5. 1. Safety- Freedom from accidental injuries.
2. Error-Failure to complete a planned action as intended, or the use of an
incorrect plan of action to achieve a given plan.
3. Adverse Event- an event that cause harm, or potential to cause harm to
patient.
4. Serious Adverse/Sentinel Event- unanticipated adverse event or “Near
Miss” event in healthcare setting resulting in death or serious physical or
psychological injury to a patients, not arising from natural course of the
patient’s illness.
5. Near Miss- Circumstances or event that had the capacity to cause an
adverse event, but did not reach the patient.
LET US DEFINE
6. Medical Errors:
1. 1 in 10 patients admitted to hospital suffers an adverse
event.
2. Institute of Medicine study found out that in USA,
Medical error injures 1 patient in 25 hospitals.
3. Kills about 48,000 to 98,000 patients every year in USA.
4. Medical errors cost the United States billions of dollars
18-30$ each year.
5. Recent Statistics: 210,000 to 400,000 annual Deaths.
6. Dr. Don Berwick (May 5, 2016) : Medical Error is the 3rd
Leading Cause of Death in US.
7. Human Factors
•Variations in healthcare provider training & experience,
fatigue, depression and burnout.
•Diverse patients, unfamiliar settings, time pressures.
•Failure to acknowledge the prevalence and seriousness of medical
errors.
•Increasing working hours of nurses.
Medical complexity
•Complicated technologies.
•Intensive care, prolonged hospital stay.
Causes of healthcare error
Health care error is a preventable adverse effect of care,
whether or not it is evident or harmful to the patient.
8. System failures
•Poor communication.
•Nurse staffing ratio increases.
•Drug names that look alike or sound alike.
•The impression that action is being taken by other groups
within the institution.
•Reliance on automated systems to prevent error.
•Cost-cutting measures.
•Environment and design factors.
10. WHO/World Alliance for Patient
Safety
Mission
to coordinate, facilitate and accelerate patient safety
improvements around the world by:
1. Being a leader and advocating for change.
2. Generating and sharing knowledge and experiments.
3. Supporting Member State in their implementation of patient
safety actions.
Vision
Every patient receives safe healthcare, every time and
everywhere.
11. Practice of Patient Safety (WHO)
1. Be aware of Look-Alike, Sound-Alike medication names.
2. Proper Patient Identification.
3. Explain in detail during patient hand/take overs.
4. Performance of correct procedure at correct body site.
5. Careful about electrolyte imbalance.
6. Assuring proper treatment during shifting.
7. Avoid catheter and tubing wrong connections.
8. Single use of injection syringes.
9. Improved hand hygiene to prevent healthcare associated infections.
10. Proper disposal of BMW and good house keeping.
11. Practice surgical safety guidelines.
17. Environment Safety
• 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 wheelchairs and trolleys
• No waterlogging in bathrooms
• Call bell system for patients
• Adequate no. of bed screens to maintain privacy of the patient
18. Medical Safety
A. Medication orders should be written legible in ink and
should include:
Patient 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. “Do Not Abbreviate”.
C. Dispensing Medicine.
C. To check at least two patient identifiers.
D. Discourage Telephonic orders. Do not accept verbal order.
D. Examine safety code.
19.
20. Surgical Safety
1. Consent of the patient/relative in writing.
2. Proper identification of patient, name wrist band.
3. Proper identification mark of parts to be operated.
4. Pre-anesthetic check-up.
5. Anesthetic Safety.
6. Ensure no foreign body left inside.
7. Safety measures from ward to OT & coming back (safety
checklist).
8. Prevention of surgical wound infections.
9. Use of surgical safety protocol format in all operations.
10. Check Safety Code if available.
Code Blue Cardiac Arrest
Allergies Red
21. Electrical Safety
1. Safety fuses with each equipment.
2. No loose wires or connections.
3. Properly plugged and fixed.
4. If there’s a short circuit, call an electrician.
5. Use of UPS.
22. Fire Safety
1. Use fireproof materials for construction.
2. Have fire exit in all buildings.
3. Smoke detectors and water sprinklers on ceiling of all floors.
4. Fire extinguishers in all areas.
5. Fire hydrants in all buildings.
6. Training in fire management.
23. Blood Safety
1. Proper grouping & cross matching.
2. Tests/Screening of HIV, Inf. Hepatitis & VDRL.
3. Proper labeling of group, name of the patient.
4. Control of mismatched reaction and expiration.
5. Follow the Standard Operating Procedure.
6. Inform adverse reaction to BB.
24. Laboratory Safety
1. Avoid needle prick & spilling of blood.
2. Safety measures in Radiology & Radiotherapy departments.
3. Safety norm guidelines for different areas of hospitals.
4. Regular pest control measures.
5. Care in handling acids, reagents, inflammable substances.
6. BMW segregation and disposal.
25. Who are the Responsible?
DOCTOR
PATIENT
NURSE
ALLIED STAFF
TECHNICIANS
THERAPIST
26. TIPS FOR IMPROVING PATIENT SAFETY
1. EFFECTIVE COMMUNICATION.
2. Patient Safety Committee.
3. Policies and protocols for patient safety.
4. Increase staff awareness.
5. Encourage transparency in the regular death review.
6. Non-punitive incident reporting.
7. Near Miss reporting.
8. Departmental patient safety protocols.
9. Investigate each accident/incident reported and take remedial measures.
10. Review, monitor & evaluate safety procedures regularly.
