This document discusses patient safety and medical errors. It notes that while human error is inevitable in healthcare, medical errors result in significant deaths and costs each year. To improve patient safety, the document advocates evaluating health systems, promoting a culture of reporting errors without blame, learning from mistakes, and designing systems to prevent errors and mitigate their effects if they do occur. The use of electronic health records and other technologies can help monitor patients and avoid some errors, but overreliance on computers also risks new types of mistakes, so limitations must be considered. Overall patient safety is improved when healthcare systems focus on evaluation, open communication, and making changes based on lessons learned over time.

1. By Yana Puckett, MD

2. 
Evaluating health status
Patient reported outcomes
Patient safety
Preventing medical errors
Technology and its impact on patient safety
and patient care
Introduction

3. 
 In order to improve patient safety, evaluation
process of some kind needs to exist.
 EHR is enabling the US Health Care system to
monitor patient safety more accurately.
 EHR allows monitoring of all patients in real time.
 Chronic Disease Management: patients who comply
with prescribed medications are typically healthier.
 This is where data collection, data sharing, and data
analysis come in.
Evaluating Health Status

4. 
Human error is inevitable, i.e. to err is human,
and poses risks to patient safety.
US Medical Health Care System: medical error
estimated 98,000 deaths and $38 billion per year.
Human error is based on cognition, and thus is
predictable.
If we can predict risks for human error, health
systems can be designed to minimize risk for
human error.
Patient Safety

5. 
 Most cases of errors are not willful negligence, rather
systemic flaws, lack of communication, patient
ignorance.
 One unintentional error is unfortunate. But, repeated
error is a crime.
Error

6. 
 Illegible writing prescription by doctors.
 Wrong medicine or wrong dose, wrong route of
administration.
 Drip sets, iatrogenic fluid overload.
 Poor handing over of patients “sign-out” during
shift change.
 Healthcare staff exhaustion.
Sources of Error in
Health Care Setting

7. 
 Adverse Health Care Event
 Adverse Drug Reaction
 Medication Error
 Sentinel Event: Surgery on wrong body part,
surgery on wrong patient, patients receiving wrong
medication.
 Healthcare Near Miss: Situation in which an event
or omission arising during clinical care fails to
develop further, thus preventing injury.
Different Types of
Errors

8. 
 Airline industry has very little room for error, as a
result
 Voluntary (without jeopardy) reporting of error
culture.
 Recurring statutory examinations.
 Systems development.
 Safety analysis of data.
 Acceptance that mistakes will be made.
 Teamwork mentality.
Airline Industry Safety
Lessons

9. 
 Morbidity and Mortality Conferences: held in all
specialties in all hospitals around the world. Focused
not on blame, but on prevention and identification of
why the error happened. Focused on systems
prevention.
 Important to cultivate a culture of open
communication in the hospital and less on blame so
as to facilitate every error recognition and ultimately
solution to improve patient safety.
Importance of Reporting
and Learning

10. 
 Design system to prevent errors
 Design procedures to make error visible when they
occur so the error may be stopped.
 Design procedures for mitigating the adverse effects
of errors when they do occur or could not be
intercepted.
Strategies for Design of
Safe Systems of Care

11. 
 Encouraging team work mentality and speaking up
freely when an error is observed.
 Double checking such as when a prescription is
ordered by a pharmacist or nurse.
 EMR automated checks for allergy and prescribed
medication ordered.
 Education of patients and creating a safe
environment where questions by patients can be
asked and answered.
Preventing Errors

12. 

13. 
 Errors cannot be reduced to zero, thus, need to know
how to mitigate errors to avoid catastrophic results.
 Ex: Antidote drugs available if an error resulted in
overdose of drug.
Mitigating Errors

14. 
 Reduce complexity: reduce steps in task, number of choices,
duration of execution, distracting tasks.
 Optimize information processing: reduce reliance of memory
or preserve short term memory for essential tasks by utilizing
checklists, protocols , etc.
 Automate wisely: use technology to support not supplant the
human operator.
 Use constraints: restrict actions, such as informed consents,
computer order systems that prevent abnormally high doses of
medication from being ordered.
 Mitigate the unwanted side effects of change: time during
learning curve for a new procedure/equipment exits, during
which harm and error are increased – take precautions.
Tactics

15. 
 A lot of emphasis on EMR to avoid medical error. But,
can too much hope be placed on a computer to avoid
medical error?
 Do protocols apply to every individual in the same way?
 What about faulty programming and technical
dysfunctions?
 Some argue that new mistakes may be generated by
utilizing computerized systems to prevent medical errors.
 Important to be aware of computer system limitations in
healthcare to prevent these mistakes from happening.
Information Technology
and Healthcare

16. 
 Study found that length/maturity of hospital quality
improvement system correlates with better patient
outcomes.
 Promising results that with time, adjustments will be
made and patient safety will improve as a result of
recent changes to the US healthcare system.
 As these changes are being made, evaluation of
changes and health programs is crucial in adjusting,
changing, or stopping certain changes.
Conclusion

17. 
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(2011). Is the maturity of hospitals’ quality improvement systems
associated with measures of quality & patient safety? BMC Health
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