The document discusses key concepts in quality management and patient safety, including definitions of safety in healthcare. It notes that medical errors lead to tens of thousands of deaths annually in the US healthcare system according to the 1999 IOM report. Both active errors at the sharp end and latent errors in system design can cause harm. While individuals may slip or make mistakes, most medical errors are systems-driven according to IHI research. A safety culture and focus on systems improvements rather than blame can help reduce errors. The Swiss cheese model of accident analysis and human factors engineering are approaches to analyzing root causes and designing safer systems.

1. Quality managment and Safety and Risk
managment -Part II
Basic Concepts

2. Definition Of Safety in
Healthcare
2
Institute of Medicine IOM)
Patient safety is the freedom from Accidental injury caused
by patient care .
 FUNDAMENTAL HEALTHCARE SLOGAN / OATH
PRIMUM NON NOCERE

3. MUPHY"S LAW
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The concept of healthcare Safety and proactive Risk
management is motivated by the murphy's law :

4. 4
US HEALTHCARE SYSTEM
Medical Errors lead to 44,000 to 98000 deaths
annually( (To Err is human IOM report1999)
7% of patient suffer from medical errors
On average very patient admitted to the ICU suffers
from adverse event .
Nearly 100,00 dealths from HAIS
Medical errors account for as much as $ 29 billion
annually in lost income , disability and healthcare costs
(To Err is human IOM report1999 )
Medical Errors lead to 44,000 to 98000 deaths
annually( (To Err is human IOM report1999)
7% of patient suffer from medical errors
On average very patient admitted to the ICU suffers
from adverse event .
Nearly 100,00 dealths from HAIS
Medical errors account for as much as $ 29 billion
annually in lost income , disability and healthcare costs
(To Err is human IOM report1999 )

5. MEDICAL ERRORS
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Medical Errors are the unintentional , preventable
mistakes in the provision of care that have actual
or potential impact on the patient .
Medical Errors are the unintentional , preventable
mistakes in the provision of care that have actual
or potential impact on the patient .
An act of commision ( doing something wrong) or
Omission ( Failing to do the right that leads to
undesirable outcome
An act of commision ( doing something wrong) or
Omission ( Failing to do the right that leads to
undesirable outcome

6. ERRORS
CAN BE
ACTIVE: At the
sharp end at point
of contact between
humans ,
machines , patients
LATENT: At the
blunt end means
failure of design,
organization or
layers of healthcare

7. EXAMPLES
(e.g., The surgeon holding the scalpel performed the
incorrect procedure)/operated wrong site or figuratively
by administering any wrong kind of treatment is an
example of ???
Computer monitors in the operating room had been placed in
such a way that viewing them forced nurses to turn away from
the patient, limiting their ability to monitor the surgery and
perhaps detect the incorrect procedure before it was
completed.???

8. BASED ON COGNITIVE PSYCHOLOGY AHRQ
(Agency of healthcare research and quality website)
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Errors at the sharp end can be further classified
into slips and mistakes
SLIP MISTAKE
Slips represent failures of
schematic behaviors, or
lapses in concentration, and
occur in the face of
competing sensory or
emotional distractions,
fatigue, or stress.
Mistakes, by contrast, reflect
incorrect choices, and more
often reflect lack of
experience, insufficient
training, or outright
negligence.

9. WHAT CAUSES MEDICAL ERRORS
The institute if healthcare improvement (IHI) research estimates
that aproximately 80% of Medical errors are systems driven .
The Factors that can cause patient harm are:
System failures
Human factors
Communication breakdown
Work Place culture
Insufficient procedures
Training deficiencies
Deficits in understanding the level of service provided

10. Dr Lucian Leape , Harvard school of
Public Health
Incompetent people are
1% of the problem .The
other 99% are good
people trying to do good
job who can make very
simple mistakes and it is
the processes that set
them up to make these
mistakes .

11. PERSONAL VRS SYSTEM
Approach
Errors are a result of human failures
Humans are generally perform
flawlessly
Perfect performance is expected
Use retraining and punishment to
root out bad apples
Focused on individual performance
and fear of reprisals keeps key
information underground
Partial or incomplete solutions that
do not resolve the root cause leave the
organization vulnerable to
reoccurrence of the event .
Based on the principle of Murphy's
law .
Don't Expect Human perfection
Design System in a proactive way
 Collective preoccupation with the
failure
Focused on improving the system
 Root cause analysis involves all the
stakeholders including frontline staff
for extensive analysis

12. Safety Culture
Product of individual and group values, attitudes , perceptions ,
competencies and patterns of behaviour that determine the
comimitment , style, proficiency of organization health and safety
managment.
Safety Culture should have
Leaders
Vision
Strategy for change
Error Managment and intervention
Minimization of Individual blame or just but accountable culture
"Moving from blame shame and train to a blame free
enviroment or just culture "

13. Patient Safety Goals

14. Swiss Cheese Model of system
analysis
The "Swiss cheese" model illustrates how a particular
hazard penetrates multiple barriers and safeguards in
order to cause harm.

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Swiss cheese model is a field of system analysis
pioneered by British psychologist James Reason,
 Most accidents result from multiple, smaller
errors in environments with serious underlying
system flaws.
 Errors made by individuals result in disastrous
consequences due to flawed systems—the holes in
the cheese.
This Model helps point the way toward solutions
—encouraging personnel to try to identify the holes
and to both shrink their size and create enough
overlap so that they never line up in the future.
Focus on the root cause not just the sharp end of
the error .
Swiss cheese model is a field of system analysis
pioneered by British psychologist James Reason,
 Most accidents result from multiple, smaller
errors in environments with serious underlying
system flaws.
 Errors made by individuals result in disastrous
consequences due to flawed systems—the holes in
the cheese.
This Model helps point the way toward solutions
—encouraging personnel to try to identify the holes
and to both shrink their size and create enough
overlap so that they never line up in the future.
Focus on the root cause not just the sharp end of
the error .

16. Human Factors Engineering
In healthcare it is a interdisciplinary field of applying what is
know about the human capabilities and limitations to the
design of products , processes , systems and enviroments
Relation between human skills and technology
Humans factors include how humans interact with the
equipments, enviroments, teams and organization including
both strengths and weaknesses .

17. Examples of Human factor engineering in healthcare to reduce
errors
 Checklists
CPOE SYSTEM
( Computerized physician
order entry)
Color Coding of Medical
gasses adaptor
Barcode medication
administration system.
Forcing functions : Removal
of concentrated potassium
from general wards

18. Reactive and Proactive Risk analysis
Root cause analysis
Proactive risk management :Failure mode
effective analySis FMEA

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Important Definitions and concepts :
Adverse Event : Unintended injury to patient as a
result of medical intervention gnerally with lesser degree
of severity but which may be a precursor for sentinel
event .
SENTINEL EVENT: An unexpected occurence
involving the death or serious physiological injury or the
risk thereoff . The phase risk thereoff includes any process
variation for which reoccurence would carry a significant
chances of a serious adverse outcome .
SENTINEL: ONE THAT KEEPS A GUARD . To
WATCH OVER AS A GUARD and requires intensive
analysis .
NEAR MISS:An error that could have caused the harm
but did not either by chance or because of timely
intervention .

20. CLINICAL AND NON CLINICAL
INCIDENTS AS PER THE UMC POLICY

25. Seven steps to patient safety
NHS Guidelines
1.Lead and support the staff
2.Foster a culture of safety
3.Promote reporting
4.Involve patient and public
5.Implement system solutions
to reduce harm
6.Learn and share safe culture
7.Multidisciplinary safety
managment

26. Summary
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