presentation

1. Patient Safety and
Professionalism
Prof. John Adwok
MBBS, MMED(Surg.), FCS(ECSA), FRCS(Edin.),
FACS, PhD.
Chairman, South Sudan General Medical Council
Consultant General & Endocrine Surgeon
Department of Surgery
Nairobi Hospital

2. Introduction
 Until about 2-3 decades ago, it was assumed that adverse
clinical outcomes resulted from unavoidable
complications caused by the patient’s condition and
comorbidities.
 This assumption started to be questioned in the 1980s &
1990s as health care started to be investigated in a more
structured and scientific manner.
 Maximizing safety is a fundamental responsibility of
individual healthcare providers and the healthcare
systems. We have a moral and ethical duty to keep
patients safe.
18th May, 2018

3. Introduction
 Many of the incidents that cause patient harm can be
minimised by practising benchmarked quality practice
guidelines.
 Patient safety research has shown that organisational-
level initiatives are vital to provide a foundation for the
more local interventions by departments targeting
specific types of harm.
 The overarching requirement is a culture conducive to
safety in the healthcare system.
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4. KNH/U.o.N Symposium: Patient Safety & Quality
Introduction
 Overview of Patient Safety.
– Definitions
– Scope & burden of patient harm
– Economic effects
– Common causes of harm
– Improving patient safety
– Summary & Recommendations
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5. Definitions
 Patient safety is the reduction of risk of unnecessary
harm associated with health care to an acceptable
minimum.
 Patient harm is any unintended and unnecessary harm
resulting from, or contributed by, healthcare. This
includes the absence of indicated medical treatment.
 Professionalism is the competence and skill expected of
a professional.
 An adverse event is an incident during care that results in
patient harm.
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6. Scope of Patient Harm by the
Healthcare System
 About 10% of patients admitted to hospital
will be harmed. Half of these could have
been prevented.
 6% of these patients will have permanent
disability and 8% will die.
 14th
leading cause of global health burden-
comparable to diseases like TB and malaria.
Slawomirski et al, 2017
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7. KNH/U.o.N Symposium: Patient Safety & Quality
Burden of Adverse Events
 There is the knock-on anguish
of families, loved ones, and
friends to be considered by
the healthcare system besides
the patient harm.
 Distress caused to the staff
involved who have to deal with
adverse events.
 Considerable financial cost to
the community, healthcare
system and economy at large.
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8. Economic effects of Safety Failures
 Need for additional treatment.
 More diagnostic testing.
 Readmission or prolonged hospital stay.
 Broader economic effects:
– Ongoing morbidity with lost capacity.
– Reduced lifetime productivity of patients and carers.
– Reduced trust in the health systems, governments and
social institutions.
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9. Causes of Harm
 Complex, dynamic and
diverse.
 Stretch across all facets
of healthcare delivery
and system behaviour
from planning to clinical
activity.
 Most of the cost burden
is associated with a few
common adverse events.
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10. Common Adverse Events—Safety
Indicators
 Medication errors
 Hospital acquired infections
 Patient falls
 Pressure ulcers
 Venous thromboembolism
 Diagnostic errors or delayed diagnosis
 Death during interventions
(Slawomirski et al., 2017)
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11. Adverse Events and Harm
 Play out at the clinical interface.
 Root causes are structural, cultural and
process oriented.
 Vast majority of patient harm, from the
operating theatre to the community clinic,
can be traced to failure in communication.
(Francis, 2013)
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12. Adverse Events in
Different Care Settings
Level of Care Adverse Event General drivers of
adverse events
Primary care Adverse drug events/
medication errors;
Diagnostic
error/delayed diagnosis Lack of
communication and
information, lack of
skills/knowledge,
inadequate
organizational culture,
misaligned incentives.
Long Term Care Adverse drug events,
pressure injuries and
falls
Hospital Care Hospital infections, VTE,
adverse drug events,
pressure injury,, wrong
site surgery.
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13. Improving Patient
Safety
Organisational-level
Interventions

14. KNH/U.o.N Symposium: Patient Safety & Quality
International Patient Safety Goals (IPSG)
 Goal 1: Identify patients correctly
 Goal 2: Improve effective communication
 Goal 3: Improve the safety of high-alert medications
 Goal 4: Ensure safe surgery--patient, site, procedure
 Goal 5: Reduce risk of healthcare-associated infections
 Goal 6: Reduce the risk of patient harm resulting from
falls
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15. Minimising the most Burdensome Adverse
Events
 Clinical level interventions
using a systems-
perspective:
– VTE Prophylaxis.
– Protocols to minimize central
line catheter insertion.
– Pressure injuries.
– Urinary catheter associated
infections.
– Procedural and surgical
check lists.
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16. WHO Surgical Safety Checklist
 It is now universally recommended by
accrediting bodies to use the WHO
safety checklist as there is
overwhelming clinical evidence that it
improves patient safety.
 Local adaptation of the checklist is
encouraged to ensure effective
integration into clinical practice in a
hospital.
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17. WHO Surgical Safety List
 ‘Sign In’ before induction of
anaesthesia.
 ‘Time out’ before start of surgical
intervention…skin incision.
 ‘Sign Out’ before any member of
the team leaves theatre
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18. WHO Surgical Safety ‘Sign In’
 Has the patient confirmed identity, site,
procedure and consent?
 Is the surgical site marked?
 Is the anaesthesia machine and medication
check complete?
 Known allergies?
 Difficult airway/aspiration risk?
 Risk of >500mls of blood loss (7ml/kg in child)?
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19. WHO Surgical Safety ‘Time Out’
 Have all team members introduced themselves by
name and role.
 Surgeon, anaesthetist & registered practitioner to
confirm name of patient, procedure, site and position
planned.
 What are the anticipated critical surgical, anaesthetic
and nursing events?
 Has the SSI bundle been undertaken as well as VTE
prophylaxis?
 Is essential imaging displayed if required?
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20. WHO Surgical Safety ‘Sign Out’
 Registered Practitioner verbally confirms:
– name of procedure is recorded
– Instrument, swab and sharp counts completed
– The specimen is labelled
– If any equipment issues have been noted that need to be
addressed
 Surgeon, anaesthetist, Nurse to state key concerns
during recovery and patient management.
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21. Improving Patient
Safety
Administrative Specific
Level Interventions

22. KNH/U.o.N Symposium: Patient Safety & Quality
Handling Incidents
 Willingness of staff to freely report accidents
especially near misses is conducive to safer health
care. Blaming frontline staff does not improve patient
safety and is wrong.
 The reporter should always be protected, have the
right to anonymity and information should always
remain confidential.
 Only intentionally unsafe acts should be considered
“blame-worthy” and all else should be placed in the
confidential reporting system.
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23. KNH/U.o.N Symposium: Patient Safety & Quality
Organisational Learning from Failure
 Unified mechanisms for reporting and analysis
when things go wrong.
 Open culture in which errors or failures can be
reported and discussed.
 Adaptation of the system approach in preventing,
analysing and learning from errors.
 Where lessons are identified, necessary changes are
put in practice.
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24. The Shewhart Cycle and Process
Improvement
Do
Make the
change on a
small scale
Check
Observe the
effects
Act
Identify
what was
learned
Plan
Study the
process
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25. The Nurse &
Patient Safety
Nurses intercept over
80% of all medication
errors made by
doctors, pharmacists,
and others prior to
the provision of those
medications to
patients.
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26. The Nurse and Patient
Safety
 It is not possible to run a safe and efficient
clinical service without well trained and
motivated nurses.
 A hospital that cannot employ and retain
good nursing staff is doomed to have quality
of care and patient safety issues.
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27. KNH/U.o.N Symposium: Patient Safety & Quality
Motivation of Staff
 Financial incentives and professional
recognition assist in the efforts to retain
experienced employees especially nurses.
 Simple measures like appropriate work
loads, appreciation, emotional support, and
sensitivity to staff needs leads to better
process outcomes.
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28. Improving Patient
Safety
Accreditation of Services
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29. Hospital Service
Accreditation
 Accreditation by international bodies like JCI
helps organize and strengthen patient safety
efforts by hospitals to manage and reduce
risk.
 It strengthens community and patient
confidence in the quality and safety of care,
treatment and services provided in a hospital.
 It makes a strong statement to the patients
about a hospital’s efforts to provide the
highest quality services.
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30. Accreditation Improves Adherence
 Accreditation has the power to
compel hospitals to adhere to
guidelines and regulations that
ensure patient safety.
 There is a need to introduce
healthcare targeted accrediting
bodies in developing countries to
improve standards of care.
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31. Improving
Patient safety
Clinical Staff
Control

32. Admitting Staff Control
 Strong criteria for permission granted to clinical
staff to use hospital facilities.
 Emphasis on the system used to determine
whether the applicants have the required
qualifications, experience and practice licenses.
 The scope of procedures a doctor should be
allowed to perform is to be limited by
experience, training and adherence to
evidence-based guidelines.
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33. Conditional Maintenance of
Admission Rights
 Institutional annual review of the
clinical staff performance and
complications rates is practiced widely
now.
 Withdrawal of services or retraining
could be enforced for individuals who
do not meet the organisational practise
quality standards.
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34. Donabedian’s Model applied
to Patient Safety
Structure
Governance and
Regulation (e.g
accountability)
Human Capital (e.g training,
education)
Culture (e.g transparency;
no blame)
Remuneration (incentives)
Process
Communication
and information
(e.g Decision
making).
Materials and
resources (e.g
sterile
environment)
Reporting (e.g
learning from
adverse events)
Outcome
Positive outcomes
(better health).
Neutral outcomes
(patient not better or
worse).
Near Misses
(opportunities for
learning).
Adverse events (patient
harm).
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35. KNH/U.o.N Symposium: Patient Safety & Quality
Summary &
Recommendations
 Patient harm comes at a high cost to the family, healthcare
system, community and national economy and yet adverse
events can be systematically minimised through better policy
and practice. The cost of prevention is typically much lower than
the cost of harm.
 Organisational leadership can use limited resources to enforce
continuous professional development, safety standards and a
solid information infrastructure.
 Hospitals can initiate integrated patient safety strategies that
encompass clinical governance frameworks, patient-
engagement and a positive safety culture.
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36. Summary &
Recommendations
 Hospitals can emphasize professionalism to ensure delivery of
quality healthcare and improved clinical outcomes by engaging
qualified and motivated nursing, support and clinical staff.
 Accreditation of services enhances adherence to guidelines and
regulations which lead to improved patient safety. It enforces
pursuit of quality improvements in the structures and processes
of the institution.
 Innovation at the clinical level is enhanced through vision and
leadership at the national level to operationalise a systems
approach for improving patient safety and broaden emphasis
from safety in hospital settings to primary care and long term
care.
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37. Thank you for
your attention
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