Patient Safety

WHAT IS SAFETY

S – Sense the error

A – Act to prevent it
F – Follow Safety Guidelines
 E – Enquire into accidents/Deaths
T – Take appropriate remedial measure
Y – Your responsibility
 WHY SAFETY IN THE HOSPITAL

 Hospital is a people intensive place

 Provide services to sick people round the clock 24 hours daily 365 days a
year.

 People have a free access to enter any part of the hospital any time for
advice and treatment

 The hospital atmosphere is filled with emotions, excitement, life &

happiness, death & sorrow

 Since hospital operates under continuous strain, it gives rise to

irritation, confrontation, conflicts & aggression, threatening the life of
hospital staff & hospital properties
 WHO’S SAFETY

SAFETY OF PLACE
SAFETY OF PROPERTY
SAFETY OF PEOPLE
 PATIENT SAFETY

Patient safety is the absence of preventable harm to a

patient during the process of health care.
The discipline of patient safety is the coordinated
efforts to prevent harm to patients, caused by the
process of health care itself.
It is generally agreed upon that the meaning of
patient safety is…“Please do no harm”
 CURRENT ENVIRONMENT

Errors and system failures repeated

Action on known risks is very slow
Detection systems in their infancy
Many events not reported
Understanding of causes limited
Few examples of successful scale up
Limited measurement of impact
Blame culture 'alive and well'
Defensiveness and secrecy
 WHO’S ERROR

66% - Accidents caused entirely by patient.

16% - Accidents due to error by hospital staff.
14% - Accidents staff and patient both equally
responsible.
 4% - Accidents due to physical, mechanical or
electrical errors
 WHY ERROR

-In most cases fault is not willful negligence, but

systemic flaws, inadequate communication and
wide-spread process variation and patient ignorance.
People responsible are the doctors, nurses,
pharmacists, technicians and Patient
 TYPES OF ERRORS

 Adverse Health Care Event – event or omission arising during

clinical care and causing physical or psychological injury to a patient
 Error – failure to complete a planned action as intended, or the use of
an incorrect plan of action to achieve a given plan
 Adverse Drug Reaction – any response to a drug which is noxious,
unintended and occurs at doses used for prophylaxis, diagnosis or
therapy1 Predictable Unpredictable
 Medication Error – any preventable event that may cause or lead to
inappropriate medication use or patient harm while the medication is in
the control of health professional, patient or consumer
 Sentinel error- Surgery on the w r o n g b o d y p a r t
Patients receiving the w r o n g m e d i c a t i o n
 Humane error “Human beings make mistakes because the systems,
tasks and processes they work in are poorly designed
 PATIENT SAFETY GOAL

Improve the accuracy of patient identification.

Improve the effectiveness of communication among
caregivers.
Improve the safety of using medications.
Reduce the risk of healthcare associated infections.
Accurately and completely reconcile medications across
the continuum of care.
Reduce the risk of patient harm resulting from falls
Special emphasis on, Dangerous abbreviations, infection
control, “Look alike and sound-alike” medications, time
outs.
 PRINCIPLE OF PATIENT SAFETY

Proper identification of patient

Matching to their care elements
Prevention of patient hand over error
Safety during transition
Assessing medical accuracy while giving care to a
patient
Performance of correct procedure at correct body
site
Take appropriate precautionary measures to avoid
infection
 TYPES OF SAFETY

Environment
Medical
Surgical safety
Equipment patient safety
Electrical safety
Installation safety sanitation
Blood safety
Infection control
Laboratory safety
 WORK ENVIRONMENT SAFETY

There is a direct link between work environment and

patient safety
Therefore, if not addressing work environment, we are
not addressing patient safety
Healthy work environments do not just happen
Therefore, if we do not have a formal program in place
addressing work environment issues, little will change
Creating healthy work environments requires
changing long-standing cultures, traditions and
hierarchies
 ENVIRONMENTAL SAFETY

 Adequate light
 Adequate ventilation, exhaust fan
 Stairs with hand rails
 Window-door-closer
 Slip preventing floors
 Fire extinguishers and fire alarms
 Prevent noise pollution
 Heavy and fixed beds
 Safe wheel chairs and trolleys
 No water logging in bathrooms
 Call bell system for patients
 Adequate no. of bed screens to maintain privacy of the patient
 MEDICAL SAFETY

1. Illegible Writing prescription by doctors.

2. Wrong medicines or wrong does or wrong patient.
3. Wrong injection, wrong does or wrong patient, wrong
route of administration.
4. Drip sets, air bubbles, over hydration, drip speed.
5. Oxygen flow check empty gas cylinders.
6. Clear, written medication guidelines.
7. Identification of each patient with Similar patient names
8. Proper handing taking over during change of shift.
9. Look alike and Sound Alike “LASA
 A- Medication orders should be written legibly in ink
and should include:

Patient’s name and location (ward, room No, and

bed No) .
Medication Generic Name.
Dosage, frequency and route of administration.
Signature of the physician.
Date and hour the order was written.
B- Any abbreviations used in medication
orders should be agreed to and jointly
adopted by the medical, nursing, pharmacy,
and medical records staff of the institution.
Lately, in the interest of patient safety, “Do
Not Abbreviate” is the new practice
nowadays
C- Before dispensing the drug The
pharmacist must receive the physician’s
original order or a direct copy of the order
(except in emergency situations). This
permits the pharmacist to:
Resolve questions or problems with drug orders
before the drug is dispensed and administered.
Eliminate errors which may arise when drug orders
are transcribed into another form for use by the
pharmacy
 SURGICAL SAFETY

1. Consent of the patient/ relative in writing

2. Proper identification of patient, name wrist band
3. Proper identification mark of parts to be operated
4. Pre- anesthetic check-up
5. Anesthetic Safety
6. Ensure no foreign body left inside
7. Safety measures from ward to OT & coming back
(Safety check list) 8. Prevention of surgical wound
infections
8. Use of Surgical safety Performa in all operations
 INSTALLATION HAZZARDS

1. Regular checking of equipment’s

2 Proper earth ling to avoid shock
3. Regular maintenance & repair
4. Training of nurses & technical staff
 ELECTRICAL SAFETY

1. Safety fuses with each equipment

2. No loose wires or connection
3. Properly plugged and fixed
4. If short circuit call electrician
5. Electricity back up battery/ generator
6. Use of CVT/UPS
 FIRE SAFETY

1. Use Fire proof material for construction.

2. Have Fire Exit in all Buildings.
3. Smoke detectors and water sprinklers on the roof
of all Floors.
4. Fire Extinguishers in all areas.
5. Fire Hydrants in all buildings.
6. Training in Fire management
 BLOOD SAFETY

1. Proper grouping & cross matching

2. Tests of HIV, Inf. hepatitis
3. Proper leveling of group, name of the patient
4. Control of mismatch reaction
5. Standard operating procedure
6. Screening against HIV, Hepatitis, Malaria.
 LABORATORY SAFETY

1. Avoid needle prick & spilling of blood

2. Safety measures in Radiology & Radiotherapy
departments
3. Safety norm guide lines for different areas of
hospitals.
4. Regular pest control measures
5. Care in handling acids, reagents, inflammable
substances
 PREVENT MEDICAL ERRORS BY PATIENT

 MEDICINES 1. Make sure that all of your doctors know

about every medicine you are taking. This includes
prescription and over-the-counter medicines and dietary
supplements, such as vitamins and herbs.

 2. Bring all of your medicines and supplements to your

doctor visits. Your medicines can help you and your doctor
talk about them and find out if there are any problems.

 3. Make sure your doctor knows about any allergies and

adverse reactions you have had to medicines.
 ERRORS BY PATIENT

4. When your doctor writes a prescription for you, make sure you can
read it.

5. Ask for information about your medicines in terms you can understand
—both when your medicines are prescribed and when you get them:
 What is the medicine for?
 How am I supposed to take it and for how long?
 What side effects are likely? What do I do if they occur?
 Is this medicine safe to take with other medicines or dietary
supplements I am taking?
 What food, drink, or activities should I avoid while taking this
medicine?
 When you pick up your medicine from the pharmacy, ask: Is this the
medicine that my doctor prescribed.
 HOSPITAL STAYS

 If you are in a hospital, consider asking all health care

workers who will touch you whether they have washed
their hands. Hand washing can prevent the spread of
infections in hospitals.
When you are being discharged from the hospital, ask
your doctor to explain the treatment plan you will follow
at home.
About your new medicines
When you can get back to your regular activities.
Continuing old medicines before your hospital stay.
When to come back to the hospital for check up
 TIPS FOR IMPROVING PATIENT SAFETY

1. Constitution of Patient Safety Committee.

2. Develop clear policies and protocols for patient safety.
3. Discuss regularly patient safety initiative within hospital
staff.
4. Orientation, Re-orientation hospital staff on patient safety
5. Encourage transparency in the regular death review
6. Non- punitive incident reporting by staff.
7. Each department to devise their own patient safety
protocols.
8. Investigate each accident/ incident reported and take
remedial measures.
9. Review, monitor & evaluate. safety procedures regularly.
 Human factors in health care

Q. What does the term “human factors”

mean?
A. Human factors apply wherever humans work.
Human factors acknowledges the universal nature of
human fallibility. The traditional approach to human
error might be called the “perfectibility” model that
assumes that if workers care enough, work hard
enough, and are sufficiently well trained, errors will
be avoided. Our experience, and that of international
experts, tells us that this attitude is counter-
productive and does not work
Q. What does the study of human factors
involve?
Human factors is a discipline that seeks to optimize
the relationship between technology and humans,
applying information about human behavior,
abilities, limitations, and other characteristics to the
design of tools, machines, systems, tasks, jobs and
environments for effective, productive, safe and
comfortable human use.
Q. Why is the issue of human factors in health
care important?
A. Human factors issues are major contributors to
adverse events in health care. In health care and
other high-risk industries, such as the aviation
industry, human factors can have serious and
sometimes fatal consequence
Q. Is it possible to manage human factors?
 Yes, management of human factors involves the
application of proactive techniques aimed at
minimizing and learning from errors or near misses.
A work culture that encourages the reporting of
adverse events and near misses in health care allows
the health-care system and patient safety to improve.
 Putting knowledge of human factors into
practice

Avoid relying on memory

Make things visible
Review and simplify processes
Standardize common processes
and procedures
Routinely use checklists
Decrease reliance on vigilance