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.

1. SIMPLE AND SAFE
APPROACHES TOWARDS
PATIENT SAFETY
Presented By:
Ehi Iden
Chief Executive Officer
ehi@ohsm.com.ng

2. The Major Concerns!
 Patient, Patient and Patient
 Why keep patient safe in our cycle of care?
 The Nightingale Theory of “PATIENT”
 What are the likely benefits?
 Can we resolve today to integrate patient
safety in our care plan?

3. We do not care to harm, we care to save

5. THE S-A-D CONCEPT
Safety
At
Design

6. The concept of patient safety
What exactly is patient safety?
 The World Health Organisation (WHO) defines
patient safety as the prevention of errors and adverse
effects to patients associated with health care.
 Patient safety is a new healthcare discipline that
emphasizes the reporting, analysis, and prevention of
medical error that often leads to adverse healthcare
events. Wikipedia

7. Standard
Policy

8. The motivation behind this
concern
 Strong leadership commitment
 Purposeful policy formulation and implementation
The Three policy imperatives include:
• Policy for social imperatives: We are saying must
save lives, do what ever it takes, health and safety is
our culture. It is system driven in utmost honesty.
• Policy for fiscal imperatives: We must save money
at all cost, we must do all it takes to make it happen.
• Policy for legal imperatives: We must stay out of
trouble, do only what we must do to avoid
consequences.

9. Rationale for Patient Safety
Institute of Medicine publication reveals the following in
the in the U.S healthcare systems:
 7% of patients suffer a medical error
 Every patient admitted to an ICU suffers an adverse
event
 44,000 – 98,000 deaths per year can be attributed to
medical error
 This has a 50 billion USD as total cost
 Similar results exist also in UK and Australia
 This has been argued as underestimated. A strong
contributor is the under reporting or also a

10. MALARIA
 300-500 mil episodes / year
 1.5-2.7 mil deaths / year
 90 countries at risk worldwide
TUBERCULOSIS
 8 mil new infections / year
 1.6 mil deaths in 2005
 1/3 of the world currently
affected
HIV
 40 mil patients affected
 4 mil new infections / year
 2.9 mil deaths in 2006
 Most countries affected with
different infection rates
HEALTHCARE ASSOCIATED
INFECTIONS
 Statistics is low because of poor
reporting.
 But assumed to be more than all 3
infections classes put together.
 Global daily infection rate in
hospitals only estimated at 1.4
million. “Prof. Didier Pettit
(UNIVERSITY OF GENEVA)”
Burden of Infections worldwide

11. The WHO Position
A health care facility is a workplace as well as a place for receiving and
giving care. Healthcare facilities around the world employ over 59 million
workers who are exposed to a complex variety of health and safety hazards
everyday. The risks span from:
 Biological hazards, such as TB, Hepatitis, HIV/AIDS, SARS and other
infections
 Chemical hazards, such as, ethylene oxide, latex allergy
 Physical hazards, such as noise, radiation, slips trips, falls and needle
sticks injuries
 Ergonomic hazards, such as, poor work environment conditions, heavy
lifting and back aches
 Psychosocial hazards, such as shift work, workplace violence, needle stick
injuries and stress
 Fire and explosion hazards, such as using oxygen, alcohol sanitizing gels
etc.

12. Clean hands save lives

13. Global Shortage of Healthcare workers
 The 2006 World Health Report “Working Together for
Health” on human resources reported a global shortage of
health personnel which had reached crisis level in 57
countries. And called for the support and protection of the
health workforce.
 11 NOVEMBER 2013 | RECIFE, BRAZIL - WHO declared
that the world will be short of 12.9 million health-care
workers by 2035; today, that figure stands at 7.2 million. The
report warns that the findings – if not addressed now – will
have serious implications for the health of billions of people
across all regions of the world.
 Sub Sahara Africa region has been predicted to suffer an
ACUTE shortage of healthcare workers

14. What we must do?
 We must recognise that everyone is fallible
 We must design systems that arrest the mistakes
before they get to the patients
 We must recognise that every system is perfectly
designed to achieve the results it gets, properly
designed systems can offer safer choices

15.  Safety Brings Cheers  Accident Brings Tears
What really has gone wrong???

16. Without leadership commitment, patient
safety is only a dream……..
 Institutional and cultural factors are the strongest
drivers of patient safety in healthcare
 No system survives outside governing policies
 Standards are created out of policies
 Responsibility naturally comes to play where a
standard is in existence
 This brings about system’s accountability
 We must be trained to work as a team

17. 5 key points to driving patient
safety
1. Establish Trust
2. You clearly define goals and measures from the
board to the bedside (everyone focusing on zero
infection or errors)
3. Create a supporting infrastructure (core group to
support the work)
4. Engage frontline connections and create culture
for peer learning
5. Transparently report results and create
accountability structure

18. Building safety into the system
 Patient centred care - PCC (comprises of the
principal patients and their family members)
 We should encourage team work
 We must also be mindful that when we are
changing or improving our systems, we might
also be introducing new sets of risks
“Every improvement requires change and every
change is definitely not an improvement”

19. Patient Centred Care (PCC)
 The caregiver-patient relationship has often times
been characterised as silencing the voice of the
patients
 It is now widely agreed that putting patients at the
centre of healthcare, by trying to provide a consistent,
informative and respectful service to patients, will
improve both outcomes and patient satisfaction.
 When patients are not at the centre of healthcare,
then patient neglect is imminent.
 There have been recommendations that the health
service puts patient experience at the heart of what it
does, and especially, that the voice of patients be
heard loud and clear within the health services

20. PCC: Healthcare through the patients’
eyes
Multiple dimensions to PCC
 Respecting patients needs, values &
preferences
 Offering emotional support and alleviating
physical discomfort
 Communicating adequately, sharing information
and providing education
 Strengthening patient-provider relationship by
including family and friends

21. What does it take to meet a patient’s need
 According John Hopkins College of Medicine survey,
patients pain has become a very significant part of
healthcare delivery in the US
 Pain assessment has now been classified as the sixth
vital sign
 Failure to address patients needs can influence the
patients’ ability to participate in their care delivery
during hospitalization
 Care-traumatised patients do not end up with good
treatment outcomes
 Patients are termed vulnerable in the hospital, it is

22. Pre – to- Post hospitalization
 Prepare patients well enough for hospitalization
 Manage all patients needs, identified ownership of
case
 Engage patients in the management of their care
 Speak daily with them, discuss their care plan and
goal for the day
 Take into account patients value and preference in the
treatment plan
 Provide adequate information even at discharge to
help patient recover well
 Patients need to be educated on the health conditions
they were treated for and let them know what to

23. Engaging patients’ relatives in direct care
 These are very integral components of our
overall care cycle but mostly ignored and
forgotten
 Treatment or interventions are termed
successful if there are no hospital returns (re-
admission) on same case
 Studies have shown that treatment outcomes
are most times better when patients’ relatives
are engaged
 We partner with family members to enact care
and connect better with sick relatives

24. Reasons why we must listen to patients
 Patients spend more time in health care services
than any regulator or quality controllers
 Patients can recognize problems such as service
delays, poor hygiene and poor conduct
 Patients are particularly good at identifying soft
problems, such as attitudes, communication and
'caring neglect‘ that are difficult to capture with
institutional monitoring
 One important way in which patients can be put at
the centre of healthcare is for health services to
be more open about patient complaints

25. Principles of safe design
 Standardization
 Eliminate steps (the ATM philosophy)
 Create a clear communication protocol
 Learn when things go wrong. What happened?
Why? What to do to reduce the risk, review of
controls etc.
 Training and education
 Effective supervision
 Create mutual support
 No blame game

26. Basic components in process of
communication
 Ensure the message sent by provider A is same
as received and understood by provider B
 This might be through phone calls in healthcare
or other acceptable communication medium
 Coding and decoding a message may happen
through out the course of the day
 Trust nothing to assumption, someone might just
be paying for that

27. Hand-Off Communication (HOC):
 This is the real time process of transmitting patient-specific
information from one care giver or team to another in ensuring
continuity and safety of care.
 Failure occur when vital information is omitted from the sender or
the receiver fails to understand properly
 The Agency for Healthcare Research and Quality (AHRQ)
reports that nearly half of hospital staff believes that patient
information is lost during transfer across hospital unit and during
shift changes
 Breakdown in communication is a leading cause of preventable
patient injuries or death and increased cost of care

28. Patient Safety Team Work Tools
 Conduct staff safety assessment
 Daily goals: This is examined to be sure we are all
in tune of expectations for the day
 AM briefing otherwise known as morning hurdle
(this brings all team members together to confirm
what the plan of care is)
 Shadowing: This is done to know how other team
members are carrying out care, a nurse following
a Doctor or vice versa
 Barrier identification and mitigation
 Learning from defect (LFD). If only we reviewed
what we have done wrong

29. A.M Briefing

30. The system: The issue
 Patient safety is system-driven
 When things go wrong, system takes the
blame
 To improve performance, we need routine
system’s review and change
 Start with a pilot case. Pick up one process
that can be improved upon
 Adopt the CUSP concept (Comprehensive
Unit-based Safety Program). A Unit’s
intervention to learn from mistakes and

31. You are not alone
 Studies have shown that, 200 – 300 patients die
in U.S hospitals annually from preventable harm
 In healthcare your personal effort does not
change everything, TEAM WORK is a better
game
 Do not play a man down
 When you feel something, say something

32. Creating a safety culture
Safety culture is characterised by a collective mindfulness that
can be achieved only when there is mutual respect among
team members and an absence of fear and intimidation.
 The key components include:
I. Collective Mindfulness: We are aware things can go
wrong, we are fallible, errors could happen and we are
mindful of all that and ready to tackle it without regard to
rank or status.
II. Accountability: Accepting responsibility for making a
patient safer. Report errors, near misses or any safety
concern.
III. Empowerment and engagement: This makes employees
feel safe to voice out their concerns about patient safety
issues, and makes them take charge of the safety of not
just their patients but colleagues alike.

33. Our Culture
 Patients suffer today because of the error
management in our past culture
 We focused on blaming and punishing the
individual providers rather than taking system’s
responsibility and learning from incidence
 There was little or no emphasis on how we can
learn from our errors, no transparency and we
could not own up to what happened.
 We ended up creating a punitive work
environment that shuts everyone up

34. The need to REHUMANISE
Healthcare

36. Conflict of Interest
 Profitability and Safety or profitability vs.
Safety
 Allowing employees to use unsafe practices in
order to meet their production goals
 In this culture, when job security is on the line,
working fast will take priority over working safe.
 In a world-class safety culture, job security
depends on working safe, not working fast. We
need to change this.

37. When blame game hurts the
system
 Blame game limits learning from errors because the
incident was never discussed
 It increases likelihood that the error will reoccur. This is
because other colleagues were not able to benefit or learn
from the problem we have had
 It may drive away self-reporting of adverse events
 It could create vicious cycle that decreases learning
“The more we blame, the more providers stop talking
The quieter providers are, the less we learn
The less we learn, the less we improve
The less we improve, the more at risk patients are”

38. Our systems created this?

39. A case study: Kimberly Hiatt

40. Outcome
 50 years old nurse with 25 years at a certain Children’s hospital
 Mistakenly dispensed 1.4 grams of calcium chloride — instead of
the correct dose of 140 milligram for an 8 months old child in Sept
14 2009.
 She reported the case and owned up to be responsible
 After the infant’s death, Kim was placed on administrative leave
and soon dismissed in weeks following
 Her license withdrawn, she cried for 2 weeks not because of her
license but that she killed a child
 Kim Hiatt eventually committed suicide on April 3, 2010
 Hiatt’s dismissal — and her death — raise larger questions about
the impact of errors on providers, the so-called “second victims” of
medical mistakes. That’s a phrase coined a decade ago by Dr.
Albert Wu, a professor of health policy and management at the
Johns Hopkins Bloomberg School of Public Health

41. Some quotes and views
 “I messed up,” Kim wrote. “I’ve been giving CaCI [calcium
chloride] for years. I was talking to someone while drawing it up.
Miscalculated in my head the correct mls according to the mg/ml.
First medical error in 25 years of working here.
 After the incident, Hiatt "was a wreck,” recalled Julie Stenger, 39,
a critical care nurse who worked with Hiatt at the hospital. “No one
needed to punish Kim. She was doing a good job of that herself.”
 “When she lost this job, it wasn’t just the job she lost, it was her
future.” Kim’s mum
 “She was in such anguish,” Crum says. “She ran out of coping
skills.”
 “Punitive actions are actually counterproductive. Everything in the
literature points to that not being the right step to take,” Watkins
said. “Nurses in that unit or hospital will not report things. There’s
this heightened awareness: It could be me.”
 “I thought it was sending the exact wrong message: If you make a
mistake, you better keep your mouth shut about it.” Kim’s

42. Mutual Support
 Mutual support is the essence of team work, It
simply means backing up your fellow team
member.
 It protects team members from overload
situations that may reduce effectiveness and
increase the risk to error
 We do not necessarily have to wait till we are
asked or invited, we use our discretion to identify
overload as a safety concern

43. When is Mutual Support
Needed
 Anytime a unit falls into “work overload mode”
This can be evident when:
I. There are unexpected events on a unit
II. New patients being simultaneously admitted
in the unit
III. There is a mismatch between providers’ skills
and patients care need
IV. There are abrupt changes in patients’ status

44. Disruptive Behaviour in
Healthcare
 Disruptive behaviour is a personal conduct whether
verbal or physical, that negatively affects or that
potentially may affect patients care and /or interferes
with ones ability to work with other members of the
healthcare team.
 Disruptive behaviour is any behaviour that
undermines the culture of safety “Joint commission
2008”
 It is a complex presentation that causes patient
harm

45. In Conclusion
He that craves for safety must think SAFE
 Spot the hazards
 Assess the risk
 Find safer ways
 Every day
“Salus Populi Suprema Lex”

46. References
 Emerging trends in global health: Infectious diseases Healthcare-
Associated Infection Prevention: Pushing Back Barriers and National
Frontiers. Prof. Didier Pittet, Department of Internal Medicine Specialties,
Faculty of Medicine, University of Geneva
 The Science of Safety in Healthcare course offered by John Hopkins
University through Coursera
 Hand Hygiene in Healthcare, by Olov Aspevall, Clinical Bacteriologist and
Infection Control Physician, Senior Consultant Public Health Agency,
Sweden
 Sax H, Allegranzi B, Uçkay I, Larson E, Boyce J, Pittet D. J Hosp Infect
2007;67:9-21
 http://www.nejm.org/doi/full/10.1056/NEJMvcm0903599
 http://www.who.int/features/qa/28/en/