Introduction To Patient Safety Lecture 1 PDF

Introduction To Patient Safety Patient Safety Lecture no. 1 COLOR INDEX Main Text Important Male Slides Female Slides Dr’s Notes Extra Recognize the magnitude and the importance of patient safety Define and describe the key elements of healthcare quality Summarize the differences between error and...

Introduction To Patient Safety Patient Safety Lecture no. 1 COLOR INDEX Main Text Important Male Slides Female Slides Dr’s Notes Extra Recognize the magnitude and the importance of patient safety Define and describe the key elements of healthcare quality Summarize the differences between error and harm Recognizing characteristics of a just culture Understand & differentiate between the different types of clinical incidence Describe several specific behaviors you can practice to foster a culture of safety in your workplace Outline: ⋗ Introduction and defining patient safety ⋗ The key dimensions of healthcare quality ⋗ Harm Versus error ⋗ Sources of System Error ⋗ Patient safety culture ⋗ Types of clinical incident ⋗ Seven levels of safety ⋗ The physician’s role in patient safety ⋗ Case scenario This lecture was presented by Dr. Sara Abou AlSaud For the required reading from Blackboard click here Patient Safety Definition The absence / reduction of risk of any unnecessary harm to a patient during / associated with the process of healthcare to an acceptable minimum. (WHO, World Alliance for Patient Safety 2009) ○ Significant numbers of patients are harmed due to their healthcare provider, either resulting in permanent injury, increased length of stay (LOS) in healthcare facilities, or even death. ○ 1,000,000 injuries/year U.S. hospitals. ○ 44,000 – 98,000 deaths caused by medical error/year. ○ There are more deaths annually as a result of healthcare than from road accidents, breast cancer and AIDS combined. Why Is It a Problem? “Numbers are not important” Hospital / Country Years in which data was collected Number of hospital admissions Number of adverse event Adverse event rate (%) US (Harvard Medical Practice Study) 1984 30195 1133 3.8 % Australian (Quality in Australian healthcare study) 1992 14179 2353 16.6 % UK 1999-2000 1014 119 11.7 % Denmark 1998 1097 176 9% KKUH 2014 47211 2950 6.2 % Source: World Health Organization. Executive board 109th session, provisional agenda item 3,4,5, 2001,EB 109/9. A worldwide problem to be highlighted and avoided. Key Elements of Professionalism The 6 key dimensions of healthcare quality Nm. Element 1 Safe Definition Avoiding injuries to patients from the care that is intended to help them. 2 Effective ○ Providing services based on scientific knowledge - don't give information based on posts you see in TikTok :) - to all who could benefit and refraining from providing services to those not likely to benefit (avoiding underuse and overuse). ○ 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). e.g. when the husband says: I want my wife to be delivered by a female doctor, not a male. you should respect that and respect patient religion & preference. 5 Efficient 6 Equal Avoiding waste, in particular waste of equipment, supplies, ideas and energy. e.g. don’t request tests for a patient who does not need them Providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location and socio-economic status. Error in Medicine ○ Errors in healthcare can be caused by ‘“active failures’’ or ‘‘latent conditions’’ ○ Most errors are not a result of human (personal) error or negligence (Active errors), but arise from system flaws or organizational failures (Latent errors). Sources of system errors: All errors can be divided into two main groups Active (human) errors (Direct): They are committed by frontline staff and tend to have direct patient consequences. 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. Example: ○ Giving the wrong medication ○ Treating the wrong patient or the wrong anatomical site ○ Not following the correct policies & procedures Example: ○ Understaffed wards ○ Inadequate equipment ○ Insurance paperwork. Swiss Cheese Model of Accident Causation It is a theoretical model that illustrates how accidents could occur in organizations. The systems has many holes some from active (human) failures and others from latent (system) conditions. It proposes that the typical accident occurs because several (human) errors that occur at all levels in the organization in a way that made such accident unavoidable. These holes are continuously opening, shutting, and shifting their location. In any one slice, the hole does not normally cause harm, because the other intact slices prevent hazards from reaching the potential victim. For example, a patient's late by its own does not lead to harm. 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 Definition 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. If a patient is found to have received the wrong medication and suffered a subsequent allergic reaction, there will be two types of response to this mistake: 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. Useless because other people will do the same mistake Just Culture we look for the system defect such as communication, protocols and processes for medication management, in addition to investigate the negligence or recklessness of the worker. We see why this mistake happened and deal with & improve it. In this way, other people will not fall into the same mistake Clinical Incident Definition ○ 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. Examples: Medication errors (e.g. wrong medication omission, overdose) Problems with blood products Patient falls Documentation errors Intended self harm or suicidal behaviour Delayed diagnosis Therapeutic equipment failure Surgical operation complications Contaminated food Hospital acquired infection Types of clinical incident Adverse Event Sentinel Event Adverse Drug Reaction ○ 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. ○ Example: hemolytic transfusion reaction involving administration of blood or blood products having major blood group incompatibilities 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 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. ○ Example: patient was going to take a drug that he was allergic to, but for any intervention, he didn’t take it so no harm occurred. Clinical Incident cont… How to Maintain Safety in Clinical Incident? Adhere and follow the national Patient safety goals / Required Organization Practice (ROP) Adverse reporting Client/patient verification Medication reconciliation Control of concentrated electrolytes Dangerous abbreviations High-alert medications Hand hygiene Falls prevention strategy Infusion pumps training Safe injection practices Pressure ulcer prevention Safe surgical practices Preventive maintenance program Transfer of client information at transition points Antibiotic prophylaxis during surgery Venous thromboembolism prophylaxis Case Study A 38-year-old woman comes to the hospital with 20min of itchy red rash and facial swelling; she has a history of serious allergic reactions. A nurse draws up 10mls of 1:10,000 adrenaline (epinephrine) into a 10ml syringe and leaves it at the bedside ready to use (1mg in total) just in case the doctor requests it. Meanwhile the doctor inserts an intravenous cannula, the doctor sees the 10ml syringe of clear fluid that the nurse has drawn up and assumes it is normal saline. There is no communication between the doctor and the nurse at this time. The doctor gives all 10 mls of adrenaline (epinephrine) through the intravenous cannula thinking he is using normal saline to flush the line. The patient suddenly feels terrible, anxious becomes tachycardia and then becomes unconscious with no pulse. She is discovered to be in ventricular tachycardia, is resuscitated and fortunately makes a good recovery. (Recommended dose of adrenaline (epinephrine) in anaphylaxis is 0.3-0.5mg IM, this patient received 1mg IV) Can you identify the contributing factors to this error? 1 Lack of communication 2 Inadequate labeling of syringe 3 Lack of care with a 4 Giving a substance without checking potent medication and double checking what it is Conclusion ◎ Patient safety is the avoidance, prevention and amelioration of harm from healthcare provider ◎ Two approaches to the problem of human fallibility exist: - The human (person) approach: focuses on the errors of individuals, blaming them - The system approach: concentrates on the conditions under which individuals work ◎ Some errors cause harm but many do not ◎ Blaming and then punishing individuals is not an effective approach for improving safety within the system ◎ Adverse events often occur because of system breakdowns ◎ Standardizing & simplifying clinical processes is a powerful way of improving patient safety MCQs Q1. What is the definition of patient safety? A. Reducing hospital admissions B. Providing healthcare based on scientific knowledge C. Avoiding harm to patients during healthcare processes D. Enhancing patient satisfaction and comfort Q2. Which of the following is NOT a key element of healthcare quality? A. Safe B. Timely C. Efficient D. Collaborative Q3. What are the two main categories of system errors in healthcare? A. Active errors and latent errors B. Medical errors and nursing errors C. Human errors and equipment errors D. Diagnostic errors and treatment errors Q4. The Swiss Cheese Model of Accident Causation suggests that its holes occur due to: A. Human errors only B. Latent errors only C. Lack of safety protocols D. Both A & B Q5. The administration of wrong blood type during a blood transfusion to a patient, falls under which category of clinical incident? A. Near miss B. Sentinel event C. Adverse reaction D. hospital acquired infection Q6. In patient safety terminology, a near miss refers to: A. A medical error that results in harm to the patient B. An incident that causes inconvenience to the patient C. A situation where harm was narrowly avoided D. A routine healthcare procedure that was successfully completed A1. C A2. D A3. A A4. D A5. B A6. C For Anki cards click here Team Leaders Aroub Almahmoud Remaz Almahmoud Lama Almutairi Team Members Farah Abukhalaf Nazmi M Alqutub Aljoharah Alkhalifah Areej Alquraini Aleen Alkulyah Moath Alhudaif Aryam Almsari Rahaf Alshowihi Mohammed Alqutub Sarah Alshahrani Aishah Boureggah Raghad Alqhatani Sultan Albaqami Lama Alotaibi Lama Alrushid Sarah Alajaji Haya Alzeer Faris Alzahrani [email protected]