Patient safety

Dr. Mohamed Mosaad Hasan

MD, CPHQ, MPH, CPPS, GBSS

Patient Safety Definition

• “ The reduction and mitigation of unsafe acts within the health-care system, as well as through the use of best practices shown to lead to optimal patient outcomes.”

• Essentially, patient safety is about constantly working to avoid, manage and treat unsafe acts within the health care system.

Definitions

Patient safety practice is a type of process or

structure whose application reduces the probability of

adverse events resulting from exposure to healthcare

system.

Mistake-proofing is the use of process or design

features to prevent errors or the negative impact of

errors.

Evolving Issues

Taxonomy – how we categorize and group different

patient safety events.

Nomenclature – using a common and universally

accepted language

Patient Safety

Patient Safety Terms

Adverse Event

Medical Error

Sentinel event

Near Miss

Retrospective Analysis

Prospective Analysis

Identifying risks and processes before they happen

Bad outcome from care

Major and enduring loss of function

An examination of past events

Deficient process of care

Could have resulted in loss, injury or illness, but did not

Patient Safety: Challenges and

Concerns

Difficulty recognizing errors

Lack of information systems to identify errors

Relationship of trust with providers

Shortages of clinical professionals

Concern about liability

Limited capacity on how to use quality

improvement tools such as PDSA

Culture of patient safety is lacking

Some Reasons Why Errors Occur

System Factors

Complexity of healthcare processes

Complexity of health care work environments

Lack of consistent administration practices

Deferred maintenance

Clumsy technology

Human Factors

Limited knowledge

Poor application of knowledge

Fatigue

Sub-optimal teamwork

Attention distraction

Inadequate training

Reliance on memory

Poor handwriting

Not Who caused the accident but

What caused the accident?

“ We cannot change the human condition, but

we can change the conditions under which

human works.” (Reason 2000)

Adoption of this paradigm by leaders is the

beginning for culture change.

Trigger

s

DEFENSES

Accident

Regulatory

Narrowness

Incomplete

Procedure

s

Mixed

Messages

Production

Pressures

Responsibility

Shifting

Inadequate

Training

Attention

Distraction

s

Deferred

Maintenanc

eClumsy

Technology LATENT

FAILURES

Goal Conflicts

and Double

Binds

The

World

The “Swiss Cheese” Theory

of System Error

After J. Reason

Patient receives wrong

medication, and has a respiratory

arrest

Different medications stored in look alike bags

Nurse staff

shortage

No warning labels on dangerous medications

Nurse

prepares to

administer

a

medication

Unanticipated

increase in

patient

volume/severity

Patient Safety

Active Failures

highly visible errors with immediate consequences

Latent Failures

may be hidden for years and generally rooted in

organizational culture

takes the right set of circumstances for the error to

become visible or known

The Anatomy of Errors in Healthcare

Blunt End of the System

Sharp end

of the

System

Organizational Factors -

culture, policies,

procedures, regulations

Environmental Factors -

equipment, staffing,

resources, constraints

Human Factors - clinical

competency, communication

skills, problem solving skills

Culture of Safety

Indicate the extent to which you agree with following statements. Scoring: strongly disagree, neutral, agree, strongly agree.

A. Senior management provides a climate that promotes patient safety

B. If people find out that I made a mistake, I will be disciplined.

C. My supervisor/manager says a good word when he/she sees a job done according to established patient safety procedures

D. Discussion around major events focuses mainly on systems-related issues, rather than focusing on the individual(s) most responsible for the event.

Important issues facing healthcare

organizations.

Establishing culture of patient safety and just

culture.

Identifying organizational champions.

Deploying patient safety strategies.

Adoption of safety-related technologies.

Just culture

Balancing safety and accountability.

The single greatest impediment to error

prevention in the medical industry “that we

punish people for the medical mistakes”.

Just culture

3 basics:

1. It doesn’t reduce the personal accountability and

discipline. It emphasizes the learning from the errors

and near misses to reduce errors in the future.

2. The greatest error not to report a mistake. Thereby

prevent learning.

3. All in the organization to serve as safety advocates.

Both providers and consumers will feel safe and

supported when they report medical errors, near

misses and voice concerns about patient safety.

It has zero tolerance for reckless behavior.

Behaviors

Human error – inadvertent action: doing other than what should

have been done.

Manage through change in processes, procedures and training.

At risk behavior: behavioral choice that increase risk where risk

is not recognized or is believed to be justified.

Manage through increase awareness, and providing incentives

for healthy behaviors and disincentives for risky behaviors.

Reckless behavior: consciously disregard substantial and

unjustifiable risk.

Manage through Remedial and punitive action.

Red rules

cannot be broken

few in number

easy to remember

associated only with processes that can cause

serious harm to employees, customers, or the

product line.

must be followed exactly as specified except in rare

or urgent situations.

Every worker, regardless of rank or experience in the

company, is expected to stop the work or production

line if the red rule is violated.

Learning Organization

A learning healthcare system “is designed to

generate and apply the best evidence for the

collaborative healthcare choices of each

patient and provider; to drive the process of

discovery as a natural outgrowth of patient

care; and to ensure innovation, Quality,

Safety, and value in healthcare”IOM Roundtable on EBM

Patient Safety

Highly Reliable Organizations

Risk auditing: monitoring of activities to identify both expected and unexpected risks

Appropriate reward systems that encourage safety-related behavior

System quality standards

Acknowledgment of risk to learn from error

Flexible management model to promote teamwork and communication

Responsibilities of Governing

body to enhance patient safety

Setting aims

Getting data

Establishing and monitoring system-level

measures.

Change the environment, policies and

cultures.

Learning.

Establish executive accountability.

More Definitions

Never events: As defined by the National Quality

Forum, these are preventable events considered so

harmful that they should never occur. Also called

serious reportable events (SREs), they include

most medication errors as well as instances of

performing surgery on the wrong body part or the

wrong patient.

Complications of care: Healthcare-associated

complications, including infections that patients

develop while in the hospital, are thought to be

largely preventable.

Patient Safety

Communication and Teamwork Challenges

Healthcare is traditionally hierarchical

Personal communication styles of staff

Lack of common language – led to development of

SBAR

Addressed with other patient safety initiatives

Simulation training

Rapid Response Teams (RRT)

Walkroundstm

Patients participating on committees/RCAs

Patient Safety

Miscommunication: Breakdowns in

communication can result in the wrong

treatment, a lack of treatment, or incorrect

self-care by the patient. Miscommunication

can be the result of faulty systems (poor

methods of reporting critical test results, for

example); lack of attention to the health

literacy of patients; or a lack of cultural

competency on the part of the healthcare

team.

Disclosure

Implement a formal (transparent) policy

and process of disclosure of adverse

events to patients/families, including

support mechanisms for patients, family,

and care/service providers

Patient Safety: Disclosure

Reasons to Disclose

Right thing to do

Patients expect it

Professional responsibility

Earn trust/possibly forgiveness of patient

Supports patient safety initiatives

Required by The Joint Commission for

unanticipated outcomes

Patient Safety: Disclosure

Personnel Barriers to Disclosure

Fear of legal liability

Fear of loss of credibility and reputation

Fear of loss of licensure

Fear of punishment by organization or loss of job

Feelings of vulnerability

Difficulty in accepting role in error

Patient Safety: Disclosure

System Barriers to Disclosure

We’ve always done it this way

Hierarchical structure of medicine

Profession demands perfection

Struggle with accepting even most well trained and

competent can make mistakes

Conflict of Interest

Patient Safety: Disclosure

Michael Woods 4R’s

Recognition

Regret

Responsibility

Remedy

Patient Safety

Human Factors

Simplification

Standardization

Use of constraints and forcing functions

Reduce reliance on memory and vigilance

Use of protocols and checklists

Avoid or reduce fatigue

Heighten awareness of error prevention through

communication and training

Patient Safety

Mistake Proofing

Knowledge in the Head

Knowledge in the Environment

Patient Safety

Technology to Improve Patient Safety

CPOE

Barcoding

Robotics

Electronic medical records

International Patient Safety Goals

International Patient Safety Goals

Goal 1 Identify Patients Correctly

Goal 2 Improve Effective Communication

Goal 3 Improve the Safety of High-AlertMedications

Goal 4 Ensure Correct-Site, Correct-Procedure, Correct-Patient Surgery

Goal 5 Reduce the Risk of Health Care-Associated Infections

Goal 6 Reduce the Risk of Patient HarmResulting from Falls

Goal 1: Identify Patients Correctly

Rationale:

Wrong-patient errors occur in virtually all

aspects of diagnosis & treatment.

The intent for this goal is two-fold:

First, to reliably identify the individual as the

person for whom the service or treatment is

intended;

Second, to match the service or treatment to

that individual.

Requirement

Use at least two patient identifiers whenever

collecting laboratory samples or

administrating medications or blood products.

Acceptable identifiers may be the individual’s

name, an assigned identification number,

telephone number, photograph or other

person-specific identifier. (e.g. birth date)

Requirement

Prior to the start of any invasive procedure,

conduct a final verification process, (such as

a “time out”) to confirm the correct patient,

procedure and communication techniques.

Problems associated with surgical safety in

developed countries account for half of the

avoidable adverse events that result in death

or disability

Goal 2: Improve Effective

Communication

Rationale:

Ineffective communication is the most

frequent cited category of root causes of

sentinel events. Effective communication,

which is timely, accurate, complete,

unambiguous, and understood by the

recipient, reduces error and results in

improved patient/client/resident safety.

Requirement

Simply repeating back the order or test result

is not sufficient. Whenever possible, the

receiver of the order or test result enter it into

a computer, then read it back, and receive

confirmation from the individual who gave the

order or test result.

Requirement

“Critical test results” are defined by the

individual health care organization and will

typically include “stat” test, “panic value”

reports, and other diagnostic test results that

require urgent response.

Requirement

o Requirement: Standardize a list of

abbreviations, acronyms, symbols, and dose

designations that are not be used throughout

the organization.

Requirement

Implement a standardized approach to “hand

off” communications, including an

opportunity to ask and respond to questions.

Requirement

Measure, assess, and if appropriate, take action

to improve the timeliness of reporting, and

the timeliness of receipt by the responsible

licensed caregiver, of critical tests and critical

results and values.

Requirement

Reconcile Medications: Accurately and

completely reconcile medications across the

continuum of care.

Reconcile Medications

o Requirement: A complete list of the patient’smedications is communicated to the next provider ofservice when a patient is referred or transferred toanother setting, service, practitioner or level of carewithin or outside the organization. The complete listof medications is also provided to the patient ondischarge from the facility

Communication in Patient Care

Is not:

- Yelling

- Accusatory (angry)

- Being respectful of authority

Is:

- Focused on patient

- Nothing your perceptions

- Persistently raising concerns, intended tomove toward desired action

SBAR

A structured communication technique

designed to convey a great deal of

information in an organized & brief manner.

This is important as we all have different

styles of communicating, varying by

profession, culture, and gender.

SBAR

Situation

A concise statement of the problem

What is going on now

Background

Pertinent and brief information related to the situation

What has happened

Assessment

Analysis and considerations of options

What you found/think is going on

Recommendation

Request/recommend action

What you want done

SBA

R

Example SBAR briefing

55 YO Man with HTN, admitted for GI Bleed –

received 2 units, last hematocrite 31

VS: BP 90/50, Pulse 120

Looking pale, sweaty

Feels confused and weak, some problem with

heavy chest

Example SBAR briefing

Situation: Dr. Jones, I have a 55 Y/O Man who looks

pale, sweaty and is complaining of chest pressure.

• Background: He has a history of HTN, admitted for GI

Bleed received 2 units, last crit two hours ago was 31

vital signs are: BP 90/50, Pulse 120

• Assessment: I think he’s got an active bleed and we

can’t rule out an MI but we don’t have a troponin or a

recent H&H.

• Recommendation: I’d like to get an EKG and labs and

I need for you to evaluate him in right away.

Goal 3: Improve the Safety of High-

Alert Medications

Implementation Expectation

Remove concentrated electrolytes (including,

but not limited to, potassium chloride,

potassium phosphate, Nacl~0.9%) from

patient care units.

Standardize & limit the number of drug

concentrations available in the organization.

Requirement

o Identify and, at a minimum, annually review alist of look-alike/sound-alike drugs used bythe organization, and

take action to prevent errors involving theinterchange of these drugs.

Requirement

Label all medications, medication containers

(for example, syringes, medicine cups,

basins) or other solutions on and off the

sterile field.

Goal 4: Ensure Correct-Site, Correct-

Procedure, Correct-Patient Surgery

Rationale

Wrong-site, wrong-patient, wrong-procedure

surgery can be prevented if appropriate

processes are in place.

The intent is to establish and implement

processes to always identify the correct site,

correct person and correct procedure.

Implementation Expectation

The requirement is for a “preoperative

verification process”. The checklist is an

example of one approach-the most common

one.

The intent of the requirement is to ensure that

all of the relevant documents are available

prior to the start of the procedure & that they

have been reviewed & consistent with each

other & with staffs’ understanding of the

intended site, patient, & procedure.

Goal 5: Reduce the Risk of Health

Care-Associated Infections

Rationale

At any given time, 1.4 million people worldwide suffer

from infections acquired in hospitals.

The risk of health care-associated infection in some

developing countries is as much as 20 times higher

than in developed countries.

Compliance with the CDC hand hygiene guidelines

will reduce the transmission of infectious agents by

staff to patients/clients/residents thereby decreasing

the incidence of healthcare associated infections.

Goal 6: Reduce the Risk of Patient

Harm Resulting from Falls

Rationale

Falls account for a significant portion ofinjuries in hospitalized patients, long-termcare residents, and home care recipients. Inthe context of the population it serves, theservices it provides, and its environment ofcare, the organization should assess, itspatient risk for falls and take action to reducethe risk of falling and to reduce the risk ofinjury, if a fall occur.

Implementation Expectation

As appropriate to the population served, the

services provided, and the environment of

care, a fall reduction program may include

risk assessment and periodic re-assessment

of individual patients or of the environment of

care.

Implementation Expectation

The program should include risk reduction

strategies involving patients/families in

education and environment of care redesign.

The program should also include

development and implementation of transfer

protocols (e.g., bed-to-chair), when relevant.

Question

The most important procedure to prevent

hospital acquired infection is :

1 . Using gloves

2 . Hand washing

3 . Wearing protective gowns

4 . All of the above

5 . None of the above

Question

For inpatient identification all of the

following Can be used except for :

1 . Patient room number

2 . Patient medical ID

3 . Patient full name

4 . Patient national ID

5 . None of the above