This newsletter from HEMAS Hospital provides a summary of recent developments in patient safety. It discusses root cause analysis and human error, including types of errors like slips and lapses. The newsletter aims to improve knowledge of patient safety principles and innovations and to share innovations with national and international groups. It also provides an update on adverse events reporting and accreditation at the hospital.

1. 1
22nd July 2015
Volume 1 Issue 2
HEMAS HOSPITAL
iajsia pSia wdlD;sh
fuu wdlD;shg wkqj wdh;khl
ls%hdldrs;ajh ia:r lSmhl Ml;=jls'
Mla pSia lE,a,la Mla ia:rhla f,i
i,lkak' bosrsfm, ia:rhg
wh;ajkafka ffjoHjre fyoshka wka
iydhlhkaf.a ls%hdldrs;ajhhs'
fojk ia:rhg m%Yia; f,i jev
lsrSug wjYH miqnuS mrsir
;;a;ajhkah wh;afjs' f;jk
ia:rhg wOSlaIKh iy u.fmkajSu
isoqjk wdldrh wh;ajk w;r is-
jsjk ia:rhg m%;sm;a;s iy
udraf.damfoaYk wh;afjs'
Root Cause Analysis [RCA] -II
udkqISh jeros j¾. [human error types]
Root Cause analysis
[RCA] is a tool used to
find out system related
cause/s to prevent re-
occurrence (kej;
isoqjSu je,elajSu& once
an incident is reported.
fuysoS flfrkafka isoqjSug
uq,a jQ wh fidhd Tjqkg
jskh ls%hdud¾. .ekSug
jvd Mh g fya;=ldrl
fidhd Majd bj;alsrSug
lghq;= lsrSuhs'
fuu l%shdj,sfhaoS wm
is;sh hq;= wkaou myiq
lrkq jia REASON
kue;a;d iajsia pSia lE,s
weiqfrka iqm%isoaO iajsia pSia
wdlD;sh bosrsm;a lf,ah'
iajsia pSia @
by; rEmfha fmkajd we;s mrsos
iajsia pSia lE,a,l jsjsO yev ;,
j,ska hq;a ys,a ;sfn's fuu pSia lE,s
lSmhla Ml fm,g ;enqjfyd;a Ml
wka;hl isg wks;a wka;h
oelhhyels jk mrsos iuyr ys,a
Ml fm,g ;snSug mq,qjk'
jvd;a jeo.;au lreK kus Mla
wka;hl isg wfkla wka;h oelSu
ioyd Mll fkdj ish,qu pSia
lE,sj, Ml ys,la fyda Ml fm,g
isgsh hq;=h
jeroaola hkq ie,iqus l, ls%
hdjlska wfmalaIs; m%;sm,h
fkd,enSu f,i w¾: oelafj's
Violations
wfmalaIs; ls%hdj iusu;
u d ¾ f . d a m f o a Y k i y
m%;sm;a;sj,g wkqj ls%hd
isoqfkdlr isoqjk jeros
fus .Khg wh;afjs'
Aims of this newsletter
 T o i m p r o v e o u r
knowledge about latest
principles, applications
and developments in pa-
tient safety
 To share our innovations
in patient safety field with
national and international
interest groups
Inside this
issue:
An intro to
RCA
1
Human
error types
1
An application
of Swiss cheese
model
2
Events 2
News 2
PATIENT SAFETY
NEWSLETTER
Mistakes
fuysoS wfmalaIs; mrsos ls%hdj
isoqflfrk uq;a wjYH
m%;sm,h fkd,efns' frda.s
mrSlaIdj isoqjqj;a jeros frda.
jsksYaph iy jeros T!IO oSu
fus .Khg wh;ah' fujeks
jeros isoqjkafka oekqu iy
m,mqreoao wvqjQ jsghs'
Slips and Lapses
fuu j¾. folu isoqjkafka
wm fyd|gu okakd ls%hdjla
isoq lrk jsghs'
Slips - wjOdkh fjk;lg
fhduq jSu ksid isoqjk jeroshs'
Lapses - hkq wu;l jSus
ksid isoqjk jeroshs'

2. 2
Aoekqu fyda u;lh fyda wjOdkh levShdu fyda iusu; l%ufjso fkdms,smeoSu ksid isoqjk jeros
iajsia pSia wdlD;shg wkqj ilS%h wiu;ajSus [active failures] f,i ie,fla' fusjd je,elajSu
ioyd m,uq fm, ndOl wm jsiska fhdokq ,nhs'
fojk iy f;jk fm, isoqjk jeros wlS%h wiu;ajSus [latent failures] f,i yeoskafj's fojk
fm,g wOsl jev uqr" wOSlaIK oqn,;d" ikaksdfjsok oqn,;d" WmlrKj, fodaI" oekqu iy
yelshdj ms,sno wvqmdvq wh;afjs' f;jk fm,g wh;ajkafka ie,eiqus" mqyqKq lsrSus" iy m%;sm;a;s
hk wxYj, oqn,;dh's fuu wdlD;sh wkqj Ml ia:rhl isoqjk wvqmdvqjla ksid muKla
wk;=rla isoq fkdfjs' lsishus isoaOshla isoqjkafka ia:r lSmhl wvqmdvq j, Ml;=jla ksidfjks'
nyq,j isoqjsh ye;s isoqjSula ioyd wm fuu oekqu wdfoaY lr.ekSug W;aidy lruq'
m,uq ia:rh( jeros T!IOh osu
fojk ia:rh( jevs frda.Ska .Kkla isgSu$ ksosu;$ kshu T!IOh iy jeros T!IOh Ml iudk jSu
f;jk ia:rh( wmeyeos,s fiajd uqr l%u$ ksosu; iy uykaish [fatigue] je,elajSfus l%ufjsofha
wvqmdvq Ml yd iudk T!IO Ml ,. ;snSu
isjs jk ia:rh( fiajd uqr" fatigue prevention , look alike sound alike [LASA] ^ Ml yd iudk
T!IO 2 la Ml ,. ;snSu kssid isoqjk jeros& jevigyk ls%hd;aul fkdjSu
Adverse events poster at SLMA
sessions 7 July 2015
iajsia pSia wdlD;sfha Ndjs;djla
my; oelafjkafka udi 24 ld,hla ;=, 2013 ckjdrs
isg 2014 foieusnr olajd iEu udihlu wm jsiska
jsiska iafjspScdfjka jd¾:d lrk ,o isoqjSus .Kkhs'
fuu ld,h ;=, 692 la jd¾:d jQ w;r uilg 28 ls
wm jsiska fus ish,qu isoqjSulau meyeos,s ls%hdoduhlg
wkqj huska fiajd .=Kd;aul nj by, kexjSu ioyd
ksrka;r W;aidyhl ksr; fjs' fujr jd¾Isl
,dxlSh ffjoH iusfus,kfhaoS fuu ls%hdouh ms,sno
fmdaiagrhla m%o¾Ykh flrsKs'
fuh Mys ;snQ fmdaiagr ish .Kkska frda.S iqr-
laIs;;dj ud;Dlj hgf;a ;snQ Mlu fmdaiagrhhs'
We displayed this poster at the Sri Lanka Medical
Association Annual Congress sessions held at Galadari.
WE DID It AGAIN!!
Congratulations to criteria owners and the
teams work hard for recertification of Austral-
ian Council Health Standards for another 4
years from 2015!
We have done well to satisfy the surveyors!
Send your comments to : prasanthad@hemashospitals.com
udih
.Kk'