Patient safety summary .docx

**Lecture 1: Intro to Patient Safety** **Patient safety:** The absence / reduction of risk of any unnecessary harm to a patient during / associated with the process of healthcare to an acceptable minimum. There are more deaths annually as a result of healthcare than from road accidents, breast c...

**Lecture 1: Intro to Patient Safety** **Patient safety:** The absence / reduction of risk of any unnecessary harm to a patient during / associated with the process of healthcare to an acceptable minimum. There are more deaths annually as a result of healthcare than from road accidents, breast cancer and AIDS combined. **The 6 key dimensions of healthcare quality:** 1. Safe: Avoiding injuries to patients from the care that is intended to help them. 2. Effective: Providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit (avoiding underuse and overuse). And doing the right thing for the right person at the right time. 3. Timely: Reducing waits and sometimes unfavorable delays for both those who receive and those who give care. 4. Family centered: Providing care that is respectful of and responsive to individual patient preferences, needs and values, and ensuring that patient values guide all clinical decisions (participate in decision-making). 5. Efficient: Avoiding waste, in particular waste of equipment, supplies, ideas and energy. 6. 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:** All errors can be divided into two main groups 1. Active (human) errors (Direct): They are committed by frontline staff and tend to have direct patient consequences. 2. Latent or system errors (Indirect): are those 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. Most errors are not a result of human (personal) error or negligence (Active errors), but arise from system flaws or organizational failures (Latent errors). **Swiss Cheese Model of Accident Causation:** - This model shows how a fault in one layer of a system of care is usually not enough to cause an accident. - Adverse events usually occur when a number of faults occur in a number of layers. - the hole does not normally cause harm, because the other intact slices prevent hazards from reaching the potential victim. - Only when the holes in many layers quickly (momentarily) line up does the trajectory of accident opportunity reach the victim causing the damage. **Patient safety culture:** An integrated pattern of individual and organizational behavior, based on a system of shared beliefs and values, that determine the organization\'s commitment to quality and patient safety and continuously seeks to minimize patient harm that may result from the process of care delivery. 1. Blame Culture: we look for the individual; student, pharmacist, nurse or doctor who ordered, dispensed or administered the wrong drug and blame that person for the patient's condition care at the time of the incident and hold them accountable. 2. Just Culture: we look for the system defect such as communication, protocols and processes for medication management, in addition to investigating the negligence or recklessness of the worker. **Clinical Incident:** Is any unplanned event or circumstance resulting from health care which causes or has the potential to cause (lead to) unintended harm to a person, loss or damage , and/or a complaint (deviation from standard of care and safety). Healthcare providers are required to report all incidents, near misses, and complaints so that risks to patient safety are recognized and action is taken to prevent recurrence. **Types of Clinical incidents:** 1. Adverse events a. Sentinel Event: Is an unexpected occurrence of an event involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function. i. Example: hemolytic transfusion b. Adverse Drug Reaction: A response to a drug which is noxious and unintended, which occurs at dose normally used in man for the prophylaxis, diagnosis, or therapy of disease, or for the modifications of physiological function 2. Near miss: Is any situation that might have resulted in harm, but the problem did not reach the patient -but could have done- (so did not cause harm to patients) because of timely intervention by healthcare providers or the patient or family, or due to good fortune. **How to maintain safety in Clinical Incidents?** Adhere and follow the national Patient safety goals / Required Organization Practice (ROP) **Lecture 2: 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; it applies wherever humans work; also known as ergonomics. **Importance of human factors in healthcare:** 1. Human factors only recently acknowledged as an essential part of patient safety 2. A major contributor to adverse events in health care 3. All health-care workers need to have a basic understanding of human factors principles **Human factors:** 1. Acknowledge: The universal nature of human fallibility and the inevitability of error 2. Assumes: that all errors will occur 3. Designs: Designs things in the workplace to try to minimize the likelihood of error or its consequences **Range of workers:** Good human factors design in health care accommodates the entire range of workers not just the calm, rested experienced clinicians, but also the inexperienced health-care workers who might be stressed, fatigued and rushing **Examples of traps in health care?** 1. Look-alike and sound-alike medications 2. Equipment design complexity e.g. infusion pump **Human factors design principles** 1. Psychomotor: hands 2. Input devices: buttons 3. Output: display and sounds 4. Senses: vision and hearing Health-care workers are quite good at compensating for some of the complex and unclear design of some aspects of the workplace like the equipment and physical layout. **Error:** The failure of a planned action to achieve its intended outcome; A deviation between what was actually done and what should have been done **Error as defined by James Reason:** \'Doing the wrong thing when meaning to do the right thing.\' **Situations associated with an increased risk of error:** 1. Unfamiliarity with the task 2. Inexperience 3. Shortage of time 4. Inadequate checking 5. Poor procedures 6. Poor human equipment interface **Individual factors that predispose to errors:** Limited memory capacity A performance-shaping factors "checklist" **(I'M SAFE)** it stands for: **Putting knowledge of human factors into practice:** 1. Apply human factors thinking to your work environment 2. Avoid reliance on memory 3. Review and simplify processes 4. Standardize common processes and procedures 5. Routinely use checklists 6. Decrease reliance on vigilance **Lecture 3: Understanding Systems and Effect of Complexity of Patient Care** **System:** Any collection of two or more interacting parts; "an interdependent group of items forming a unified whole". **Complex system:** Involves many interacting parts that it is difficult, if not Impossible, to predict the behavior of the system based on knowledge of its component parts; The delivery of health care fits this definition of a complex system. **Health services**: Health services present as a system---buildings, people, processes, desks, equipment, unless the people involved understand the common purpose and aim, the system will not operate in a unified fashion. People are the glue that binds and maintains the system. **Why is Healthcare Complex?** 1. Diversity of patients, clinicians and other staff 2. Dependency of Health-care providers on one another 3. Diversity of tasks 4. Huge number of relationships 5. Vulnerability of patients 6. Variations in the physical layout 7. Variability or lack of regulations 8. Implementation of new technology in healthcare 9. Diversity of care pathways 10. Increased specialization of Health-care professionals **A systems approach:** requires us to look at health care 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. **The traditional approach to problems:** This approach is to blame and shame the health-care professionals most directly involved in caring for the patient at the time of an adverse event or error. **Why is the traditional approach to problems not accepted?** 1. Health-care professionals do not deliberately (Intentionally) harm a patient (deliberate action is called a violation). 2. A health-care professional involved in an adverse event /error can accidentally be destroyed and become the "second victim". 3. Health-care professionals are hesitant to report incidents/errors if they will be blamed and become the second victim. 4. Operating in a culture of blame, a health-care organization will have great difficulty in learning from errors and thus decreasing the chance of future adverse incidents. 5. A systems approach emphasizes the importance of understanding the underlying factors that caused an adverse event without diminishing the responsibilities or accountability of health professionals. In all cultures, individual health professionals are required to be accountable for their actions and to maintain competence and practice ethically. **Accountability is a professional obligation.** **Why Accountability is important for Health Professionals?** 1. To demonstrate professional behavior to the public and colleagues 2. To ensure they are working in their scope of practice 3. To liable what action they are taken to provide care to the public 4. To follow the organizational policy **System thinking approach:** 1. Patient factors 2. Provider factors 3. Task factors 4. Technology and tools factors 5. Team factors 6. Organizational factors 7. Environmental factors **Reason's defense:** Successive layers of protection that are designed to guard against the failure. **High Reliability Organization (HRO):** Refers to organizations that operate under hazardous conditions, but manage to function in a way that is almost completely "failure-free". **Some examples of HROs include:** 1. Air traffic control systems. 2. Nuclear power plants. 3. Naval aircraft carriers. **Characteristics of HROs:** 1. Preoccupation with failure: Acknowledge and plan for the possibility of failure due to the high-risk, error- prone nature of their activities. 2. Sensitivity to operations: Pay close attention to the issues facing workers at the frontline. 3. Commitment to resilience: Proactively seek out unexpected threats and contain them before they cause harm. 4. Establishing and maintaining a culture of safety: Individuals feel comfortable drawing attention to potential hazards or actual failures without fear of criticism. **Key Principles from HRO theory:** 1. Maintain a powerful and uniform culture of safety 2. Use optimal structures and procedures 3. Provide intensive and continuous training of individuals and teams 4. Conduct thorough organizational learning and safety management. **Lecture 4: Being effective team player** **Team:** A team is a group of two or more individuals (have limited lifespan of membership) who: 1. Have a common goal/ objective/mission 2. Have been assigned for specific tasks 3. Possess specialized and complementary skill 4. Interact dynamically **Why teamwork is an essential element of patient safety ?** 1. The increased incidence of complexity and specialization of care 2. Increasing co-morbidities and incidence chronic disease 3. Global workforce shortages 4. Initiatives for safe working hours **What are the benefits of working as a team ?** 1. **Organizational benefits:** a. Reduced hospitalization time and costs b. Reduced unanticipated admissions c. Better accessibility for patients 2. **Team benefits:** d. Improved coordination of care e. Efficient use of healthcare services f. Enhanced communication & professional diversity 3. **Patient benefits:** g. Enhanced satisfaction with care h. Acceptance of treatment i. Improved health outcomes & quality of care j. Reduced medical errors 4. **Benefits to team members:** k. Enhanced job satisfaction l. Greater role clarity m. Enhanced wellbeing **Teams Found in Healthcare:** 1. **Core Teams:** a. Core teams consist of team leaders and members who are directly involved in caring for the patient. b. Include direct care providers such as nurses, pharmacists, doctors, dentists, assistants and, of course, the patient. 2. **Coordinating Teams:** c. Is the group responsible for day-to-day operational management, coordination functions and resource management for core teams. d. Nurses often fill such coordinating. 3. **Contingency Teams:** e. Contingency teams are formed for emergent or specific events f. (e.g. cardiac arrest teams disaster response teams, rapid response e teams) 4. **Ancillary Services** g. Ancillary service teams consist of individuals who provide direct, task-specific, time-limited care to patients or support services that facilitate patient care. h. Such as radiologist, pharmacist, and so on. 5. **Support Services:** i. Support services teams consist of individuals who provide indirect, task-specific services in a health-care facility j. Such as Transportation team, security team, cleaners' team. 6. **Administration:** k. Administration includes the executive leadership of a unit or facility and has 24-hour accountability for the overall function and management of the organization. **Stages of Team Development:** 1. **Forming stage:** a. Initial stage when the team is formed and the members are coming together for the first time. b. best candidates should be selected to form a dynamic team, but flexibility should be adopted in selection process. c. The skills of the members should match the team task & goals. d. Voluntary team membership seems to work best when given as a choice. 2. **Storming stage:** e. Each member tends to rely on his/her own experience. f. Resistance to work together openly. g. Hesitate to express new ideas and opinions. h. Interpersonal disagreement and conflicts. i. Personal goals rather than team goal 3. **Norming stage:** j. Start to know each other. k. Start to accept each other's ideas and opinions. l. Understand the strengths and weaknesses of the team. m. Members become friendly to each other. n. Work together to overcome personal disagreement. o. Share responsibilities and help each other. 4. **Performing stage:** p. Members are satisfied with the team progress. q. Members are capable to deal with any task based on their strength and weaknesses. r. Work together to achieve the team goals. **How to Move from Storming to Norming Stage?** 1. Team members should be introduced to each other in more details. 2. Responsibilities must be assigned accordingly. 3. Clear communication. 4. Social activities. 5. Roles should be in rotation. 6. Everyone should be treated equally. **Characteristics Of Successful Teams:** 1. Measurable Goals: a. Teams set goals that are measurable and focused on the team's task. 2. Mutual Respect: b. Effective teams have members who respect each other's talents and beliefs, in addition to their professional contributions. 3. Common Purpose: c. Team members generate a common and clearly defined purpose that includes collective interests and demonstrates shared ownership. 4. Good Cohesion: d. Cohesive teams have a unique and identifiable team spirit and commitment and have greater longevity as team members want to continue working together. 5. Effective Leadership: e. Teams require effective leadership that set and maintain structures, manages conflict, listens to members and trusts and supports members. f. Effective leadership is a key characteristic of an effective team. 6. Effective Communication: g. SBAR - ↠ Situation: What is going on with the patient? - ↠ Background: What is the clinical background or context? - ↠ Assessment: What do I think the problem is? - ↠ Recommendation: What would I do to correct it? a. Call-out and Check- back strategies. **Challenges to Effective Teamwork:** 1. Changing Roles: In many healthcare environments there is considerable change and overlap in the roles played by different healthcare professionals. 2. Changing Settings: The nature of healthcare is changing in many ways, including increased delivery of care for chronic conditions in community care settings and the transfer of many surgical procedures to outpatient centers. 3. Healthcare Hierarchies: Healthcare is strongly hierarchical in nature, which can be counterproductive to well-functioning and effective teams where all members' views should be considered. 4. Individualistic Nature of Healthcare: Many healthcare professions, such as nursing, dentistry and medicine, are based on the autonomous one-to-one relationship between the provider and patient. **Lecture 5: Learning From Errors To Prevent Harm** **Error:** Non-deliberate deviation from what was intended: When someone is trying to do the right thing, but actually does the wrong thing. **Errors may occur through:** 1. Commission: doing the wrong thing 2. Violations: errors caused by a deliberate deviation from an accepted protocol or standard of care. 3. Omissions: failing to do the right thing. **Errors and outcomes:** - A patient may have a bad outcome without human error - Some errors do not result in bad outcomes - Near miss: an incident that did not cause harm. - Hindsight bias: the nature of the outcome influences perception of the error. **Culture of infallibility:** medical culture often denies the prevalence of error. **Errors occur as a result of two main types of failure:** 1. Errors of Execution: actions do not go as intended a. Slip: if this action is observable (e.g. accidently pressing wrong button.) b. Lapse: if it is not (e.g. forgetting to administer a medication.) 2. Mistakes: failing of planning c. Rule based: a "wrong" rule is applied. (e.g. wrong diagnosis leads to wrong treatment plan.) d. Knowledge based: the clinician does not know the correct course of action. (e.g. in new situations.) **Situations That Increase the Risk of Error:** 1. Unfamiliarity with a task a. Students/ junior doctors performing a procedure for the first time b. Should be practiced on an educational aid. c. If performed on a patient, must be closely supervised. 2. Shortage of time d. Might result in cutting corners and taking shortcuts (e.g. not washing hands properly) 3. Inadequate checking e. Proper checking techniques ensure patients receive the correct medications. 4. Poor procedures f. Inadequate preparation (sterilization, equipment); E.g dispenses heparin instead of insulin g. Inadequate staffing. h. Inadequate attention to the particular patient. **Individual Factors That Predispose to Error** 1. Limited Memory Capacity 2. Fatigue 3. Stress, hunger, illness 4. Language or cultural factors: Communication errors caused by language and cultural factors; Many patient--doctor interactions occur without an interpreter or understanding of the language. 5. Hazardous attitudes: E.g. being more interested in practicing or getting experience than having concern for the patient's well-being. **Incident reporting:** - Collecting and analyzing information about any event that harmed or could have harmed a patient. - An incident-reporting system allows the health organization to identify and eliminate "error traps". - Organizations with a strong reporting culture learn from errors because staff report problems without fear of ridicule or reprimand. - Successful reporting strategies: 1. Anonymous reporting. 2. Timely feedback. 3. Open acknowledgement of successes resulting from reporting. **Root cause analysis:** - A highly structured system approach to incident analysis that is generally reserved for the most serious patient harm episodes. - Goal is to evaluate, analyze and develop system improvements for the most serious adverse events. - Triages the reported incidents to ensure those indicating the most serious risk to the organization are dealt with first. - Prevention- not blame or punishment. - Systems level vulnerabilities, not individual performance. - Multiple factors: communication, training, fatigue, scheduling, rostering, environment, equipment, rules, policies and barriers. **Defining characteristics of Root cause analysis:** 1. Review by an interprofessional team knowledgeable about the processes involved in the event. 2. Analysis of systems and processes rather than individual performance. 3. Deep analysis using "what" and "why" probes until all aspects of the process are reviewed and contributing factors are considered. 4. Identification of potential improvements that could be made in systems or processes to improve performance and reduce the likelihood of such adverse events or close calls in the future **What is the most cause of medical errors?** Miscommunication **Health:** Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. **Practice Strategies to Reduce Errors:** 1. Know yourself (eat well, sleep well and look after yourself). 2. Know your environment and know your task(s). 3. Preparation and planning (What if\...). 4. Build checks into the routine and Ask if you do not know 5. Assume that errors will be made. Be prepared for them. 6. Identify those circumstances that most likely lead to errors.. 7. Have contingencies in place to cope with problems, interruptions and distractions. 8. Always mentally rehearse complex procedures or if it is the first time you are doing an activity involving a patient. **Lecture 6: Understanding & Managing Clinical Risk** Risk management is routine in most industries and has traditionally been associated with limiting litigation costs. Hazard: is any activity, situation or, substance that potential to cause harm, including ill health, injury, loss of product and/or damage to patient and property. Risk: is the probability that harm (illness or injury) will actually occur. Risk Management: Organizational effort to identify, assess, control and evaluate the risk to reduce harm to patient, visitors and staff and protect the organization from financial loss. Purpose of Risk Management: 1. Improve organizational and client safety 2. Identify and minimize the risks and liability losses 3. Protect the organization resources 4. Support regulatory, accreditation compliance 5. Creating and maintaining safe systems of care, designed to reduce adverse events and improve human performance