Introduction to Patient Safety

Dr. Shailendra.V.L.Patient Safety Department

Al Bukeriya general hospital

Outline

• Introduction to the concept of Patient Safety• Occurrence Variance Report (OVR)– Adverse Events– Near Miss– Sentinel Events

• International Patient Safety Goals

SECTION-I

INTRODUCTION TO THE CONCEPTOF

PATIENT SAFETY

Patients and Medical Errors

• Healthcare errors impact 1 in every 10 patients around the world (WHO)

• Institute of Medicine, USA found in a study:-– Medical errors injure 1 in 25 hospital patients– Kills about 44,000 to 98,000 every year– Medical errors costs USA billions of dollars each

year

Risk Comparison• Less than one death per 100,000 encounters– Commercial airlines– Nuclear power generation– Off shore oil rigs

• One death in 1,000 – 100,000 encounters:– Motor vehicle driving– Chemical manufacturing

• More than one death per 1,000 encounters– Bungee jumping– Mountain climbing– Health care

Why Errors?“To err is human”

• Not always willful negligence but systemic flaws• Inadequate communication• Wide-spread process variation• Patient ignorance

Every error has a root causeEvery cause has a solution

Errors can be prevented with every one’s participation in the system

Here comes the role of the patient safety department

Patient Safety

• Patient safety is a new healthcare discipline that emphasizes on – Reporting– analysis, and– prevention ofmedical errors that may leads to adverse patient

outcomes

Patient Safety• Goals of Patient Safety– Detection of safety issues– Preventive & corrective actions– Processes to reduce risks

• Broad Strategies– Self reporting (OVR)– Safety oriented Leadership Walk Rounds– Communication / education– MOH – Patient safety standards monitoring– Promoting patient safety culture

SECTION-II

OCCURRENCE VARIANCE REPORT (OVR)

Sources of Errors

1. Individual made: Errors due to human factor in the process e.g. wrong calculations of dosage

2. System made: Holes in the system that allow to slip through e.g. no clear, detailed policy, no double checking systems

3. Environment made: Hazards that come from the environment of the hospital e.g. emotions, dangerous medicines, radiation hazards

How to Make it Safer

• Acceptance, not denial• Identifying the causes of the medical errors

and patient harm• Finding solutions• Improving systems

Identifying the Causes

• Significant patient harm• Patient complaints• Colleagues reporting• Management trying to detect• Self Reporting i.e. OVR

Occurrence Variance Report (OVR)

• Self Reporting – corner stone of improvement– Voluntary reporting of process variation by all

health care workers– Non punitive – no punishments– To improve the quality of services– To prevent recurrence of same errors – To target system, not individuals

Types of Events

1. Adverse Event: Any variation in the processes leading to unsafe situations in everyday working life

2. Near Miss: An event or situation that could have resulted in patient harm but did not, either by chance or timely intervention

3. Sentinel Event: Unexpected incident involving death or serious physical or psychological injury or the risk thereof

Example

• An inpatient received 2 (two) unit of the incorrect type of blood at the time. The patient’s blood was drawn for a type/cross match, the sample was mislabeled with another patient's name. The transfusion was given to the patient whose name appeared on the type/cross match lab report, not the patient whose blood was in the lab specimen vial.

Examples of Reportable Events

• Eclampsia in booked patient• APGAR score less than 7 at 5 minutes• Unplanned blood transfusion• Wrong implant or prosthesis• Injury or unplanned repair or removal of an organ• Complications post ERCP• Complications post angiogram • Retinopathy of prematurity (ROP) needing laser

SECTION-III

INTERNATIONAL PATIENT SAFETY GOALS

International Patient Safety GoalsGoal 1: Identify patients correctlyGoal 2: Improve effective communicationGoal 3: Improve the safety of high-alert

medicationsGoal 4: Ensure correct-site, correct-procedure,

correct-patient surgeryGoal 5: Reduce the risk of health care–associated

infectionsGoal 6: Reduce the risk of patient harm resulting

from falls

Goal 1

• Identify Patients Correctly– Wrong-patient errors occur in virtually all aspects

of diagnosis and treatment – At least two patient identifiers• File number• Name

– Before• Administering medications, blood, or blood products • Taking blood and other specimens for clinical testing

Goal 2

• Improve Effective Communication– Verbal and telephone order or test result is• written down by the receiver• then read back by the receiver, and• confirmed by the giver

– Reporting back of critical test results and panic values

Goal 3

• Improve the Safety of High-alert Medications– Medicines with high risk of patient harm

– Policies to address the location, labeling, and storage of concentrated electrolytes

Goal 4

• Ensure Correct-site, Correct-procedure, Correct-patient Surgery– Mark surgical site identification and involve the

patient in the marking process

– Use time-out procedure before starting a surgical procedure

Goal 5

• Reduce the Risk of Health care–associated Infections– Implement an effective hand hygiene program

– Catheter associated infections

Goal 6

• Reduce the Risk of Patient Harm Resulting from Falls– Policies to reduce the risk of patient harm

resulting from falls – Implement initial assessment of patients for fall

risk and reassessment when indicated – Implement measures to reduce fall risk for those

assessed to be at risk

Conclusion

• Identification and prevention of patient harm

• Self reporting the events

• Adherence to the Six International Patient Safety Goals

THANK YOU