Topic – Principles of Patients Safety

PRINCIPLES OF PATIENT’S SAFETY

BASIC HEALTH SKILLS

(GRU1251)

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 Topic – Principles of Patients Safety

Objectives
By the end of this lecture you will be able to:

 Identify the major principles of patients safety in healthcare settings.

 Differentiate between different terms related to patient safety such as Adverse Event and errors,
near miss,...

 Identify and discuss the WHO 10 facts of patient safety.

 Identify and discuss the WHO 7 goals of patient safety.

 Discuss the adverse event reporting policy within healthcare settings.

 Identify the principles of risk management and its role in preventing , minimizing, and managing
adverse and medical errors.

 Apply patient safety thinking in all clinical activities

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 Topic – Principles of Patients Safety

Learning Outcomes
 Demonstrate ability to recognize the role of patient safety in
safe health-care delivery
 Understand the principles of patient safety

 Understand the role of risk management in minimizing the incidence

and impact of adverse events, and maximizing patients recovery
from them.

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 Topic – Principles of Patients Safety

Introduction
• Everyday a large number of patients are treated and
cared for without incident by health care practitioners
worldwide.

• Like other high risk industries, safety incidents occur

during the course of medical care placing patients at risk
for injury or harm.

• Over the past ten years, patient safety has been

increasingly recognized as an issue of global importance,
but much work remains to be done.

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 Topic – Principles of Patients Safety

Introduction
 Patient safety is a fundamental principle of health care.

 Every point in the process of care-giving contains a

certain degree of inherent unsafety.

 Adverse events may result from problems in practice,

products, procedures or systems.

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Patient safety improvements demand a complex system-wide
effort involving a wide range of actions in:
 performance improvement
 environmental safety
 risk management including:
-infection control
-safe use of medicines
-equipment safety
-safe clinical practice

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 Topic – Principles of Patients Safety

Patient Safety

• Requires a commitment from YOU!

• Patients’ expectations have changed …

• They want to know that they are safe.
• They want to know that you are their
advocate.
• They want to know your “practice” is safe.

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 Topic – Principles of Patients Safety

Definitions
Patient safety:
 is the absence of preventable harm to a patient
during the process of health care.
 Patient safety include the coordinated efforts to
prevent harm, caused by the process of health care
itself, from occurring to patients.

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 Topic – Principles of Patients Safety

Definitions
 Error
• the failure of a planned action to be completed as intended (i.e.,
error of execution)
• OR the use of a wrong plan to achieve an aim (i.e., error of
planning)
• Medication-related errors occur frequently in hospitals
 Adverse event :
 An injury that was caused by medical management or complication
instead of the underlying disease and that resulted in prolonged
hospitalization or disability at the time of discharge from medical
care, or both

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 Topic – Principles of Patients Safety

Factors that contribute to adverse patient events could be

categorized as:
 diagnostic (Error or delay in diagnosis, failure to employ
indicated tests, Use of outmoded tests or therapy, Failure to
act on results of monitoring or testing)
 Treatment (Error in the performance of an operation,
procedure, or test, error in administering the treatment, error
in the dose or method of using a drug)
 Preventive (Failure to provide prophylactic treatment,
Inadequate monitoring or follow-up of treatment)
https://www.nap.edu

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 Topic – Principles of Patients Safety

 Negligent adverse event

the care provided failed to meet the standard of care
reasonably expected of an average physician qualified to
take care of the patient.

 Near miss
The situations that did not cause harm to patients, but could have
done.
 An event that almost happened or an event that did happen but
no one knows about.
 If the person involved in the near miss does not report, no one
may ever know it occurred.
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 Topic – Principles of Patients Safety

Slips
Action conducted is not what was intended
• EXAMPLE: physician chooses an appropriate medication,
writes 10 mg when the intention was to write 1 mg

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 Topic – Principles of Patients Safety

Causation of harms
 Individuals made
 Errors that are done due the human factor in the process.
 (mix up , wrong calculations , not following the 5 or 7 rights in medication
administration)
 System made
 Holes in the system that allow errors to slip through
 (no clear and detailed policy and procedures, no double checking system, no
warning signs)
 Environmental made
 The dangers that come from the setting of the hospital and the material and
equipment used inside it ( no exit doors , warn out cables and cords )

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 Topic – Principles of Patients Safety

Medication and medical Errors

• Leading cause of harm in hospitals in developed countries

• About one patient in 10 is harmed
 About a third are preventable
• One medication error per patient per day
 Most don’t result in harm

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 Topic – Principles of Patients Safety

10 FACTS ON PATIENT SAFETY

FACT 1
Patient safety is a serious global public health issue. In recent years, countries have
increasingly recognized the importance of improving patient safety. In 2002, WHO
Member States agreed on a World Health Assembly resolution on patient safety.
FACT 2
Estimates show that in developed countries as many as one in 10 patients is harmed
while receiving hospital care. The harm can be caused by a range of errors or adverse
events.
FACT 3
In developing countries, the probability of patients being harmed in hospitals is higher than
in industrialized nations. The risk of health care-associated infection in some
developing countries is as much as 20 times higher than in developed countries.
FACT 4
At any given time, 1.4 million people worldwide suffer from infections acquired in hospitals.
Hand hygiene is the most essential measure for reducing health care-associated
infection and the development of antimicrobial resistance.

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10 FACTS ON PATIENT SAFETY

FACT 5
At least 50% of medical equipment in developing countries is unusable or only partly
usable. Often the equipment is not used due to lack of skills or commodities. As a
result, diagnostic procedures or treatments cannot be performed. This leads to
substandard or hazardous diagnosis or treatment that can pose a threat to the safety of
patients and may result in serious injury or death.
FACT 6
In some countries, the proportion of injections given with syringes or needles reused
without sterilization is as high as 70%. This exposes millions of people to infections.
Each year, unsafe injections cause 1.3 million deaths, primarily due to transmission of
blood-borne pathogens such as hepatitis B virus, hepatitis C virus and HIV.
FACT 7
Surgery is one of the most complex health interventions to deliver. More than 100 million
people require surgical treatment every year for different medical reasons. Problems
associated with surgical safety in developed countries account for half of the avoidable
adverse events that result in death or disability.

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 Topic – Principles of Patients Safety

10 FACTS ON PATIENT SAFETY

FACT 8
The economic benefits of improving patient safety are compelling. Studies show that
additional hospitalization, litigation (lawsuits) costs, infections acquired in hospitals, lost
income, disability and medical expenses have cost some countries between US$ 6
billion and US$ 29 billion a year.
FACT 9
Industries with a perceived higher risk such as aviation and nuclear plants have a much
better safety record than health care. There is a one in 1 000 000 chance of a traveler
being harmed while in an aircraft. In comparison, there is a one in 300 chance of a
patient being harmed during health care.
FACT 10
Patients' experience and their health are at the heart of the patient safety movement. The
World Alliance for Patient Safety is working with 40 champions – who have in the past
suffered due to lack of patient safety measures – to help make health care safer
worldwide.

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 Topic – Principles of Patients Safety

How is patient safety cared for in hospitals?

Protecting the patient from case prognoses.

 This is done by making the right diagnoses and formulating the
correct treatment plan and making the needed intervention as quick
as possible

Protecting the patient from medical errors.

 This is done by setting a clear and unified departmental manual
of policies and procedures that comply with international standards
and patient safety guidelines for medical practices and make sure
that every one fallow's it.

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How is patient safety cared for in hospitals?

Protecting the patient from the physical surrounding.

 That is done by making sure that the patient is placed in a safe
place and free from any harmful matter that might cause harm to the
patient.

 The patients consciousness level must be monitored to prevent any

possible danger of falling down for patients during sleep. Precautions
like putting side rails & decreasing bed height must be taken.

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 Topic – Principles of Patients Safety

International Patient Safety Goals

• GOAL (1) Identify Patients Correctly
• GOAL (2) Improve Effective Communication
• GOAL (3) Improve the Safety of High-alert medications
• 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 Harm Resulting from fall
• GOAL (7) Improve the Safety of Using Infusion Pump

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 Topic – Principles of Patients Safety

International Patient Safety Goals

GOAL (1) Identify Patients Correctly

 Two Identifiers
1- Patient Name
2- Hospital Identification Number

(PATIENT ROOM CANNOT BE USED AS AN IDENTIFIER)

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International Patient Safety Goals

 GOAL (1) Identify Patients Correctly

Two positive identifiers whenever performing a procedure/ treatments

such as:
 Medication administration
 Transfusion of blood/blood products
 Taking blood samples and other specimens for clinical testing
 Prior to any transport outside the ward/unit

Failure to correctly identify the patients lead to:

 Medication error
 Transfusion error
 Testing error
 Wrong person procedure

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International Patient Safety Goals

GOAL (2) Improve Effective Communication

Effective reporting back of Critical Results

 Policy and/or procedure for verbal and telephone orders

 Clear communication among nurses during endorsement.

 Documentation (for all healthcare workers):

o Clear and legible hand writing.
o Date, time, signature for each entry.

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 Topic – Principles of Patients Safety

International Patient Safety Goals

GOAL (2) Improve Effective Communication

TELEPHONE ORDER VERBAL ORDER

 WRITE DOWN THE ENTIRE

 REPEAT BACK
ORDER
 START THE ORDER
 READ BACK
 SIGN AFTER SITUATION IS
 WITNESS
OVER OR BEFORE PHYSICIAN
 SIGN WITHIN 24 HOURS
LEAVE THE AREA

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 Topic – Principles of Patients Safety

International Patient Safety Goals

GOAL (3) Improve the safety of high alert medications
• DRUGS THAT BEAR A HIGHTENED RISK CAUSING SIGNIFICANT PATIENT
HARM WHEN USED IN ERROR

 TOP FIVE HIGH ALERT MEDICATIONS ARE:

1. Insulin
2. Narcotics.
3. Injectable potassium chloride concentrated
4. Intravenous anticoagulant
5. Sodium chloride solutions above 0.9 %

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 Topic – Principles of Patients Safety

International Patient Safety Goals

GOAL (3) Improve the safety of high alert medications
• Follow the 7 RIGHTS of medication administration every time:

1. RIGHT PATIENT
2. RIGHT MEDICATION
3. RIGHT TIME
4. RIGHT ROUTE
5. RIGHT DOSAGE
6. RIGHT FREQUENCY
7. RIGHT DOCUMENATION

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 Topic – Principles of Patients Safety

These should be every where

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 Topic – Principles of Patients Safety

International Patient Safety Goals

GOAL (4) Ensure Correct –Site, Correct Procedure, Correct
Patient Surgery

• Policies and procedures are developed that will support uniform processes
to ensure the correct site, correct procedure, and correct patient.

These errors are the result of

 ineffective or inadequate communication
 lack of patient involvement in site marking
 lack of procedures for verifying the operative site.
 a culture that does not support open communication among surgical team
members.

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 Topic – Principles of Patients Safety

International Patient Safety Goals

 GOAL (4) Ensure Correct –Site, Correct Procedure, Correct Patient Surgery
• UNIVERSAL PROTOCOL FOR WRONG SITE, PROCEDURE, AND SURGERY
PREVENTION:

 MARKING THE SURGICAL SITE

 A PRE – OPERATIVE VERIFICATION PROCESS

 A TIME – OUT THAT IS HELD IMMEDIATELY BEFORE THE START OF A

PROCEDURE

(The pause before surgery begins is known as "time out" and is intended to make
everyone slow down for a few moments and double check what they are about to
do.)

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 Topic – Principles of Patients Safety

International Patient Safety Goals

GOAL (5) Reduce the Risk of Health Care associated
Infections

 EFFECTIVE HAND – HYGIENE

 COMPLY WITH THE CURRENT PUBLISHED & GENERAL ACCEPTED HAND –

HYGIENE GUIDELINES

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 Topic – Principles of Patients Safety

International Patient Safety Goals

GOAL (6) Reduce the Risk of Patient Harm
Resulting from fall

 INITIAL ASSESSMENT OF PATIENT FALL RISK &

REASSESSMENT OF PATIENT WHEN INDICATED BY A
CHANGE IN CONDITION OR MEDICATIONS

 Document and report your observations and your

interventions

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 Topic – Principles of Patients Safety

Clinical risk management

Risk management is the identification, assessment, and prioritization of risks followed by

coordinated and economical application of resources to minimize, monitor, and control the
probability and/or impact of unfortunate events.

• In easy words clinical risk

management is identifying the
Safety cycle
risk factors and sources of
harm that might cause a
threat to patient safety in a
health service setting and
working on reducing and
eliminating them

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Incident reporting
 Incident reporting and monitoring involve collecting and analysing information about
an adverse event that could have harmed or did harm a patient in a clinical setting.
 An incident-reporting system is a fundamental component of an organization’s ability
to learn from error. The lessons learned through the use of these procedures allow the
organization to identify and eliminate errors
 Organizations or hospitals with a strong reporting culture are well placed to learn
from errors because the staff members feel free to report problems without fear of
reprimand.

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 Topic – Principles of Patients Safety

Incident reporting
Strategies for incident reporting include
 Anonymous reporting of near misses
 Timely feedback by leadership on actions to prevent same
errors
 Public acknowledgment of successes of organization’s reporting
in lowering adverse events and errors
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The optimum goal

Safety culture
 A culture that exhibits the following five high-level attributes that health
care professionals strive to operationalize through the implementation of
strong safety management systems.

1. A culture where all workers (including front-line staff, physicians, and

administrators) accept responsibility or the safety of themselves, their
coworkers, patients, and visitors.
2. A culture that prioritizes safety above financial and operational
goals.
3. A culture that encourages and rewards the identification,
communication, and resolution of safety issues.
4. A culture that provides for organizational learning from accidents.
5. A culture that provides appropriate resources, structure, and
accountability to maintain effective safety systems.

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 Topic – Principles of Patients Safety

Some tips to avoid Health care errors:

 Avoid reliance on memory

 Simplify
 Standardize
 Use constraints and forcing functions
 Use protocols & checklists wisely
 Improve information access
 Reduce handoffs
 Increase feedback

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Please always remember

• Learn basic patient safety skills and

techniques to prevent harm to
patients

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References
 (JCIA – 4th Edition, 2011).

 http://patientsafety.wusm.wustl.edu

 http://www.who.int/topics/patient_safety/en/

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