Patient Safety Overview

Patient Safety

• Patient safety is a science that uses evidence-based medicine to minimize harm from human error.
• Patient Safety Incidents (PSI) are preventable events that could cause harm to a patient.
• Adverse events cause harm to a patient, either due to underlying conditions or treatment. These can be preventable or non-preventable.
• A near miss is an incident that could have led to unwanted consequences but did not.
• A no harm event is an incident that reaches a patient but results in no injury.
• Never events are serious and largely preventable adverse events that should not occur.
• Negligence is care that falls below the expected standard of care for a reasonable physician.
• This standard of care is based on similar knowledge, training, and experience.
• Competence is the knowledge, skills, and attitudes required for carrying out duties.
• Credentialing ensures clinicians are prepared for patients with specific problems and procedures.
• In advanced hospital settings, one in ten patients suffers preventable harm.
• Unsafe care costs billions of dollars annually.

Objectives

• Important definitions.
• Prevalence.
• Etiology of PSI.
• Error models.
• Aspects of improvement.
• Saudi Patient safety center.

Important Definitions

• Patient safety:
  • Science of minimizing human error-related harm in patient care.
  • Includes evidence-based medicine and local wisdom.
• Patient Safety Incidents (PSI):
  • Preventable circumstances or events potentially leading to avoidable harm to the patient.
• Adverse event:
  • Incident resulting in harm to a patient, either due to the underlying condition itself or associated treatment.
• Near miss:
  • Incident that could have caused harm but did not due to intervention or chance.
• A no-harm event:
  • An incident that reached the patient, but did not cause any injury.
• Never Event:
  • Serious adverse events that are largely preventable.
• Negligence:
  • Care falling below the recognized standard of care.
• Competence:
  • Necessary knowledge, skills, and attitudes to perform tasks.
• Credentialing:
  • Way to ensure clinicians adequately prepared to treat specific patients with particular needs or carry out certain procedures.

Etiology of PSI

• Human factors: inadequate patient assessment, errors in diagnosis or treatment, inadequate monitoring, deficiencies in training, experience, fatigue, psychological factors, poor communication, and insufficient staffing.
• System failure: poor communication between healthcare providers, inadequate staffing levels, disconnected reporting systems overreliance on automated systems, drug similarities, environmental design issues, infrastructure problems, equipment failure, and insufficient systems for reporting and reviewing incidents.
• Medical complexity: potent drugs, their side effects and interactions, and the complexities of working environments.

Error Models

• Heinrich's pyramid: Importance of reporting near misses and adverse events for continuous learning.
• Error models help understand factors causing events and where safeguards are needed.

Aspects of Improvement

• Open communications with the patient.
• Clinical risk management
• Proper staff communications
• Healthy working environment.
• Surgical Check List.
• Safe prescription.
• Technical & operation errors

Saudi Patient Safety Center

• Established in 2017.
• First of its kind in the Middle East.
• Main custodian of patient safety strategies.

Brain Storming

• A 33-year-old male patient underwent a surgical error
• How to describe the surgical error
  • A near miss
• At what step of the surgical checklist does the nurse check the count of sponges and instruments
  • Sign out

References

• Bailey and Love's Short Practice of Surgery (26th edition).