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    What Is Patient Safety PDF

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    R. Arief Santoso
    The document discusses patient safety in healthcare. It defines patient safety as freedom from accidental injury during healthcare and outlines some key concepts. Patient safety incidents are unintended or unexpected incidents that could or did lead to harm for patients receiving NHS healthcare. Adverse events are unintended injuries or complications caused by healthcare management. Communication breakdowns are responsible for around 70% of patient safety issues. The document recommends a culture of safety, learning from other industries, and emphasizing system design to promote patient safety.

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    What Is Patient Safety PDF

    Uploaded by

    R. Arief Santoso
    80 views43 pages
    The document discusses patient safety in healthcare. It defines patient safety as freedom from accidental injury during healthcare and outlines some key concepts. Patient safety incidents are unintended or unexpected incidents that could or did lead to harm for patients receiving NHS healthcare. Adverse events are unintended injuries or complications caused by healthcare management. Communication breakdowns are responsible for around 70% of patient safety issues. The document recommends a culture of safety, learning from other industries, and emphasizing system design to promote patient safety.

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    What is Patient Safety.pdf

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    The document discusses patient safety in healthcare. It defines patient safety as freedom from accidental injury during healthcare and outlines some key concepts. Patient safety incidents are unintended or unexpected incidents that could or did lead to harm for patients receiving NHS healthcare. Adverse events are unintended injuries or complications caused by healthcare management. Communication breakdowns are responsible for around 70% of patient safety issues. The document recommends a culture of safety, learning from other industries, and emphasizing system design to promote patient safety.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    80 views43 pages

    What Is Patient Safety PDF

    Uploaded by

    R. Arief Santoso
    The document discusses patient safety in healthcare. It defines patient safety as freedom from accidental injury during healthcare and outlines some key concepts. Patient safety incidents are unintended or unexpected incidents that could or did lead to harm for patients receiving NHS healthcare. Adverse events are unintended injuries or complications caused by healthcare management. Communication breakdowns are responsible for around 70% of patient safety issues. The document recommends a culture of safety, learning from other industries, and emphasizing system design to promote patient safety.

    Copyright:

    © All Rights Reserved
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    Download as pdf or txt
    of 43

    WHAT IS

    PATIENT
    Reporting
    SAFETY
    PREFACE
    • The hospital environment presents
    particular and, in some cases, unique
    safety problems when compared with
    other industrial settings. These problems
    affect the patient, staff, and visitor;
    • The causes of such hazards fall into two
    broad categories:
    a)Failure of a device to correctly perform the
    desired function; and
    b)Failure of hospital personnel to correctly use
    medical equipment.
    FIVE DIAMONDS PATIENT SAFETY
    1. To promote patient safety values;
    2. To create an awareness of patient
    safety issues;
    3. To help hospital units learn more
    about specific areas of patient
    safety; and
    4. To build a patient safety culture
    and commitment in every unit.
    What Is Patient Safety?
    Patient safety is the freedom from
    accidental injury in health care.
    A patient safety incident is any unintended or
    unexpected incident which could have or
    did lead to harm for one or more patients
    receiving NHS funded healthcare.
    This is also referred to as an adverse event/incident,
    mistake or clinical error, and includes near
    misses.
    DEFINITIONS
    Patient Safety:
    The reduction and mitigation of unsafe acts within
    the health-care system, as well as through the use
    of best practices shown to lead to optimal patient
    outcomes.
    Canadian Patient Safety Dictionary, 2003

    Adverse Event:
    An adverse event is an unintended injury or
    complication which results in disability, death or
    prolonged hospital stay, and is caused by health-
    care management.
    Wilson et al
    ADVERSE EVENTS
    • Delayed or missed • Mislabeled
    diagnoses; specimen;
    • Medication errors; • Patient falls;
    • Wrong side surgery; • Time delay errors;
    • Wrong patient • Laboratory errors;
    surgery; • Radiology errors;
    • Equipment failure; • Procedural error;
    • Patient identity; • Wrong gas delivery.
    • Transfusion errors;
    6
    ADVERSE EVENTS
    • Lost, delayed, or failures to follow up reports;
    • Retention of foreign object following surgery;
    • Contamination of drugs, equipment;
    • Intravascular air embolism;
    • Failure to treat neonatal hyperbilirubinemia;
    • Stage lll or lV pressure ulcers acquired after
    admission;
    • Deaths associated with restraints or bedrails;
    • Sexual or physical assault.
    7
    Sources of System Error
    • Overall Culture;
    • Education / Training / Experience;
    • System Design / HFE;
    • Resource Availability;
    • Demand / Volume;
    • Throughput Impedance; and
    • Shift-Work / Schedules.
    8
    ERROR TYPES
    Based on the work of James Reason
    Basic Error Types

    Routine
    Violations Reasoned
    Reckless & Malicious
    Intended
    actions
    Rule & Knowledge
    Mistakes Based errors
    Unsafe
    acts Skill based errors
    Lapses Memory failures
    Unintended
    actions
    Skill based errors
    Slips Attentional failures
    Magnitude of the Problem
    • Atleast 1 person dies every 5-10 minutes
    due to harmful events in hospitals;
    • 70% of these events is the result of
    breakdown in communication:
    – Where breakdowns occur:
    • Between patients and health-care
    providers; and
    • Between health-care providers.
    Connection Between
    Communication and Patient Safety
    • Information is communicated between
    health-care team members for purposes
    of:
    – Making clinical decisions;
    – Planning treatments;
    – Performing interventions; and
    – Note: The patient and family are the
    most important members of the
    health-care team!
    Connection Between
    Communication and Patient Safety
    • Every aspect of patient care requires high-
    level communication competency to gather
    and interpret information about the patient;
    • When communication failures result in
    information that is incomplete or
    misinterpreted, patient harm will occur due
    to inappropriate or inadequate treatment.
    Nurses use communication to:
    • Establish the nurse-patient relationship;
    • Exchange information with the patient/family;
    • Ensure accuracy in delivering the correct
    treatment regime;
    • Exchange information with other health-care
    providers;
    • Transfer responsibility of care; and
    • Ensure accuracy in interpreting information.
    – These are areas for potential breakdown
    in communication for nurses.
    Patient-Safe Communication
    Goal-oriented communication focused on
    helping patients attain optimal health outcomes
    – Gather and share information;
    – Clarify and verify accurate interpretation of
    information; and
    – Establish a process of collaboration with
    • Patients / Families; and
    • Health-care team members.
    Preventing Harmful Events
    Just as important as learning to use a
    stethoscope, nurses need to learn:
    – How to use communication as a key
    instrument for patient safety;
    – Patient-safe communication
    strategies; and
    – Recommendations for safe
    communication from World Health
    Organization.
    Safety management
    leads to:
    • Increased productivity;
    • Avoiding injuries; and
    • Avoiding costly, time
    consuming, stressful
    and inconvenient
    incidents.
    PATIENTS SAFETY
    Learning From Other Safety
    Critical Industries
    To minimise patient safety
    incidents, the Health Fields
    should learn from other
    safety-critical industries and
    target the underlying
    systems failures.
    A Culture of Safety
    31,033 Pilots, Surgeons, Nurses and Residents Surveyed*

    % Positive Responses from: Pilots Medical


    Is there a negative impact of fatigue
    74% 30%
    on your performance?

    Do you reject advice from juniors? 3% 45%

    Is error analysis system-wide? 100% 30%

    Do you think you make mistakes? 100% 30%

    Easy to discuss/report mistakes? 100% 56%


    *Sexton JB, Thomas EJ, Helmreich RL, Error, stress and teamwork in medicine and
    aviation: cross sectional surveys. BrMedJour, 3-18-2000.
    The Importance of Design for
    Patient Safety
    Seven Steps to Patient Safety
    1. Lead and support your staff;
    2. Foster a culture of safety;
    3. Promote reporting;
    4. Involve patients and the public;
    5. Implement solutions to reduce / avoid
    harm;
    6. Learn and share safety solutions; and
    7. Integrate your safety management activity.
    Adapted from: National Patient Safety Agency for the National Health Service
    “Seven Steps to Patient Safety – An Overview Guide for NHS Staff”
    Human Factors –
    Confront Two Myths
    • The perfection myth.
    If people try hard enough
    they will not commit
    patient safety incidents.

    • The punishment myth.


    If we punish people when
    they make patient safety
    incidents they will make
    fewer of them.
    Forms of NPSA Advice
    • A patient safety alert requires
    prompt action to address high
    risk safety problems;
    • A safer practice notice strongly
    advises implementing particular
    recommendations or solutions;
    • Patient safety information
    suggests issues or effective
    techniques that healthcare staff
    might consider to enhance
    safety
    Safe Medication Practice Activity
    • Potassium chloride; • Epidural infusions;
    • Oral methotrexate; • Wrong route errors;
    • Confusing labelling, • Injectable Medicines;
    packaging and • Anticoagulants;
    presentations; • Paediatric Infusions;
    • Vaccines; • Psychotropic medicines;
    • Diamorphine and • Insulin;
    morphine; • Lithium; and
    • Dispensed medicines; • Medication histories on
    admission and discharge.
    Purchasing for Safety
    • Risk assessment of products as part of
    healthcare contracting and purchasing.
    • Safety before price; purchase products with the
    following:
    – Clear labelling and packaging;
    – Well differentiated from similar products to
    prevent misidentification;
    – Appropriate secondary and warning labels;
    – Bar codes;
    – Ready to administer/use or simple
    preparation and administration; and
    – Adequate information for practitioners,
    patients and carers.
    Diamorphine and Morphine Injections

    • Between 2000 and 2005 there have been seven


    published case reports of deaths due to the
    administration of high dose (30mg or greater)
    diamorphine or morphine to patients who had
    not previously received doses of opiates.

    • Between January and October 2005, the NPSA


    received 16 reports of similar patient safety
    incidents of which two had resulted in the death
    of the patients.
    Diamorphine and Morphine Injections
    • Many of these incidents involved diamorphine
    and morphine 30mg ampoules being selected
    in error for lower strength ampoules and
    overdoses were administered.
    • In addition 30mg doses or higher were
    sometimes prescribed as first doses for
    patients who had not previously received
    doses of opiates and this can result in
    overdose, respiratory depression, loss of
    consciousness and death if support
    procedures are not implemented.
    Ampoule Labelling
    Ampoule Labelling
    Repevax and Revaxis Vaccine
    • In January 2005 the NPSA received a report that 93
    teenage school children were vaccinated with Repevax
    instead of Revaxis.
    • Repevax (diphtheria, tetanus, 5 component acellular
    pertussis, and inactivated polio vaccine dTaP/IPV)
    This vaccine is supplied as a pre-filled syringe and is
    administered by intramuscular injection as a pre-school
    booster following primary vaccination. The vaccine may
    be given from the age of three years onwards.
    • Revaxis (tetanus, diphtheria and inactivated polio
    vaccine Td/IPV)
    This vaccine is supplied as a pre-filled syringe. The
    vaccine may be administered by intramuscular injection
    from the age of six years, and may be used for
    adolescents and adults as a booster following primary
    vaccinations.
    Critical Information In The Same
    Field of Vision On At Least Three
    Non-Opposing Faces
    Orientate Text In The Same Direction
    Use Blank Space To Emphasise
    Critical Information
    Use Colours To Differentiation to
    Highlight Information
    Optimum Font Size, Font, and
    Spacing
    Do Not Use Trailing Zero’s
    Use of Tall Man Lettering to
    Differentiate Look Alike and
    Sound Alike Names
    Allocate Space for a Dispensing
    Label
    Put Medicine Name and Strength
    Clearly on Each Blister
    Use Non-reflective Foil
    Match Styles of Primary and
    Secondary Packaging
    Machine Readable Codes On
    Medicines
    CONCLUSION
    • It cannot be assumed that all medicine
    products are equally safe in use;
    • Risk assessment and purchasing for safety
    initiatives are integral to the Hospital Patient
    Safety Strategy;
    • The hospital should clearly specify to industry
    the patient safety requirements for medicine
    products ( these may exceed those required
    by the Goverment Medicines Directive)
    • The safer practice recommendations will
    increasingly include purchasing for safety and
    supply chain initiatives.

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