Patient Safety in Healthcare

Patient Safety Overview

• Fundamental principle: "First do no harm" emphasizes patient safety in healthcare practice.
• Patient safety encompasses avoiding, preventing, and mitigating adverse outcomes from healthcare processes.

Current Landscape of Patient Safety

• NHS compensation bill reached £2.35 billion last year, indicating financial stakes in patient safety.
• Most frequent claims arise from slips and trips, followed by medication errors, which account for 11% of claims.
• Surgery and obstetrics remain primary sources of significant claims.

Errors in Healthcare

• Adverse event rate in health services is approximately 10%.
• About 20% of patients may experience adverse events post-hospital discharge, highlighting the need for collaboration between primary and secondary care.

Consequences of Adverse Events

• Adverse events lead to pain, disability, psychological harm, and in severe cases, death.
• These events impose financial burdens on healthcare systems and personal costs on practitioners.

Types of Errors

• Errors can be categorized as:
  • Causes: Those responsible for patient harm.
  • Events/Actions: The specific actions leading to harm.
  • Outcomes: The resultant harm or complications.

Active and Latent Failures

• Active failures stem from human errors and equipment failures.
  • Include errors of commission (wrong actions taken) and omission (failure to act).
• Latent failures represent system flaws that predispose to errors, often unnoticed until an active failure occurs.

Human Factors Contributing to Errors

• Common human error types:
  • Slips: Mistakes in routine tasks, e.g., miscommunication of patient allergies.
  • Lapses: Failure to adhere to protocols, e.g., not prescribing critical medications.
  • Mistakes: Errors in judgment due to inadequate knowledge or applying the wrong guidelines.
  • Violations: Deliberately ignoring established rules.

Communication Failures

• Communication issues contribute to about 90% of compensation claims.
• Patients' unique cultural contexts impact their understanding and perspective of healthcare.

Technology and Consultation

• While face-to-face consultations prevail, growing use of telecommunication changes dynamics and may lead to errors due to lack of non-verbal cues.
• The World Health Organization highlights transitions in care as critical risk areas, particularly with frequent medication errors during these transitions.

Practical Strategies for Safety

• Emphasize patient safety as a research and practice priority.
• Adhere to local guidelines and seek assistance when uncertainty arises.
• Foster risk management and incident reporting procedures within healthcare settings.

Legal Framework for Patient Safety

• Statutory duties under the Health and Safety at Work Act 1974.
• Common law obligations encompass duty of care, implicating healthcare providers in negligence cases.

Rights and Obligations in Patient Safety

• Rights pertain to legally protected interests, while duties ensure respect and protection of those rights in healthcare.

Legal Compliance and Responsibilities

• Employers must comply with numerous regulations related to health and safety, including the Management of Health & Safety at Work Regulations and the Control of Substances Hazardous to Health Regulations.

Specific Case Studies

• Notable incidents illustrate the consequences of safety breaches, such as a 93-year-old woman who died following misplacement by an ambulance service, leading to fines for negligence.

Manual Handling Protocols

• Regulations mandate risk assessment and the implementation of no-lift policies to prevent injury during manual patient handling.
• Individualized assessments must focus on patient and worker capabilities.

Control of Hazardous Substances

• Employers are mandated to control exposure to harmful substances and ensure health risks are adequately addressed.
• Case laws highlight employer liabilities for injuries resulting from hazardous substances, as seen with a nurse’s allergy to latex leading to significant damages.

Consequences of Inadequate Safety Measures

• Severe breaches in safety can result in criminal charges and significant financial penalties for the healthcare organizations involved.