Patients Safety.pdf

PATIENTS SAFETY  Introduction and defining patient safety The key dimensions of healthcare quality Harm Versus error Outline Sources of System Error Patient safety culture Types of clinical incident Seven levels of safety...

PATIENTS SAFETY  Introduction and defining patient safety The key dimensions of healthcare quality Harm Versus error Outline Sources of System Error Patient safety culture Types of clinical incident Seven levels of safety The physician’s role in patient safety Case scenario  Objectives After completing this lecture you should: 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 Differentiate between the different types of clinical incidence Describe several specific behaviors you can practice to foster a culture of safety in your workplace Defining patient safety The reduction of risk of unnecessary harm associated with health care to an acceptable minimum. (WHO, World Alliance for Patient Safety 2009).  Introduction Significant numbers of patients are harmed due to their health care, either resulting in permanent injury, increased length of stay (LOS) in health-care facilities, or even death. 44 – 98,000 deaths annually caused by medical error. There are more deaths annually as a result of health care than from road accidents, breast cancer and AIDS combined. Defining patient safety- https://www.youtub Video e.com/watch? v=BJP2rvBchnE Why is it a problem? Source: World Health Organization. Executive board 109th session, provisional agenda item3,4,5, 2001,EB 109/9  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 (avoiding underuse and overuse). Doing the right thing for the right person at the right time.  The 6 key dimensions of healthcare quality 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, and ensuring that patient values guide all clinical decisions.  The 6 key dimensions of healthcare quality 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  INTERNATIONAL PATIENT SAFETY GOALS Identify patients Improve Effective correctly Communication Eliminate Wrong-site, Improve The safety of Time Wrong-patient, Wrong High-ALERT Medication Out procedure surgery Reduce The Risk of Reduce The Risk of Health Care - Assocated Patient Harm Resulting Infections from Falls  All errors can be divided into two main groups: Active errors or human error are committed by frontline staff and tend to have direct patient consequences. Sources –Example, giving the wrong medication, treating the wrong patient or the wrong of System anatomical site, or not following the correct policies and procedures. Error Latent or system errors 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 : understaffed wards or inadequate equipment.  Errors in health care can be caused by ‘‘active failures’’ or Error in ‘‘latent conditions.’’ medicine Most errors are not a result of personal error or negligence, but arise from system flaws or organizational failures "Swiss cheese" model of accident causation  "Swiss cheese" model of accident causation The systems have many holes: some from active failures and others from latent conditions. These holes are continuously opening, shutting, and shifting their location. In any one slice, they do not normally cause harm, because the other intact slices prevent hazards from reaching the potential victim. Only when the holes in many layers momentarily line up does the trajectory of accident opportunity reach the victim causing the damage  Definition of patient safety culture An integrated pattern of individual and organizational behavior, based on a system of shared beliefs and values, that continuously seeks to minimize patient harm that may result from the process of care delivery.  Patient safety culture If a patient is found to have received the wrong medication and suffered a subsequent allergic reaction, 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 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  Definition: A clinical incident is an event or circumstance resulting from health care which could have, or did lead to unintended harm to a person, loss or The damage, and/or a complaint. (deviation from standard of care and safety ) concept of Examples: Medication errors (e.G. Wrong medication, omission, overdose); Clinical Patient falls; Intended self harm or suicidal behaviour; incident Therapeutic equipment failure; Contaminated food; Problems with blood products; Documentation errors; Delayed diagnosis; Surgical operation complications; Hospital acquired infection; Types of Clinical incident  Types of Clinical incident Sentinel events: A sentinel event is an unexpected occurrence 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  Types of Clinical incident Near miss: Is any situations that did not cause harm to patients (that did not reach the patient) , but could have done.  Types of Clinical incident Adverse Drug Reaction: A response to a drug which is noxious and unintended, and which occurs at doses normally used in man for the prophylaxis,diagnosis, or therapy of disease, or for the modifications of physiological function'.( WHO,1972)  Adverse reporting Client verification Medication reconciliation How to maintain Dangerous abbreviations Transfer of client information at transition points safety in clinical Control of concentrated electrolytes Infusion pumps training incident ? High-alert medications Adhere and follow the National Hand hygiene Patient Safety Goals/ Antibiotic prophylaxis during surgery ROP(Required Organization Falls prevention strategy Practice ) Pressure ulcer prevention Venous thromboembolism prophylaxis Safe injection practices Safe surgical practices Preventive maintenance program  CASE STUDY  Case Study A 38-year-old woman comes to the hospital with 20 minutes of itchy red rash and facial swelling; she has a history of serious allergic reactions A nurse draws up 10 mls of 1:10,000 adrenaline (epinephrine) into a 10 ml syringe and leaves it at the bedside ready to use (1 mg in total) just in case the doctor requests it Meanwhile the doctor inserts an intravenous cannula The doctor sees the 10 ml syringe of clear fluid that the nurse has drawn up and assumes it is normal saline  Continue…. 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 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 - 0.5 mg IM, this patient received 1mg IV  Continue…. Can you identify the contributing factors for this error?  Continue…. Can you identify the contributing factors for this error? Lack of communication Inadequate labeling of syringe Giving a substance without checking and double checking what it is Lack of care with a potent medication  Patient safety is the avoidance, prevention and amelioration of harm from healthcare. Two approaches to the problem of human fallibility exist: –The person approach focuses on the errors of individuals, blaming them –The system approach concentrates on the Conclusion 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 and simplifying clinical processes is a powerful way of improving patient safety THANK YOU