2. Patient safety is a serious global
public health issue
o There is now growing recognition that patient
safety and quality is a critical dimension of
universal health coverage.
o Since the launch of the WHO Patient Safety
Programme in 2004, over 140 countries have
worked to address the challenges of unsafe
care.
3. One in 10 patients may be harmed
while in hospital
o Estimates show that
in developed
countries as many as
1 in 10 patients is
harmed while
receiving hospital
care.
o The harm can be
caused by a range of
errors or adverse
events.
4. Hospital infections affect 14 out of
every 100 patients admitted
o Of every 100 hospitalized
patients at any given time, 7 in
developed and 10 in developing
countries will acquire health
care-associated infections
(HAIs).
o Hundreds of millions of patients
are affected worldwide each
year.
o Simple and low-cost infection
prevention and control
measures, such as appropriate
hand hygiene, can reduce the
frequency of HAIs by more than
50%.
5. Most people lack access to
appropriate medical devices
o There are an estimated 1.5 million
different medical devices and over 10
000 types of devices available
worldwide.
o The majority of the world's population is
denied adequate access to safe and
appropriate medical devices within their
health systems.
o More than half of low- and lower middle-
income countries do not have a national
health technology policy which could
ensure the effective use of resources
through proper planning, assessment,
acquisition and management of medical
devices.
6. Unsafe injections decreased by 88%
from 2000 to 2010
o Key injection safety
indicators measured in
2010 show that
important progress has
been made in the reuse
rate of injection devices
(5.5% in 2010),
o While modest gains were
made through the
reduction of the number
of injections per person
per year (2.88 in 2010).
7. Delivery of safe surgery requires a
teamwork approach
o An estimated 234 million
surgical operations are
performed globally every
year.
o Surgical care is associated
with a considerable risk of
complications.
o Surgical care errors
contribute to a significant
burden of disease despite
the fact that 50% of
complications associated
with surgical care are
avoidable.
8. About 20%–40% of all health spending
is wasted due to poor-quality care
o Safety studies show that
additional hospitalization,
litigation costs, infections
acquired in hospitals,
disability, lost productivity
and medical expenses cost
some countries as much as
US$ 19 billion annually.
o The economic benefits of
improving patient safety are
therefore compelling.
9. A poor safety record for health care
o Industries with a perceived
higher risk such as the aviation
and nuclear industries have a
much better safety record
than health care.
o There is a 1 in 1 000 000
chance of a traveller being
harmed while in an aircraft.
o In comparison, there is a 1 in
300 chance of a patient being
harmed during health care.
10. Patient and community engagement
and empowerment are key
o People’s experience
and perspectives are
valuable resources
for identifying needs,
measuring progress
and evaluating
outcomes.
11. Hospital partnerships can play a
critical role
o Hospital-to-hospital
partnerships to improving
patient safety and quality of
care have been used for
technical exchange between
health workers for a number
of decades.
o These partnerships provide
a channel for bi-directional
patient safety learning and
the co-development of
solutions in rapidly evolving
global health systems.
12. Hospital partnerships can play a
critical role
o Hospital-to-hospital
partnerships to improving
patient safety and quality of
care have been used for
technical exchange between
health workers for a number
of decades.
o These partnerships provide
a channel for bi-directional
patient safety learning and
the co-development of
solutions in rapidly evolving
global health systems.
13. Introduction to Patient Safety:
Definition
o Patient safety is a discipline in the health care
sector that applies safety science methods
toward the goal of achieving a trustworthy
system of health care delivery. Patient safety is
also an attribute of health care systems; it
minimizes the incidence and impact of, and
maximizes recovery from, adverse events
(Emanuel et al., 2008) .
14. Introduction to Patient Safety:
Background
o Adverse medical events are widespread and
preventable (Emanuel et al., 2008) .
o Much unnecessary harm is caused by health-
care errors and system failures.
– Ex. 1: Hospital acquired infections from poor
hand-washing.
– Ex. 2: Complications from administering the
wrong medication.
15. Introduction to Patient Safety:
Goal
o Prevent and/or minimize the adverse events
and eliminate preventable harm in health care.
o All health care professionals including nurses
are responsible for ensuring patient safety
17. Global Infection Problems
According to WHO (2005),
o On average, 8.7% of hospital patients suffer
health care-associated infections (HAI).
o In developed countries: 5-10%
o In developing countries:
– Risk of HAI: 2-20 times higher
– HAI may affect more than 25% of patients
o At any one time, over 1.4 million people
worldwide suffer from infections acquired while
in hospital.
18. Health Care-Associated Infections
(HAI)
According to WHO:
o HAI is also called “nosocomial”.
o HAI is defined as:
– an infection acquired in hospital by a patient
who was admitted for a reason other than
that infection.
– an infection occurring in a patient in a
hospital or other health-care facility in whom
the infection was not present or incubating
at the time of admission.
19. Impacts of Health Care-Associated
Infections (HAI)
HAI can:
o Increase patients’ suffering.
o Lead to permanent disability.
o Lead to death.
o Prolong hospital stay.
o Increase need for a higher level of care.
o Increase the costs to patients and hospitals.
20. Preventing infections
Requires health care providers who have:
– Knowledge of common infections and their
vectors
– An attitude of cooperation and commitment
– Skills necessary to provide safe care
21. Required Knowledge
o Knowledge of the extent of the problem;
o Knowledge of the main causes, modes of
transmission, and types of infections.
23. Required Skills
o Apply universal precautions*
o Use personal protection methods
o Know what to do if exposed
o Encourage others to use universal precautions
o Report breaks in technique that increase
patient risks
o Observe patients for signs and symptoms of
infection
24. One more important thing!
Protect YourselfProtect Yourself
Be sure you have been immunized against
Hepatitis B since it is very easy to transmit!
25. Main Sources of Infection
o Person to person via hands of health-care
providers, patients, and visitors
o Personal clothing and equipment (e.g.
Stethoscopes, flashlights etc.)
o Environmental contamination
o Airborne transmission
o Hospital staff who are carriers
o Rare common-source outbreaks
26. Campaigns to Decrease Infection Rates
o WHO “Clean hands are safer hands” campaign
o Centers for Disease Control and Prevention
(CDC) “prevent antimicrobial resistance”
campaign in health-care settings
o Institute for Healthcare Improvement (IHI) “5
million lives” campaign
– Developing country focus
27. Main Routes for infections
o Urinary tract infections (UTI)
– Catheter-associated UTIs are the most frequent,
accounting for about 35% of all HAI.
o Surgical infections: about 20% of all HAI
o Bloodstream infections associated with the use of
an intravascular device: about 15% of all HAI
o Pneumonia associated with ventilators: about15%
of HAI
28. Burke J Infection control-a problem for patient safety New Eng Journal
of Medicine (February 13, 2003)
Types of Infections
29. Four Ways to Prevent HAI
1. Maintain cleanliness of the hospital.
2. Personal attention to handwashing before and
after every contact with a patient or object.
3. Use personal protective equipment whenever
indicated.
4. Use and dispose of sharps safely.
30. Prevention in Hospitals and
Clinics
o Studies show infections are minimized when
hospitals/clinics:
– Are visibly clean;
– Use increased levels of cleaning during
outbreaks;
– Use hypochlorite and detergents during
outbreaks.
31. Prevention through Handwashing
o Handwashing: the single most important
intervention before and after patient contact.
o Required knowledge and skills:
– How to clean hands
– Rationale for choice of clean hand practice
– Techniques for hand hygiene
– Protect hands from contaminants
– Promote adherence to hand hygiene guidelines
32. Five moments for hand hygiene
o Before patient contact
o Before an aseptic task
o After body fluid exposure even if wearing
gloves!
o After patient contact
o After contact with patient surroundings
34. How to Clean Hands
o Remove all wrist and hand jewelry.
o Cover cuts and abrasions with waterproof
dressings.
o Keep fingernails short, clean, and free from nail
polish.
35. Effective Handwashing Technique
o Wet hands under tepid running water
o Apply soap or antimicrobial preparation
– solution must have contact with whole
surface area of hands
– vigorous rubbing of hands for 10–15 seconds
– especially tips of fingers, thumbs and areas
between fingers
o Rinse completely
o Dry hands with good quality paper towel.
36. How to use waterless handrub
o Apply a palmful of product in cupped hand
o Rub hands palm to palm
o Right palm over left hand with interlaced fingers
o Palm to palm with fingers interlaced
o Backs of fingers to opposing palms with fingers
intelocked
o Rub between thumb and forefinger
o Rotational rubbing, backwards and forwards with
clasped fingers of right hand in left palm and vice versa
o Once dry your hands are safe.
37. Personal Protective Equipment
o Gloves, aprons, gowns, eye protection, and
face masks
o Health care workers should wear a face mask,
eye protection and a gown if there is the
potential for blood or other bodily fluids to
splash.
38. Personal protective equipment 2
o Masks should be worn
– if an airborne infection is suspected or
confirmed
– to protect an immune compromised patient.
39. Gloves
Gloves must be worn for:
o all invasive procedures
o contact with sterile sites
o contact with non-intact skin or mucous membranes
o all activities assessed as having a risk of exposure to
blood, bodily fluids, secretions and excretions, and
handling sharps or contaminated instruments.
Hands should be washed before and after gloving
40. Safe Use and Disposal of Sharps
o Keep handling to a minimum
o Do not recap needles; bend or break after use
o Discard each needle into a sharps container at
the point of use
o Do not overload a bin if it is full
o Do not leave a sharp bin in the reach of
children
41. Required Performance
Need to:
o apply universal precautions
o be immunized against Hepatitis B
o use personal protection methods
o know what to do if exposed
o encourage others to use universal precautions
42. Act to Minimize
Spread of Infection-1
Before contact with each and every patient:
– clean hands before touching a patient
– clean hands before an aseptic task
43. Act to Minimize
Spread of Infection-2
After contact with each and every patient:
– clean hands after any risk of exposure
to body fluids
– clean hands after actual patient
contact
– clean hands after contact with patient
surroundings
44. Encourage Others to Participate in
Infection Control
May routinely observe staff who:
– apply inadequate technique in handwashing
– fail to wash hands
– routinely violate correct infection control
procedures
45. MOST COMMON CLINICAL RISKS AND
PATIENT SAFETY INCIDENT TYPES
IDENTIFIED
o Acute Kidney Injury (AKI)
o Antimicrobial Resistance (AMR) strategy
o Caring for the acutely ill elderly safely
o Preventing avoidable deterioration (including
sepsis)
o Improving the safety of discharge
46. o Falls prevention
o Improving the safety of handover
o Preventing healthcare associated infections
o Preventing medication errors
o Preventing medical device errors
o Mental health care safety
o Preventing pressure ulcers
o Improving the safety of transition – children &
young people to adult care
o Preventing avoidable venous thromboembolism
(VTE)
o Patient safety in general practice
47.
48. THE SEVEN STEPS TO PATIENT
SAFETY
o Step 1 Build a safety culture Create a culture
that is open and fair
o Step 2 Lead and support your staff Establish a
clear and strong focus on patient safety
throughout your organization
o Step 3 Integrate your risk management activity
Develop systems and processes to manage your
risks and identify and assess things that could
go wrong
49. o Step 4 Promote reporting Ensure your staff can
easily report incidents locally and nationally
o Step 5 Involve and communicate with patients
and the public Develop ways to communicate
openly with and listen to patients
o Step 6 Learn and share safety lessons Encourage
staff to use root cause analysis to learn how
and why incidents happen
o Step 7 Implement solutions to prevent harm
Embed lessons through changes to practice,
processes or systems
50. 10 STEPS FOR PREVENTION OF HAI
Prevent central line-associated blood stream
infections.
Be vigilant preventing central line-associated
blood stream infections by taking five steps every
time a central venous catheter is inserted:
owash your hands,
ouse full-barrier precautions,
oclean the skin with chlorhexidine,
oavoid femoral lines,
oand remove unnecessary lines
51. Re-engineer hospital discharges.
Create a simple, easy-to-understand discharge
plan for each patient that contains a medication
schedule, a record of all upcoming medical
appointments, and names and phone numbers of
whom to call if a problem arises.
52. Prevent venous thromboembolism.
Eliminate hospital-acquired venous
thromboembolism (VTE), the most common cause
of preventable hospital deaths
Educate patients about using blood thinners
safely.
Patients who have had surgery often leave the hospital
with a new prescription for a blood thinner, such as
warfarin brand name: Coumadin®), to keep them from
developing dangerous blood clots. However, if used
incorrectly, blood thinners can cause uncontrollable
bleeding and are among the top causes of adverse drug
events.
53. Limit shift durations for medical residents and
other hospital staff if possible.
oEvidence shows that acute and chronically
fatigued medical residents are more likely to
make mistakes.
oEnsure that residents get ample sleep .
oResidents who work 30-hour shifts should only
treat patients for up to 16 hours and should have
a 5-hour protected sleep period between 10 p.m.
and 8 a.m.
54. Use good hospital design principles.
oFollow evidence-based principles for hospital design to
improve patient safety and quality.
oPrevent patient falls by providing well-designed patient
rooms and bathrooms and creating decentralized nurses'
stations that allow easy access to patients.
oReduce infections by offering singlebed rooms, improving
air filtration systems, and providing multiple convenient
locations for hand washing.
oPrevent medication errors by offering pharmacists well-
lit, quiet, private spaces so they can fill prescriptions
without distractions.
55. Measure your hospital's patient safety culture.
Survey hospital staff to assess your facility's
patient safety culture.
Build better teams and rapid response systems.
oTrain hospital staff to communicate effectively
as a team.
Insert chest tubes safely.
Remember UWET when inserting chest tubes. The easy-to-
remember mnemonic is based on a universal protocol
from the Joint Commission and stands for:
Universal Precautions (achieved by using sterile cap,
mask, gown, and gloves);
Wider skin prep;
Extensive draping; and
Tray positioning.
Editor's Notes
According to Institute of Medicine, safety is defined as “freedom of accidental injury”.
Reference:
Emanuel, L., Berwick, D., Conway, J., Combes, J., Hatlie, M., Leape, L., Reason, J., Schyve, P., Vincent, C., & Walton, M. (2008). What exactly is patient safety? Advances in Patient Safety, Vol. 1: Assessment. Retrieved from http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=aps2v1&part=advances-emanuel-berwick_110
The unit of patient safety includes two parts. Part 1 is infection control; part 2 is safe medication administration.
Why infection control is relevant to patient safety?
The spread of infection in health-care settings today affects hundreds of millions of people worldwide. In the health care settings, infection is one of adverse events; some of infections are preventable. Through improved infection control, infection can be minimized. Therefore, improved infection control can facilitate health care providers reach the goal of patient safety.
In a WHO sponsored survey study conducted in 55 hospitals of 14 countries representing four WHO regions (South-East Asia, Europe, the Eastern Mediterranean and the Western Pacific) it was found that, on average, 8.7% of hospital patients suffer health care-associated infections.
Between 5% and 10% of patients admitted to modern hospitals in the developed world acquire one or more infections.
The risk of HAI in developing countries is from 2 to 20 times higher than in developed countries.
WHO [12] defines a health care-associated infection (also called “nosocomial”) as:
An infection acquired in hospital by a patient who was admitted for a reason other than that infection.
An infection occurring in a patient in a hospital or other health-care facility in whom the infection was not present or incubating at the time of admission. This includes infections acquired in the hospital but appearing after discharge, and also occupational infections among staff of the facility.
In the United States, 1 out of every 136 hospital patients becomes seriously ill as a result of acquiring an infection in hospital; this is equivalent to two million cases and about 80 000 deaths a year.
In England, more than 100 000 cases of health care-associated infection lead to over 5000 deaths directly attributed to infection each year.
In Mexico, an estimated 450 000 cases of health care-associated infection cause 32 deaths per 100 000 inhabitants each year.
Health care-associated infections in England are estimated to cost £1 billion a year. In the United States, the estimate is between US$ 4.5 billion and US$ 5.7 billion per year. In Mexico, the annual cost approaches US$ 1.5 billion.
What students need to know (knowledge requirements):
• know the extent of the problem;
• know the main causes and types of infections.
Universal precautions: "Universal precautions," as defined by CDC, are a set of precautions designed to prevent transmission of human immunodeficiency virus (HIV), hepatitis B virus (HBV), and other bloodborne pathogens when providing first aid or health care. Under universal precautions, blood and certain body fluids of all patients are considered potentially infectious for HIV, HBV and other bloodborne pathogens. Retrieved from CDC web site http://www.cdc.gov/ncidod/dhqp/bp_universal_precautions.html
Health care-associated infections
Infections are caused by bacteria, fungi or viruses entering the body through one or more of the following routes.
• person-person via hands of health-care providers patients and visitors;
• personal equipment (e.g. stethoscopes, computers) and clothing;
• environmental contamination;
• airborne transmission;
• carriers on the hospital staff;
• rare common-source outbreaks.
Epidemiological evidence suggests that multidrug-resistant organisms are carried from person-to-person by health-care professionals.
Carriers are individuals who harbor disease organisms in their body without visible symptoms and may pass the infection to another person. It is possible to carry an organism without being aware of it for example, Typhoid Mary a woman who carried the typhoid bacillus and unknowingly started an epidemic in the US in the 1880s .
Outbreak is a term used in epidemiology to describe an occurrence of disease greater than would otherwise be expected in a particular time and place. It may be small and localized group or impact upon thousands of people across an entire continent. Two linked cases of a rare infectious disease may be sufficient to constitute an outbreak. Outbreaks may also refer to epidemics, which affect a region in a country or a group of countries, or pandemics, which describe global disease outbreaks.
Common source outbreak
Some diseases arise from a single definable source, such as a common water supply.
The basic idea is that common source outbreaks are not propagated from individual-to-individual (e.g., person-to-person). Instead, sick individuals typically are propagation dead ends.
Yet the disease continues to be endemic and perhaps epidemic as a consequence of contact with some typically geographically well-defined disease reservoir.
Clean hands are safer hands
prevent antimicrobial resistance
5 million lives
Developing country focus
Recognizing this worldwide crisis, WHO established the campaign Clean hands are safer hands and joins other campaigns by addressing the high infection rates through the implementation of endorsed guidelines aimed at reducing death from transmission of health care-associated infections.
The CDC’s campaign to Prevent antimicrobial resistance aims to prevent antimicrobial resistance in health-care settings by a range of strategies aimed at preventing infection, diagnosing and treating infection, using antimicrobials wisely and preventing infection transmission. The campaign is targeting clinicians who treat particular patient groups such as hospitalized adults, dialysis patients, surgical patients, hospitalized children and long-term care patients.
The IHI campaign called the 5 million lives aims to reduce MRSA infections through the implementation of five key interventions:
1. hand hygiene;
2. decontamination of environment, equipment;
3. active surveillance cultures;
4. contact precautions for infected and colonized patients;
5. compliance with central venous catheter and ventilator bundles.
The following four types of infections account for more than 80% of all health care-associated infections:
• urinary tract infections usually associated with catheters:
- catheter-associated urinary tract infections are the most frequent, accounting for about 35% health care-associated infections;
• surgical infections:
- these are second in frequency, about 20%;
• bloodstream infections associated with the use of an intravascular device:
- about 15%;
• pneumonia associated with ventilators:
- about 15%.
Reference:
Burke, J. P. (2003). Infection control — A problem for patient safety. The New England Journal of Medicine, 348, p. 651-656.
Students should approach every situation as having the potential to infect a patient or a health-care worker or themselves.
Infections are preventable when health-care workers use the right techniques and remain on the look out for unclean and unsafe situations.
Handwashing today is the single most important intervention before and after patient contact.
Every health-care worker is required to act responsibly and without fail to apply the techniques for handwashing at every patient encounter. They also should advise patients and families of the importance of handwashing and give them permission to remind the staff.
Decontamination refers to the process for physical removal of blood, bodily fluids and the removal or destruction of micro-organisms from the hands.
• limited studies available to test the technique of hand decontamination;
• methods based on expert opinion:
- before clinical shift begins remove all wrist and hand jewelry;
- cuts and abrasions covered with waterproof dressings;
- fingernails kept short clean and free from nail polish.
Soap solution must have contact with whole surface area of hands—vigorous rubbing of hands for 10–15 seconds (especially tips of fingers, thumbs and areas between fingers).
A link to drawings showing the procedure - Effective Handwashing Technique
Links to drawings and directions for this procedure - How to use waterless handrub
Click on to start video (link to the file)
Personal protective equipment includes the use of gowns, gloves, aprons, eye protection and face masks.
The use of these equipment is usually based on assessment of the risk of micro-organism transmission to the patient or to the carer as well as the risk of contamination of the health-care practitioner’s clothing and skin by the patient’s blood, bodily fluids, secretions or excretions.
1. Gloves are now an everyday part of clinical practice. There are two main indicators for wearing gloves in the clinical setting:
• to protect the hands from contamination with organic matter and micro-organisms;
• to reduce the risk of transmitting microorganisms to both patients and staff.
2. Even if a student is required to wear gloves this does not replace the need for cleaning one’s hands.
3. Gloves must be worn for:
- all invasive procedures;
- contact with sterile sites;
- contact with non-intact skin or mucous membranes;
- all activities assessed as having a risk of exposure to blood, bodily fluids, secretions and excretions, and handling sharps or contaminated instruments.
4. Gloves should be worn only once and should be put on immediately before the care activity, removed immediately afterwards and changed between patients and pisodes of care;
5. Gloves must be disposed of as clinical waste and hands must be decontaminated by washing appropriately.
Students should be aware of the significant problem for health-care workers caused by needle stick injuries, which are as prevalent as injuries from falls and handling and exposure to hazardous substances.
Nursing students need to make every effort to minimize the spread of infection and to encourage patients and other health-care workers to actively engage in practices that minimize the spread of infection in the community, the hospitals, and the clinics.
Before contact with each and every patient a student should clean their hands before touching a patient.
This is important to protect the patient against harmful micro-organisms carried on the hands. Students may have been travelling on a bus immediately before entering the hospital and the ward where they intend to take a history from a patient. In doing so they may shake the hand of
the patient or comfort the patient as a humane gesture. They may also be requested to assist a patient to move from the bed to a chair, or to a
sitting area for more privacy. They might be required to perform a physical examination, take the pulse of the patient or blood pressure and
abdominal palpation.
A student should clean hands before an aseptic task.
It is essential that students clean their hands immediately before any aseptic task. This is necessary to protect the patient against harmful
micro-organisms, including the patient’s own micro-organisms, entering his or her body. Students must protect against transmission through contact with mucous membrane: oral/dental care, giving eye drops, secretion aspiration. Often students will be treating patients who have open wounds and any contact with non-intact skin: skin lesion care, wound dressing, any type of injection is an opportunity for transmission.
Medical devices are well known for harbouring potentially harmful micro-organisms and contact with devices such as catheter insertion, opening a
vascular access system or a draining system must be done with careful preparation. Students should also be diligent in preparation of food, medications and dressing sets.
After contact with each and every patient a student should clean hands after any risk of exposure to body fluids.
Students should habitually clean their hands immediately after an exposure risk to body fluids and after glove removal. Cases of transmission
have been to know to occur even with gloving. This is essential to limit the opportunity of the student receiving an infection. It is also necessary
to maintain a safe health-care environment.
Students should wash hands after actual patient contact.
All students should clean their hands after touching a patient and his or her immediate surroundings. This should be done using one of the methods available to the clinic or hospital immediately after the patient contact is over. This is because in busy environments there are many
distractions and busy people tend to rush onto the next job or patient. Many people forget in the rush to wash their hands. Forgetting to wash
hands can lead to the student getting an infection and increasing the chances of the microorganisms spreading throughout the environment.
Saying goodbye to the patient by shaking a hand or touching a shoulder provides opportunities for micro-organisms to be transferred to the student and vice versa. Activities in addition to those mentioned above that involve direct physical contact include helping a patient to move around, to get washed or to give a massage, which are known routes for micro-organisms spreading to others. Students performing clinical examination such as taking pulse, blood pressure, chest auscultation and abdominal palpation are all opportunities for cross-infection.
Students must handwash after contact with patient surroundings
Micro-organisms are also known to survive on inanimate objects. So it is important to clean one’s hands after touching any object or furniture in the patient’s immediate surroundings when leaving them, even without touching the patient. Students may find themselves helping other staff and
change bed linen, adjust perfusion speed, monitor an alarm, hold a bed rail or make room on a side bed table for a patient.
When this occurs students should maintain correct handwashing techniques and if appropriate have a discussion about the techniques used in the hospital or clinic and
the reasons for the variation. However, in many cultures this may not be appropriate.
How a student deals with this situation will depend on the relationship of the student to the person who fails to wash their hands, the culture of the hospital and the culture of the society.
