Wu et al., 2019). Strong leadership and commitment from manger are essential because their attitudes and actions influence the wider workforce's behaviors, perceptions, and attitudes. The other important aspects of patient safety culture include; effective communication, mutual trust, shared views on the importance of patient safety, engaging the healthcare workforce, acknowledging mistakes, and having a system that recognizes, responds, and gives feedback on adverse events (Alquwez et al., 2018). Patient safety culture is influenced by burnouts, hospital characteristics, communication, position, work area, commitment to the patient safety program, leadership, and patient safety resources and management.
Thesis statement.
Patient safety culture focuses on safety in health care by emphasizing the prevention, reporting, and investigation of medical errors that may cause patients' adverse effects, thus reducing harm by implementing necessary measures. Several factors are affecting the culture of patient safety in hospitals. This paper highlights patient safety culture and the factors affecting patient safety culture in public hospitals.
Body.
Patient safety culture encompasses shared values and beliefs about healthcare delivery system, training and education of healthcare workers on patient safety culture, commitment from leaders and managers, ope ...
10Patient Safety Culture in hospitals.Student’s NameCoSantosConleyha
10
Patient Safety Culture in hospitals.
Student’s Name
Course
Instructor’s name.
Institutional Affiliation
September 24, 2021.
Patient Safety Culture in hospitals.
Introduction.
Patient safety is an issue of global public health concern. It refers to preventing patients from harm by implementing a care system that contains errors and learns from medical errors to build a safety culture involving healthcare workers, patients, and healthcare organizations. The safety of patients is critical in care quality. Many patients worldwide have suffered injuries, disabilities, and death due to medical errors or unsafe care. Patient safety culture can be defined as healthcare organizations' values about what is essential and how to operate to protect patients. To achieve a safe culture, organizations and their members must understand the values, norms, and beliefs about essential and attitudes and behaviors related to patient safety (Ali et al., 2018).
To achieve a culture of safety, organizations should emphasize addressing disparities in the quality of care because the current challenges may worsen the efforts to narrow the gap. The key issues in establishing and providing accessible, responsive, and effective health systems are quality and safety. Poor quality and unsafe patient care increase mortality and morbidity rates throughout the world. About 75% of the healthcare delivery gaps are preventable, and approximately 10% of inpatient admission result from preventable patient harm (Amiri et al., 2018).
Patient safety cultures with strong collaboration and leadership drive and prioritize safety (Wu et al., 2019). Strong leadership and commitment from manger are essential because their attitudes and actions influence the wider workforce's behaviors, perceptions, and attitudes. The other important aspects of patient safety culture include; effective communication, mutual trust, shared views on the importance of patient safety, engaging the healthcare workforce, acknowledging mistakes, and having a system that recognizes, responds, and gives feedback on adverse events (Alquwez et al., 2018). Patient safety culture is influenced by burnouts, hospital characteristics, communication, position, work area, commitment to the patient safety program, leadership, and patient safety resources and management.
Thesis statement.
Patient safety culture focuses on safety in health care by emphasizing the prevention, reporting, and investigation of medical errors that may cause patients' adverse effects, thus reducing harm by implementing necessary measures. Several factors are affecting the culture of patient safety in hospitals. This paper highlights patient safety culture and the factors affecting patient safety culture in public hospitals.
Body.
Patient safety culture encompasses shared values and beliefs about healthcare delivery system, training and education of healthcare workers on patient safety culture, commitment from leaders and managers, ope ...
1EU HCM505 - 146Research Methodology in Health CriAnastaciaShadelb
1
EU HCM505 - 146
Research Methodology in Health
Critical Thinking Assignment: Research Paper_ Module 12
130 Points
/
Saami Comment by Dale Gooden: Hello Saleh,
Thank you for the hard work on this submission. I enjoyed reading it and have provided my feedback below.
Warmly,
Dr. Gooden
November 26, 2021
Patient Safety Culture in hospitals.
Introduction. Comment by Dale Gooden: You provided a solid introduction, background, and overview of the central theme of your research.
Patient safety is an issue of global public health concern. It refers to preventing patients from harm by implementing a care system that contains errors and learns from medical errors to build a safety culture involving healthcare workers, patients, and healthcare organizations. The safety of patients is critical in care quality. Many patients worldwide have suffered injuries, disabilities, and death due to medical errors or unsafe care. Patient safety culture can be defined as healthcare organizations' values about what is essential and how to operate to protect patients. To achieve a safety culture, organizations and their members need to understand the values, norms and beliefs about the essential attitudes and behaviors associated with patient safety (Ali et al., 2018).
To achieve a culture of safety, organizations should emphasize addressing disparities in the quality of care because the current challenges may worsen the efforts to narrow the gap. Quality and safety are key issues in establishing and delivering accessible, responsive and effective healthcare systems. Poor quality and unsafe patient care increase mortality and morbidity rates throughout the world. About 75% of the healthcare delivery gaps are preventable, and approximately 10% of inpatient admission result from preventable patient harm (Amiri et al., 2018).
Patient safety cultures with strong collaboration and leadership drive and prioritize safety (Wu et al., 2019). Strong leadership and commitment from manger are essential because their attitudes and actions influence the wider workforce's behaviors, perceptions, and attitudes. Other important aspects of the patient safety culture are; effective communication, mutual trust, shared views on the importance of patient safety, engaging the healthcare workforce, acknowledging mistakes, and having a system that recognizes, responds, and gives feedback on adverse events (Alquwez et al., 2018). Patient safety culture is influenced by burnouts, hospital characteristics, communication, position, work area, commitment to the patient safety program, leadership, and patient safety resources and management.
Thesis statement. Comment by Dale Gooden: Include a research question supported with peer-reviewed references to improve your grade.
Patient safety culture focuses on safety in health care by emphasizing the prevention, reporting, and investigation of medical errors that may cause patients' adverse effects, thus reducing harm by implementing n ...
Call for a standard framework for clinical risk management program to ensure ...Ruby Med Plus
Globally, the patient safety movement got focused in risk management by the publication of “To Err Is Human: Building a Safer Health System”, in 1999, which articulated the findings of a study of Institute of Medicine (IOM) of the devastating consequences of widespread medical error in the hospitals in USA. In addition to the unfortunate health consequences of medical error, there are direct and indirect costs borne by society as a whole. Patient Safety is the fundamental of the health care system. If care is not provided in a safe manner in a safe environment, the chances for a good outcome are lessened significantly.
As, Institute of Medicine (IOM) noted, “Patients should not be harmed by the care that is intended to help them, nor should harm come to those who work in health care.” The goal of risk management in health care must be to prevent harm from reaching patients and those involved in providing care to those patients and the place where the care is being provided . The aim of Clinical Risk Management is to improve both the safety and quality of care for patients and to reduce the costs of such risks for health care providers ” Hence, the Clinical Risk Management program needs a standard framework to fulfill this objective of Clinical Risk Management in clinical Dentistry. It gives the realization to the Dentist / Dental Team that fallibility is part of the human condition and human condition can’t be changed, but the conditions under which people work can be changed. That explains the need of Clinical Risk Management in Dentistry.
Objectives:
1.Introduce the Measuring and Monitoring of Safety Framework to a Canadian healthcare audience
2.Describe how the framework would work in Canada
Unit –IV Nursing Management oragnization M,Sc II year 2023.pptxanjalatchi
Organization is aprocess of grouping the necessary responsibilities and activities into workable units, determining the lines of authority and communication and developing patterns of coordination." "It is conscious development of role structures of superior and subordinate, line and staff. "
Unit -III Planning and control M.sc II year.pptxanjalatchi
planning and control, often known as production planning and control, are management functions that seek to determine: first, what market demands are stating and second, reconcile how a company can fill those demands through planning and monitoring.
ER(Entity Relationship) Diagram for online shopping - TAEHimani415946
https://bit.ly/3KACoyV
The ER diagram for the project is the foundation for the building of the database of the project. The properties, datatypes, and attributes are defined by the ER diagram.
1.Wireless Communication System_Wireless communication is a broad term that i...JeyaPerumal1
Wireless communication involves the transmission of information over a distance without the help of wires, cables or any other forms of electrical conductors.
Wireless communication is a broad term that incorporates all procedures and forms of connecting and communicating between two or more devices using a wireless signal through wireless communication technologies and devices.
Features of Wireless Communication
The evolution of wireless technology has brought many advancements with its effective features.
The transmitted distance can be anywhere between a few meters (for example, a television's remote control) and thousands of kilometers (for example, radio communication).
Wireless communication can be used for cellular telephony, wireless access to the internet, wireless home networking, and so on.
Multi-cluster Kubernetes Networking- Patterns, Projects and GuidelinesSanjeev Rampal
Talk presented at Kubernetes Community Day, New York, May 2024.
Technical summary of Multi-Cluster Kubernetes Networking architectures with focus on 4 key topics.
1) Key patterns for Multi-cluster architectures
2) Architectural comparison of several OSS/ CNCF projects to address these patterns
3) Evolution trends for the APIs of these projects
4) Some design recommendations & guidelines for adopting/ deploying these solutions.
This 7-second Brain Wave Ritual Attracts Money To You.!nirahealhty
Discover the power of a simple 7-second brain wave ritual that can attract wealth and abundance into your life. By tapping into specific brain frequencies, this technique helps you manifest financial success effortlessly. Ready to transform your financial future? Try this powerful ritual and start attracting money today!
This 7-second Brain Wave Ritual Attracts Money To You.!
patient safety and staff Management system ppt.pptx
1. D R . A N J A L A T C H I M U T H U K U M A R A N
V I C E P R I N C I P A L
E R A C O L L E G E O F N U R S I N G
S A R F R A Z G A N J , E R A U N I V E R S I T Y
L U C K N O W - 2 2 6 0 0 3
PATIENT AND STAFF SAFETY
MANAGEMENT SYSTEM
3. Key facts about patient safety by WHO
report
The occurrence of adverse events due to unsafe care is likely one of the 10 leading
causes of death and disability in the world (1).
In high-income countries, it is estimated that one in every 10 patients is harmed
while receiving hospital care (2). The harm can be caused by a range of adverse
events, with nearly 50% of them being preventable (3).
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 (4).
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 (5).
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 (6).
In OECD countries, 15% of total hospital activity and expenditure is a direct result of
adverse events (2).
Investments in reducing patient harm can lead to significant financial savings, and
more importantly better patient outcomes (2). An example of prevention is engaging
patients, if done well, it can reduce the burden of harm by up to 15% (6).
4. Definition
“ The reduction and mitigation of unsafe
acts within the health-care system, as well as
through the use of best practices shown to
lead to optimal patient outcomes.”
• Essentially, patient safety is about
constantly working to avoid, manage and
treat unsafe acts within the health care
system.
6. Definition
Patient safety practice is a type of process or
structure whose application reduces the probability
of adverse events resulting from exposure to
healthcare system.
Mistake-proofing is the use of process or design
features to prevent errors or the negative impact of
errors.
8. PATIENT SAFETY
Evolving Issues
Taxonomy – how we categorize and group
different patient safety events.
Nomenclature – using a common and universally
accepted language Patient Safety
9. Patient Safety Terms
Adverse Event - Identifying risks and processes
before they happen
Medical Error -Bad outcome from care
Sentinel event -Major and enduring loss of
function
Near Miss -An examination of past event
Retrospective Analysis - Deficient process of
care
Prospective Analysis -Could have resulted in loss,
injury or illness, but did not
10. Patient Safety: Challenges and Concerns
Difficulty recognizing errors
Lack of information systems to identify errors
Relationship of trust with providers
Shortages of clinical professionals
Concern about liability
Limited capacity on how to use quality improvement
tools such as PDSA
Culture of patient safety is lacking
11. Some Reasons Why Errors Occur
System Factors
Complexity of healthcare processes
Complexity of health care work environments
Lack of consistent administration practices
Deferred maintenance
Clumsy technology
Human Factors
Limited knowledge
Poor application of knowledge
Fatigue
Sub-optimal teamwork
Attention distraction
Inadequate training
Reliance on memory
Poor handwriting
12. Not Who caused the accident but What
caused the accident?
“ We cannot change the human condition, but we
can change the conditions under which human
works.” (Reason 2000)
Adoption of this paradigm by leaders is the
beginning for culture change
16. Patient Safety
Active Failures
highly visible errors with immediate consequences
Latent Failures
may be hidden for years and generally rooted in
organizational culture
takes the right set of circumstances for the error to
become visible or known
17. The Anatomy of Errors in Healthcare
Blunt End of the System
Organizational Factors - culture, policies,
procedures, regulations
Environmental Factors - equipment, staffing,
resources, constraints
Sharp end of the System
Human Factors - clinical competency,
communication skills, problem solving skills
18. Culture of Safety
Indicate the extent to which you agree with following
statements.
Scoring: strongly disagree, neutral, agree, strongly agree.
A. Senior management provides a climate that promotes
patient safety
B. If people find out that I made a mistake, I will be
disciplined.
C. My supervisor/manager says a good word when
he/she sees a job done according to established patient
safety procedures
D. Discussion around major events focuses mainly on
systems-related issues, rather than focusing on the
individual(s) most responsible for the event.
19. Important issues facing healthcare
organizations.
Establishing culture of patient safety and just
culture.
Identifying organizational champions.
Deploying patient safety strategies.
Adoption of safety-related technologies.
20. Just culture
Balancing safety and accountability.
The single greatest impediment to error prevention
in the medical industry “that we punish people for
the medical mistakes”.
21. 3 basics features of just culture
1. It doesn’t reduce the personal accountability and
discipline. It emphasizes the learning from the errors
and near misses to reduce errors in the future.
2. The greatest error not to report a mistake. Thereby
prevent learning.
3. All in the organization to serve as safety
advocates. Both providers and consumers will feel
safe and supported when they report medical errors,
near misses and voice concerns about patient safety.
It has zero tolerance for reckless behavior.
22. Behaviors
Human error – inadvertent action: doing other than what
should have been done. Manage through change in
processes, procedures and training.
At risk behavior: behavioral choice that increase risk where
risk is not recognized or is believed to be justified. Manage
through increase awareness, and providing incentives for
healthy behaviors and disincentives for risky behaviors.
Reckless behavior: consciously disregard substantial and
unjustifiable risk. Manage through Remedial and punitive
action.
23. Red rules
cannot be broken
few in number
easy to remember
associated only with processes that can cause serious
harm to employees, customers, or the product line.
must be followed exactly as specified except in rare
or urgent situations.
Every worker, regardless of rank or experience in
the company, is expected to stop the work or
production line if the red rule is violated.
24. Learning Organization
A learning healthcare system “is designed to
generate and apply the best evidence for the
collaborative healthcare choices of each patient and
provider;
to drive the process of discovery as a natural
outgrowth of patient care;
and to ensure innovation, Quality, Safety, and value
in healthcare”
( IOM Roundtable on EBM)
25. Patient Safety
Highly Reliable Organizations
Risk auditing: monitoring of activities to identify
both expected and unexpected risks
Appropriate reward systems that encourage safety-
related behavior
System quality standards
Acknowledgment of risk to learn from error
Flexible management model to promote teamwork
and communication
26. Responsibilities of governing bodies of
organization
Zone safety
Work around interruptions
Deviation from policy
Deviation from best practices
Standard :
policies and practices
Procedure
Standard of care
SOP guidelines
Routine practice of guidelines
27. Responsibilities of Governing body to
enhance patient safety
Getting data
Establishing and monitoring system-level measures.
Setting aims
Change the environment, policies and cultures.
Learning- Establish executive accountability.
28. More Definitions
Never events: As defined by the National Quality
Forum, these are preventable events considered so
harmful that they should never occur. Also called
serious reportable events (SREs), they include
most medication errors as well as instances of
performing surgery on the wrong body part or the
wrong patient.
Complications of care: Healthcare-associated
complications, including infections that patients
develop while in the hospital, are thought to be
largely preventable.
29. Patient Safety
Communication and Teamwork Challenges
Healthcare is traditionally hierarchical
Personal communication styles of staff
Lack of common language – led to development of
SBAR
Addressed with other patient safety initiatives
Simulation training
Rapid Response Teams (RRT)
Walk rounds
Patients participating on committees/RCAs
30. Patient Safety
Miscommunication:
Breakdowns in communication can result in the
wrong treatment, a lack of treatment, or incorrect
self-care by the patient. Miscommunication can be
the result of faulty systems (poor methods of
reporting critical test results, for example);
lack of attention to the health literacy of patients; or
a lack of cultural competency on the part of the
healthcare team.
31. Disclosure
Implement a formal (transparent) policy and process
of disclosure of adverse events to patients/families,
including support mechanisms for patients, family,
and care/service providers
32. Reasons to Disclose
Disclosure
Right thing to do
Patients expect it
Professional responsibility
Earn trust/possibly forgiveness of patient
Supports patient safety initiatives
Required by The Joint Commission for
unanticipated outcomes
33. Personnel Barriers to Disclosure
Fear of legal liability
Fear of loss of credibility and reputation
Fear of loss of licensure
Fear of punishment by organization or loss of job
Feelings of vulnerability
Difficulty in accepting role in error
34. System Barriers to Disclosure
We’ve always done it this way
Hierarchical structure of medicine
Profession demands perfection
Struggle with accepting even most well trained and
competent can make mistakes
Conflict of Interest
37. Patient Safety - Technology to Improve
Patient Safety
CPOE
Barcoding
Robotics
Electronic medical records
38. International Patient Safety Goals
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
39. The burden of harm
Every year, millions of patients suffer injuries or die because of unsafe and poor-
quality health care. Many medical practices and risks associated with health care are
emerging as major challenges for patient safety and contribute significantly to the
burden of harm due to unsafe care. Below are some of the patient safety situations
causing most concern.
Medication errors are a leading cause of injury and avoidable harm in health care
systems: globally, the cost associated with medication errors has been estimated at
US$ 42 billion annually (10).
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 (11).
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 (12).
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; they 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)) (5).
40. Continued
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 (13).
Unsafe transfusion practices expose patients to the risk of adverse transfusion
reactions and the transmission of infections (14). 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 (15).
Radiation errors involve overexposure to radiation and cases of wrong-patient
and wrong-site identification (16). A review of 30 years of published data on safety
in radiotherapy estimates that the overall incidence of errors is around 15 per 10
000 treatment courses (17).
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, affecting an estimated 31 million people worldwide
and causing over 5 million deaths per year (18).
Venous thromboembolism (blood clots) is one of the most common and
preventable causes of patient harm, contributing to one third of the complications
attributed to hospitalization. Annually, there are an estimated 3.9 million cases in
high-income countries and 6 million cases in low- and middle-income
countries (19).
41. Goal 1: Identify Patients Correctly
Rationale:
Wrong-patient errors occur in virtually all aspects of
diagnosis & treatment. The intent for this goal is two-
fold:
First, to reliably identify the individual as the person
for whom the service or treatment is intended;
Second, to match the service or treatment to that
individual.
42. Requirement
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
43. Requirement
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)
44. Goal 2: Improve Effective Communication
Rationale:
Ineffective communication is the most frequent
cited category of root causes of sentinel events.
Effective communication, which is timely, accurate,
complete, unambiguous, and understood by the
recipient, reduces error and results in improved
patient/client/resident safety.
45. Requirement
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.
Requirement
“Critical test results” are defined by the individual health
care organization and will typically include “stat” test,
“panic value” reports, and other diagnostic test results that
require urgent response.
46. Requirement o Requirement:
Standardize a list of abbreviations, acronyms, symbols,
and dose designations that are not be used throughout
the organization.
Requirement
Implement a standardized approach to “hand off”
communications, including an opportunity to ask and
respond to questions.
Requirement
Measure, assess, and if appropriate, take action to
improve the timeliness of reporting, and the timeliness of
receipt by the responsible licensed caregiver, of critical
tests and critical results and values.
47. Communication in Patient Care
Is not:
- Yelling
- Accusatory (angry)
- Being respectful of authority
Is:
- Focused on patient
- Nothing your perceptions
- Persistently raising concerns, intended to move
toward desired action
48. SBAR
A structured communication technique designed to
convey a great deal of information in an organized &
brief manner.
This is important as we all have different styles of
communicating, varying by profession, culture, and
gender.
49. SBAR description
Situation
A concise statement of the problem What is going on now
Background
Pertinent and brief information related to the situation
What has happened
Assessment
Analysis and considerations of options What you
found/think is going on
Recommendation
Request/recommend action What you want done S B A R
50. SBAR Situation
A concise statement of the problem What is going on
now Background Pertinent and brief information
related to the situation What has happened
Assessment Analysis and considerations of options
What you found/think is going on Recommendation
Request/recommend action What you want done S B
A R
51. Example SBAR briefing
55 YO Man with HTN, admitted for GI Bleed –
received 2 units, last hematocrite
VS: BP 90/50, Pulse 120
Looking pale, sweaty
Feels confused and weak, some problem with heavy
chest
52. Example SBAR briefing Situation:
Situation :
Dr. Jones, I have a 55 Y/O Man who looks pale, sweaty
and is complaining of chest pressure.
Background: He has a history of HTN, admitted for GI
Bleed received 2 units, last crit two hours ago was 31 vital
signs are: BP 90/50, Pulse 120
Assessment: I think he’s got an active bleed and we can’t
rule out an MI but we don’t have a troponin or a recent
H&H.
Recommendation:
I’d like to get an EKG and labs and I need for you to
evaluate him in right away.
53. Goal 3: Improve the Safety of High- Alert
Medications Implementation
Expectation Remove concentrated electrolytes
(including, but not limited to, potassium chloride,
potassium phosphate, Nacl~0.9%) from patient care
units. Standardize & limit the number of drug
concentrations available in the organization
54. Requirement
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.
55. Goal 4: Ensure Correct-Site, Correct- Procedure,
Correct-Patient Surgery
Rationale
Wrong-site, wrong-patient, wrong-procedure
surgery can be prevented if appropriate processes are
in place.
The intent is to establish and implement processes to
always identify the correct site, correct person and
correct procedure.
56. Goal 5: Reduce the Risk of Health Care-
Associated Infections
Rationale
At any given time, 1.4 million people worldwide
suffer from infections acquired in hospitals. The risk
of health care-associated infection in some
developing countries is as much as 20 times higher
than in developed countries.
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.
57. Goal 6: Reduce the Risk of Patient Harm
Resulting from Falls
Rationale
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.
58. Implementation Expectation As appropriate to the
population served, the services provided, and the
environment of care, a fall reduction program may
include risk assessment and periodic re-assessment
of individual patients or of the environment of care.
59. Implementation Expectation The program
should include risk reduction strategies involving
patients/families in education and environment of
care redesign. The program should also include
development and implementation of transfer
protocols (e.g., bed-to-chair), when relevant.
59. Question
The most important procedure to prevent hospital
acquired infection is :
1 . Using gloves
2 . Hand washing
3 . Wearing protective gowns
4 . All of the above
5 . None of the above
60. question
For inpatient identification all of the following Can
be used except for :
1 . Patient room number
2 . Patient medical ID
3 . Patient full name
4 . Patient national ID
5 . None of the above
61. Thank you so much for your patience for
listening
62. Refernces
References
1. Jha AK. Presentation at the “Patient Safety – A Grand Challenge for Healthcare
Professionals and Policymakers Alike” a Roundtable at the Grand Challenges
Meeting of the Bill & Melinda Gates Foundation, 18 October 2018
(https://globalhealth.harvard.edu/qualitypowerpoint, accessed 23 July 2019).
2. Slawomirski L, Auraaen A, Klazinga N. The economics of patient safety:
strengthening a value-based approach to reducing patient harm at national level.
Paris: OECD; 2017 (http://www.oecd.org/els/health-systems/The-economics-of-
patient-safety-March-2017.pdf, accessed 26 July 2019).
3. de Vries EN, Ramrattan MA, Smorenburg SM, Gouma DJ, Boermeester MA. The
incidence and nature of in-hospital adverse events: a systematic review. Qual Saf
Health Care. 2008;17(3):216–23. http://doi.org/10.1136/qshc.2007.023622
https://www.ncbi.nlm.nih.gov/pubmed/18519629
4.National Academies of Sciences, Engineering, and Medicine. Crossing the global
quality chasm: Improving health care worldwide. Washington (DC): The National
Academies Press; 2018 (https://www.nap.edu/catalog/25152/crossing-the-global-
quality-chasm-improving-health-care-worldwide, accessed 26 July 2019).