Topic 1
What is patient safety?
Moustafa Abdelnasser
Professor of Microbiology & Immunology
Faculty of Medicine, Al-Azhar University
Diploma of TQM, Master of Health Profession
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Education
Learning objective
• Understand the discipline of patient safety.
• Introduce the history of patient safety.
• List patient safety goals.
• Clarify its role in minimizing the incidence
and impact of adverse events.
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Learning objective
• Apply patient safety thinking in all clinical
activities
• Recognize the role of patient safety in safe
healthcare delivery.
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What is Patient Safety?
• Patient Safety is a health care discipline
that emerged with the evolving complexity
in health care systems and the resulting
rise of patient harm in health care facilities.
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What is Patient Safety?
• It aims to prevent and reduce risks, errors
and harm that occur to patients during
provision of health care.
• A cornerstone of the discipline is
continuous improvement based on
learning from errors and adverse events.
• Patient safety is fundamental to delivering
quality essential health services.
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To realize the benefits of quality health care,
health services must be
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IOM's Six Quality Aims For Healthcare
To ensure successful implementation of
patient safety strategies; are all needed:
• clear policies
• leadership capacity
• data to drive safety,
• skilled health care professionals and
• effective involvement of patients in their
care.
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Harm caused by health-care
errors and system failures
We should know what is the:
• extent of adverse events
• categories of adverse events
• economic costs
• human costs
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History of patient safety and
origins of the blame culture
• Why do we blame?
• Person approach
• System approach
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Person approach
(Blame culture)
• The way we have traditionally managed
failures and mistakes in health care has
been called the person approach.
• We single out the individuals directly
involved in the patient care at the time of
the incident and hold them accountable.
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System approach
(No Blame- “Just” culture)
• Just (Fair) culture adopt a no blame
approach that focuses on the system that
led to the error rather than on the
individual.
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Swiss cheese model
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A model of patient safety
(healthcare system is divided into four main domains)
1. Those who work in health care.
2. Those who receive health care or have a
stake in its availability.
3. The infrastructure of systems for
therapeutic interventions (health-care
delivery processes).
4. The methods for feedback and continuous
improvement.
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Core Aspects of Safety Culture
Schein E. Organizational culture and leadership, 4th edition. San
Francisco, CA: Jossey-Bass; 2010.
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Knowledge & Expertise
Patients Clinicians
• experience of illness • diagnosis disease
• social circumstances • etiology
• attitude to risk • prognosis
• values • treatment options
• preferences • outcome
probabilities
Coulter A Picker Institute 2001
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Students should:
• understand the multiple factors involved in
failures
• avoid blaming
• practise evidenced-based care
• maintain continuity of care for patients
• be aware of the importance of self-care
• act ethically everyday
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SOURCES OF LEARNING
-WHO Patient Safety/Curriculum Guide for Medical Schools 2009
-Egyptian Neonatal safety training network standards for NICU at
www.egyneosafety.net and www.researchgate.com
https://www.researchgate.net/publication/322831357_Egyptian_Neonatal_Safet
y_Standards
-Egyptian Neonatal safety training network ;scientific content of the physician
course at www.egyneosafety.net and www.researchgate.com
• https://www.researchgate.net/publication/322831567_NICU_Patient_Safety
_Course_Scientific_Content
- WHO patient safety solutions. www.who.int/patientsafety/solutions/en/.
- The web site www.webmm.ahrq.gov has case archives that can be used for
potential case studies that may be helpful in your teaching.
- Institute for Safe Medication Practices at www.ismp.org.
-National Patient Safety Agency at www.npsa.nhs.uk.
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Books
-Vicente K. The human factor. London, Routledge,
2004:195–229.
-Cooper N, Forrest K, Cramp P. Essential guide to
generic skills. Blackwell Publishing, 2006.
-Institute of Medicine. Preventing medication
errors: quality chasm series. Washington, DC,
National Academy Press, 2006
(http://www.iom.edu/?id=35961).
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