Patient Safety and Medical Errors Quiz

Patient Safety Lecture

• Lecture for medical students
• Professor Rainer Petzina, MaHM
• Medical School Hamburg (MSH), Medical School Berlin (MSB), Health and Medical University (HMU)

Agenda

• Objectives for the day
• Review
• WHO – Patient safety
• Safety I – Safety II
• First, second, third victim
• Sepsis
• Conclusion

Objectives for the Day

• Understanding WHO data on patient safety
• Describing Safety I and Safety II
• Learning the importance of first, second, and third victims in healthcare
• Gaining first impressions of the importance of sepsis

Risk Management Matrix

• Risk is a combination of likelihood and impact
• Likelihood ranges from frequent to unlikely
• Impact is categorized as insignificant to catastrophic

Risk Management System

• Framework for risk management
• Identifying, analyzing, and evaluating risks
• Risk mitigation and ongoing monitoring
• Policy of the organization/task and commitment
• Planning, action, and verification

Risk Management Methods (Proactive/Preventive)

• Scenario analysis
• Audits, documentation walkthroughs
• Peer review
• Simulators/training exercises
• Process analysis

Risk Management Methods (Reactive)

• Error reporting systems
• Quality data analysis
• Patient-orientated/complaint management
• Meetings/discussions about incidents

Scenario Analysis (Proactive/Preventive)

• Current situation of 10 defibrillators in the building
• Training on use occurs during initial installation
• Staff members were absent when training happened, no replacements
• This creates an increased risk of the defibrillator being used incorrectly

Audits & Walkthroughs (Proactive/Preventive)

• Audits/walkthroughs in various departments (e.g., wards, operating rooms)
• Focus on specific areas/themes (e.g., hygiene, documentation, medication safety)

Peer Review Methods (Proactive/Preventive)

• Common issues encountered in hospitals
• Analysis of care documentation
• Missing treatment goals (e.g., antibiotics)
• Communication problems/interfaces between departments (e.g., wards and intensive care)

Crew/Crisis Resource Management (CRM) (Proactive/Preventive)

• Simulation and communications training
• Ward (labor) training exercises/education
• Resuscitation training
• Operating room training exercises

Process Analysis (Proactive/Preventive)

• Recommendations for preventing surgical procedures
• Identification of patients
• Marking procedure sites
• Correct ward/operating room assignments
• Team-time-out before the procedure

Critical Incident Reporting System (CIRS) (Reactive)

• Anonymous reporting system for events, errors, near misses
• Analysis of error patterns for preventive measures
• Focus on critical, safety-related events

Safety I - Safety II

• Healthcare is complex, both socially and technically • Interdisciplinary and interprofessional collaboration • Medical expertise and competences • Manual skills/procedures • Interactions with sophisticated devices and processes • Automation and standardization factors

Safety I - Perspective

• Aiming for minimal negative/unwanted/unexpected events/incidents
• Standardizing/optimizing processes and human interactions
• Minimizing errors

Safety II - Perspective

• Emphasizing positive outcomes/factors
• Adaptability based on unpredictability/risk
• Maximizing the number of positive factors possible

First, Second, Third Victim

• First victim -patients
• Second victim -healthcare professionals encountering traumatizing events
• Third victim - the department, hospital, or clinic itself

Sepsis

• Life-threatening organ dysfunction caused by an inappropriate response to infection
• Sepsis-related Organ (SOFA) Score assessed
• Septic shock is severe Sepsis

WHO - Global Action Plan for Patient Safety 2021-2030

• Goal is to eliminate avoidable patient harm in healthcare
• High financial and economic cost to provide/support healthcare
• Loss of trust in the healthcare system
• Impact on affected healthcare personnel
• Patient Safety Culture

7 Strategic Goals with 35 Specific Strategies

Patient Safety Curriculum Guide - Multi-Professional Edition

Patient Safety - Key Facts

• Patient harm is one of the leading causes of death and disability
• In high-income countries, 1 out of 10 patients experience harm during hospital treatment
• 15% of healthcare spending is frequently lost dealing with adverse events in OECD countries
• Large financial savings are possible by properly dealing with patient harm and safety
• In low-to-medium-income countries, adverse events are frequently responsible for 2/3 of lost years (DALY) due to disability and death