Patient Safety Lecture 1

Patient Safety

• Patient safety is the absence or reduction of risk of unnecessary harm to a patient during healthcare to an acceptable minimum.
• There are more deaths annually due to healthcare than from road accidents, breast cancer, and AIDS combined.

The 6 Key Dimensions of Healthcare Quality

• Safe: Avoiding injuries to patients from the care that is intended to help them.
• Effective: Providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit.
• Timely: Reducing waits and sometimes unfavorable delays for both those who receive and those who give care.
• Family-centered: Providing care that is respectful of and responsive to individual patient preferences, needs, and values.
• Efficient: Avoiding waste, in particular waste of equipment, supplies, ideas, and energy.
• Equal: Providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socio-economic status.

Sources of System Errors

• Active (human) errors: Committed by frontline staff and tend to have direct patient consequences.
• Latent or system errors: Errors that occur due to a set of external forces and indirect failures involving management, protocols/processes, organizational culture, transfer of knowledge, and external factors.

Serious Injury and Adverse Events

• Serious injury includes loss of limb or function.
• Adverse drug reaction: A response to a drug that is noxious and unintended, which occurs at a dose normally used in man for the prophylaxis, diagnosis, or therapy of disease, or for the modification of physiological function.
• Near miss: Any situation that might have resulted in harm, but did not reach the patient due to timely intervention or good fortune.

Maintaining Safety in Clinical Incidents

• Adhere to and follow national patient safety goals and required organizational practices (ROP).

Human Factors and Patient Safety

• Human factors: The study of all the factors that make it easier to do the work in the right way; also known as ergonomics.
• Importance of human factors in healthcare: Human factors are a major contributor to adverse events in healthcare, and all healthcare workers need to have a basic understanding of human factors principles.

Human Factors Principles

• Acknowledge: The universal nature of human fallibility and the inevitability of error.
• Assume: That all errors will occur.
• Design: Designs things in the workplace to try to minimize the likelihood of error or its consequences.

Examples of Traps in Healthcare

• Look-alike and sound-alike medications.
• Equipment design complexity, e.g., infusion pump.

Systems Approach

• A systems approach requires looking at healthcare as a whole system, with all its complexity and interdependence, shifting the focus from the individual to the organization.
• It forces us to move away from a blame culture towards a systems approach.

Traditional Approach to Problems

• Blame and shame the healthcare professionals most directly involved in caring for the patient at the time of an adverse event or error.
• Why it's not accepted: Healthcare professionals do not deliberately harm patients, and a blame culture makes it difficult to learn from errors and decrease the chance of future adverse incidents.

Accountability

• Accountability is a professional obligation for healthcare professionals.
• Importance of accountability: To demonstrate professional behavior, ensure working within scope of practice, and maintain competence and practice ethically.

Stages of Team Development

• Forming stage: Initial stage when the team is formed, and members are coming together for the first time.
• Storming stage: Each member tends to rely on their own experience, and there is resistance to work together openly.
• Norming stage: Members start to know each other, accept each other's ideas and opinions, and work together to overcome personal disagreements.
• Performing stage: Members are satisfied with the team's progress, and work together to achieve the team's goals.

Characteristics of Successful Teams

• Measurable goals: Teams set goals that are measurable and focused on the team's task.
• Mutual respect: Effective teams have members who respect each other's talents and beliefs.
• Common purpose: Identification of potential improvements that could be made in systems or processes to improve performance and reduce the likelihood of adverse events or close calls.

Practice Strategies to Reduce Errors

• Know yourself: Eat well, sleep well, and look after yourself.
• Know your environment and know your task(s).
• Preparation and planning: What if...?
• Build checks into the routine and ask if you do not know.
• Assume that errors will be made, be prepared for them, and identify those circumstances that most likely lead to errors.
• Have contingencies in place to cope with problems, interruptions, and distractions.
• Always mentally rehearse complex procedures or if it is the first time you are doing an activity involving a patient.

Understanding and Managing Clinical Risk

• Risk management: Organizational effort to identify, assess, control, and evaluate the risk to reduce harm to patients, visitors, and staff and protect the organization from financial loss.
• Purpose of risk management: Improve organizational and client safety, identify and minimize risks and liability losses, protect the organization's resources, support regulatory and accreditation compliance, and create safe systems of care designed to reduce adverse events and improve human performance.
• Hazard: Any activity, situation, or substance that has the potential to cause harm, including ill health, injury, loss of product, and/or damage to patients and property.
• Risk: The probability that harm will actually occur.