Patient Safety Lecture Notes PDF

Patient Safety Mohammad Samy Kharoub Assistant Professor of General Surgery OBJECTIVES ✓ Important definitions. ✓ Prevalence. ✓ Etiology of PSI. ✓ Error models. ✓ Aspects of improvement. ✓ Saudi Patient safety center. Medicine will never be a risk-free practice. From...

Patient Safety Mohammad Samy Kharoub Assistant Professor of General Surgery OBJECTIVES ✓ Important definitions. ✓ Prevalence. ✓ Etiology of PSI. ✓ Error models. ✓ Aspects of improvement. ✓ Saudi Patient safety center. Medicine will never be a risk-free practice. From the beginning of training, doctors are taught that errors are unacceptable and that the philosophy of (first, do no harm) should permeate all aspects of treatment.  Term Definition Patient safety: A science that promotes the use of evidence-based medicine and local wisdom to minimize the impact of human error on quality patient care. Patient Safety incidents A preventable events or circumstances that could have, or did, result in unnecessary (PSI): harm to the patient. This might be an adverse event, near miss and no-harm event Adverse event: An incident which results in harm to the patient (either due to the underlying condition or its treatment. Could be preventable or non-preventable. A near miss: An incident that could have resulted in unwanted consequences but did not, either by chance or through a timely intervention preventing the event from reaching the patient. A no-harm event: An incident that occurs and reaches the patient but results in no injury to the patient. Harm is avoided by chance or due to mitigating circumstances. Never Event: Adverse events that are serious and largely preventable. A kind of medical error that should never happened. Negligence: Care that falls below the recognized standard of care. Standard of care: The care that a reasonable physician of similar knowledge, training and experience would use in similar circumstances.  Term Definition Competence: Knowledge, skills and attitudes required to be able to carry out one’s duties.. Credentialing: A way that is used to ensure that clinicians are adequately prepared to safely treat patients with particular problems or to undertake defined procedures.  WHO estimates that, even in advanced hospital settings, one in ten patients receiving healthcare will suffer preventable harm. The financial burden of unsafe care is due to prolonged hospitalization, loss of income, disability and litigation costing many billions of dollars every year. PSI = Patient Safety Incidents  Factors Examples Inadequate patient assessment; delays or errors in diagnosis Failure to use or interpret appropriate tests Error in performance of an operation, treatment or test Inadequate monitoring or follow up of treatment Human factors: Deficiencies in training or experience Fatigue, overwork, time pressures Personal or psychological factors, e.g. depression or drug abuse Lack of recognition of the dangers of medical errors Poor communication between healthcare providers Inadequate staffing levels Disconnected reporting systems or overreliance on automated systems System failure: Drug similarities Environment design, infrastructure Equipment failure, due to lack of parts or skilled operators Inadequate systems to report and review patient safety incidents Advanced and new technologies Medical complexity: Potent drugs, their side effects and interactions Working environments – intensive care, operating theatres  The problem of error can be viewed in two ways Person approach System approach Human performance principles tell us that humans are Health systems add complex organisational fallible and that errors can occur through: structures to human fallibility thus substantially Errors of commission: doing the wrong thing. increasing the potential for errors. Errors of omission: failure to act. A systems approach to error recognises that adverse events rarely have a single isolated Errors of execution: doing the right thing incorrectly. cause and that they are best addressed by For most errors, the person approach on its own tends examining why the system failed rather than to blame the individual and restricts learning. who made the mistake. Even most of the individual potentially catastrophic events, eg.: retained instrument, wrong site surgeries, unchecked blood transfusion,…. Could be prevented by implementation of safer hospital system.  Heinrich’s pyramid It is important to report all near misses or adverse events so that we can constantly learn from mistakes. Error models can help us understand the factors that cause near misses and adverse events and also direct us to where our defences against harm need to be improved. Open communications with the patient Clinical risk management Proper staff communications Healthy working environment Surgical Check list Safe prescription Technical & operation errors  Open communications with the patient A patient-centred approach by medical staff, with involvement of patients and their carers as partners is now recognized as being of fundamental importance. There are better treatment outcomes and fewer errors when there is good communication while poor communication is a common reason for patients taking legal actions. Information to be provided when seeking consent for surgery.  Clinical risk management It is a specific task, based upon reporting risk identification, analysis and control of events, carried out within a ‘blame-free’ environment. Proper staff communications Good team work, good communication and continuity of care reduce errors and improve patient care. Healthy working environment Stress, tiredness and mental fatigue in the workplace are significant occupational health and safety risks in healthcare.  Surgical Check list Accepted as standard safety protocol. ✓ The use of a surgical safety checklist in 8 hospitals around the world was associated with a reduction in major complications from 11.0 % before, to 7.0 % after. ✓ The main aims are to overcome: wrong patient in the operating room; wrong side or site surgery; wrong procedure performed; failure to communicate changes in the patient’s condition; disagreements about proceeding; retained instruments or swabs.  Safe prescription ✓ Unfortunately, medication errors are common and their many causes include:  Technical & operation errors ✓ High surgical proficiency: It is a state of automatic unconscious processing, with the execution being effortless, intuitive and untiring. ✓ Nonproficient execution: Characterized by conscious control processing requiring constant attention and resulting in slow, deliberate execution and inducing fatigue. The transition from one state to the other is better known as the ‘learning curve’. ❖Failures in operative technique include: Cognitive errors of judgement: such as failure or late conversion of a difficult laparoscopic procedure into an open one. Procedural: when the steps of an operation are not followed, or omitted. Executional: for example, too much force is used which may result in damage. Misinterpretation: which is unique to minimal access surgery and is a function of the misreading of a two-dimensional image. Misuse of instrumentation: such as with energized dissection modalities, for example, diathermy. Missed iatrogenic injury: either at the time of surgery or diagnosed late. ❖A lot of national important strategies should be developed to maintain the patient safety and quality of health care, as: regulating and licensing of physicians and healthcare institutions; developing and adopting policies for patient safety and quality improvement; providing patient safety education programs; instituting national clinical audits; reporting (and learning from) adverse events; setting up agencies to resolve concerns about the practice of doctors by providing case and incident management services. So, Saudi Patient Safety Center was established in 2017. This is the 1st of its kind in the middle east. It is the main custodian of the patient safety strategies. BRAIN STORMING A 33-year-old male patient underwent open repair of right sided oblique inguinal hernia. The surgeon by mistake incised over the left inguinal canal. How to describe this surgical error? a) A near miss. b) No harm event. c) Never event. d) Non-preventable adverse event. BRAIN STORMING At which step of the surgical check list, the nurse should check the count of sponge and instruments? a) Sign In. b) Time out. c) Sign out. REFERENCES ✓ Bailey and Love’s Short Practice of Surgery 26th edition. Thank You