contents
Introduction to Patient Safety
Types of Error
Goal One, Two and Three
Goal Four, Five and Six
Patient Safety 1
Introduction to Patient Safety
ELECTIVE COURSE
PRESENTED BY
DR. MENNATALLAH SAID HOSNEY
LECTURER OF PUBLIC HEALTH AND
COMMUNITY MEDICINE
CAIRO UNIVERSITY
Content
1. ILOs for the course
2. History of Patient Safety
3. Patient Safety importance.
4. Burden of unsafe care.
5. Definitions.
ILOs
Acknowledge the importance of patient safety.
Understand the international patient safety goals.
Describe the nature of error and how health-care
providers can learn from errors to improve patient
safety.
Identify basics of infection prevention & control in
health-care settings.
Understand medication safety.
Acknowledge proper communication.
History of Patient Safety
1995 Harvard Medical Practice Study results
published
1998 To Err Is Human, Institute of Medicine
2000 An Organization with a Memory
2002: 55th World Health Assembly
Resolution
2004: Launch of the World Alliance for
Patient Safety
2005: Launch of the first Global Patient
Safety Challenge
Importance of PS
Patient safety is a serious global public health
issue.
One in 10 patients may be harmed while in
the hospital.
Hospital infections affect 14 out of every 100
patients admitted.
Importance of PS
Most people lack access to appropriate
medical devices.
Unsafe injections.
Health spending is wasted due to poor-
quality care.
Importance of PS
For patient and community engagement and
empowerment.
Healthcare has a poor safety record
compared to other industries.
Patients safety among vulnerable group (pregnant
women and newborns)
Burden of Unsafe Care
Burden of Unsafe Care
Burden of Unsafe Care
Burden of Unsafe Care
Definitions
Error
The failure of a planned action to be completed as
intended or use of a wrong inappropriate, or
incorrect plan to achieve an aim.
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
Near miss
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 come forward, no
one may ever know it occurred.
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.
Patient safety
The avoidance, prevention, and amelioration of
adverse outcomes or injuries stemming from the
processes of health care.
These events include “errors,” “deviations,” and
“accidents.” Safety emerges from the interaction of
the components of the system;
Patient safety
it does not reside in a person, device, or department.
Improving safety depends on learning how safety
emerges from the interactions of the components.
Patient safety is a subset of health care quality
Safety culture
A culture that exhibits the following five high-level
traits that health care professionals struggle 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
Patient Safety 2
Types of Error
ELECTIVE COURSE
PRESENTED BY
DR. MENNATALLAH SAID HOSNEY
LECTURER OF PUBLIC HEALTH AND
COMMUNITY MEDICINE
CAIRO UNIVERSITY
Introduction
What is the difference between error and violation by
definition?
Introduction
Error: the failure of a planned action to be completed
as intended or use of a wrong inappropriate, or
incorrect plan to achieve an aim.
Violation: A deliberate deviation from an accepted
protocol or standard of care.
Types of Error
Types of Error
1. Actions do not go as intended: is a so-called
error of execution and may be further described as
being either a slip, if the action is observable, or a
lapse, if it is not.
An example of a slip is accidentally pushing the
wrong button on a piece of equipment.
An example of a lapse is a memory failure, such as
forgetting to administer a medication.
Types of Error
2. The intended action is the wrong one: a
failure that occurs when the intended action is
actually incorrect is clearly a ‘mistake’. A mistake is
a failure of planning. This can be either:
Rule-based, when the wrong rule is applied,
Or knowledge-based, when a clinician does not take
the correct course of action.
Types of Error
An example of a rule-based mistake would be getting
the diagnosis wrong and so embarking on an
inappropriate treatment plan.
Knowledge-based mistakes tend to occur when
providers are confronted with unfamiliar clinical
situations.
Situations Associated with increased Risk of
Error
What do you think ?
Situations Associated with increased Risk of Error
Poor Inexperience
procedures
Time Inadequate
Pressures information
Inadequate Emergency
checking
Individual Factors that Predispose Health-care
Providers to Errors
Limited memory capacity
Fatigue
Stress, hunger and illness
Language
Hazardous attitude
Individual factors that predispose health-care
providers to errors
There are many mnemonic strategies to help health-
care providers monitor themselves.
HALT: Hungry, Angry, Late or
Tired
IM SAFE: Illness, Medication,
Stress, Alcohol, Fatigue, Emotion
Individual factors that predispose health-care
providers to errors
Individual factors that predispose health-care
providers to errors
Ways to Learn from Errors
How do you think system can learn from errors?
Ways to Learn from Errors
Incident reporting
Root Cause analysis
Incident Reporting
Incident reporting and monitoring involve collecting
and analyzing information about an adverse event
that could have harmed or did harm a patient in a
clinical setting.
Incident Reporting
For successful reporting the following should be
applied:
Anonymous reporting (use of electronic anonymous
systems)
Timely feedback to prevent same errors.
Root Cause Analysis
Root Cause Analysis is a structured systemic
approach to incident analysis.
The most common tool is fishbone
Fish Bone Tool
It is used to provide a graphic display of a list in
which you identify and organize possible causes of
problems, or factors needed to ensure success of
some effort.
Fish Bone Tool
Patient Safety 3
Goal One, Two and Three
ELECTIVE COURSE
PRESENTED BY
DR. MENNATALLAH SAID HOSNEY
LECTURER OF PUBLIC HEALTH AND
COMMUNITY MEDICINE
CAIRO UNIVERSITY
What is IPSG
They are a group of goals to:
(1) promote specific improvements in patient safety
(2)Highlight problematic areas in health care
(3)Describe evidence-and expert-based consensus
solutions to these problems
IPSGs
IPSGs
1. Identify Patients Correctly
2. Improve Effective Communication
3. Improve the Safety of High-Alert Medications
4. Ensure Correct-Site, Correct-Procedure, Correct-
Patient Surgery
5. Reduce the Risk of Health Care-Associated
Infections
6. Reduce the Risk of Patient Harm Resulting from
Falls
IPSG.1Identify Patients Correctly
The hospital should establish a process to accurately
identify patients.
Using two unique patient identifiers for example full
name and medical record number or hospital
number etc., the identifiers shouldn’t include
patient’s room or location
IPSG.1Identify Patients Correctly
This should be applied:
Before administering medications, blood, or blood
products
Before taking blood and other specimens for clinical
testing
Before providing treatments and procedures
Policies and procedures should support consistent
practice.
IPSG.1Identify Patients Correctly
IPSG.1Identify Patients Correctly
IPSG.2Improve Effective Communication
The hospital should establish a process to improve
the effectiveness of communication among
Healthcare workers. This entails the following:
Verbal and telephone order
Reporting critical results of diagnostic tests.
Handover communication.
IPSG.2Improve Effective Communication
Read Back as a tool to improve communication in
healthcare setting:
Read-back includes documenting the information
and reading what was documented back to the
sender.
Read-back is vital for telephone orders and critical
lab values.
IPSG.2Improve Effective Communication
Read Back :
For example:
Sender initiates using receiver’s name
Receiver acknowledges with “I understand…” (… and
repeats the message precise)
Sender acknowledges with “that’s correct”
IPSG.2Improve Effective Communication
Read Back :
IPSG.2Improve Effective Communication
ISBAR:
A standardized approach to patient care handover.
I= Introduction
S=Situation
B= Background
A=Assessment
R= Recommendation
IPSG.2Improve Effective Communication
ISBAR:
IPSG.2Improve Effective Communication
ISBAR:
IPSG.3Improve the Safety of High-Alert
Medications
High-Alert Medications are
Medications involved in a high percentage of errors
and/or sentinel events
Medications that carry a higher risk for adverse
outcomes
Look-alike/sound-alike medications
IPSG.3Improve the Safety of High-Alert Medications
Policies and/or procedures should be developed to
address the identification, location, labeling,
and storage of high-alert medications.
The policies and/or procedures are implemented.
IPSG.3Improve the Safety of High-Alert Medications
Concentrated electrolytes are not present in
patient care units unless clinically necessary.
Concentrated electrolytes that are stored in patient
care units are clearly labeled and stored in manner
that restricted areas.
Patient Safety 4
Goal Four, Five and Six
ELECTIVE COURSE
PRESENTED BY
DR. MENNATALLAH SAID HOSNEY
LECTURER OF PUBLIC HEALTH AND
COMMUNITY MEDICINE
CAIRO UNIVERSITY
IPSGs
IPSG.4Ensure Correct-Site, Correct-Procedure,
Correct-Patient Surgery
Uses an instantly recognized mark for surgical-site
identification and involves the patient in the marking
process.
IPSG.4Ensure Correct-Site, Correct-Procedure,
Correct-Patient Surgery
Uses a checklist or other process to verify
preoperatively the correct site, correct procedure,
and correct patient and that all documents and
equipment needed are on hand, correct, and
functional.
IPSG.4Ensure Correct-Site, Correct-Procedure,
Correct-Patient Surgery
The full surgical team conducts and documents a
time-out procedure just before starting a surgical
procedure.
IPSG.4Ensure Correct-Site, Correct-Procedure,
Correct-Patient Surgery
Policies and procedures are developed that support
uniform process to ensure the correct site, correct
procedure, and correct patient, including medical
and dental procedures done in settings other than
the operating theatre.
IPSG.4Ensure Correct-Site, Correct-Procedure,
Correct-Patient Surgery
IPSG.5Reduce the Risk of Health Care-
Associated Infections
The organization has adopted or adapted currently
published and generally accepted hand-hygiene
guidelines.
The organization implements an effective hand-
hygiene program.
IPSG.5Reduce the Risk of Health Care-
Associated Infections
Policies and/or procedures are developed that
support continued reduction of health care-
associated infections.
IPSG.5Reduce the Risk of Health Care-
Associated Infections
IPSG.5Reduce the Risk of Health Care-
Associated Infections
Wash hands with soap and water when hands are
visibly soiled.
Use alcohol-based hand rub when hands are not
visibly soiled.
IPSG.5Reduce the Risk of Health Care-
Associated Infections
IPSG.6Reduce the Risk of Patient Harm
Resulting from Falls
IPSG.6Reduce the Risk of Patient Harm
Resulting from Falls
Implements a process for the initial assessment of
patients for fall risk.
Reassessment of patients when indicated by a
change in condition or medications, among others.
IPSG.6Reduce the Risk of Patient Harm
Resulting from Falls
IPSG.6Reduce the Risk of Patient Harm
Resulting from Falls
Measures are implemented to reduce fall risk for
those assessed to be at risk.
Measured are monitored for results, both successful
fall injury reduction and any unintended related
consequences.