introductory on patient safety, magnitude of problem, common causes, strategy for implementation

Abdalla Ibrahim Accreditation Specialist Healthcare Surveyor 2014 Email: abdallaibrahim@hotmail.com

Does healthcare service is safe as it

should be and can be??

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First Do No Harm is a 1997

American television film.

About a boy whose

severe epilepsy, unresponsive to

medications with terrible side

effects, is controlled by

the ketogenic diet.

Aspects of the story mirror the

Director Jim Abrahams' own

experience with his son Charlie.

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Estimated extent of medical injuries 3.7% (1114 Out of 30 121) patients admitted to 51

acute care hospitals in New York state reported adverse

events/injuries caused by medical management

A subsequent analysis of the same data found that 69%

of injuries were caused by preventable errors. (The

Harvard Study, USA, 1984)

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Adverse events occurred at a rate of 2.9 percent.

Death resulted in 8.8 percent of adverse events due to

negligence.

The total proportion of adverse events causing death

was 6.6 percent.

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“At least 44,000 people, and perhaps as many as

98,000 people, die in hospitals each year as a

result of medical errors that could have been

prevented”. (IOM Report, 1999)

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The total number of estimated admissions in USA in 1997 was 33.6

million.

When the results of the New York study are applied (13.6 percent

of adverse events leading to death) the number of deaths due to

adverse events was 98 000.

When the Utah/Colorado results are used (6.6 percent of adverse

events leading to death) the number of deaths was estimated to be

44 000.

This is the claim that 44 000 to 98 000 people die each year due to

medical errors, making medical errors the 8th leading cause of

death in the United States.

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16.6% of 14 179 admissions to 28 hospitals in New

South Wales and South Australia in 1995 developed an

adverse event and resulting in permanent disability in

13.7% of patients and death in 4.9%

51% of adverse events were considered to have been

preventable.

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Can we afford the losses of

a daily airplane crash?

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DEFINITION

The failure of a planned

action to be completed as

intended

OR

The use of a wrong plan to

achieve an aim. (IOM, 1999)

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DEFINITION

“A preventable adverse effect of

care, whether or not it is evident

or harmful to the patient. (Wikipedia)

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Is it a “ BAD APPLE” problem?!!

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The majority of medical errors do not result

from individual irresponsibility or the actions of

a particular group

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More Commonly, Errors Are Caused By:

These lead people to make mistakes or fail to

prevent them.

Faulty System

Faulty Process

Faulty Condition

SOURCE: Leape, Lucian; Lawthers, Ann G.; Brennan, Troyen A., et al. Pr e-venting Medical Injury. Qual Rev Bull. 19(5):144–149, 1993.

Diagnostic Treatment prevention

Communication Equipment System

DIAGNOSTIC ERROR

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

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TREATMENT ERROR

Performance error of

operation, procedure, or test

Administration error of

wrong treatment, dose or

method

Delay in treatment or in

responding to an abnormal

test

Inappropriate or not

indicated care

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PREVENTIVE ERROR

Failure to provide

prophylactic treatment

Inadequate monitoring or

follow-up of treatment

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OTHER FAILURE

Communication

Equipment failure

Other system failure

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Common Medical Errors

Adverse

Drug Event

Miss matched

Transfusion

Surgical

Injury

Wrong Site Restraint-

related

injuries

No

proper

Photos

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Fall Burn Pressure

Ulcer

Mistaken

Patient

identities

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High error rates with serious

consequences occurs in:

A/E

O/R

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High error rates with serious

consequences occurs in:

ICU

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Cost of Error

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Errors are costly in terms of:

Loss of trust in the health care system

Diminished satisfaction by both patients and health

professionals.

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Total costs estimated between $17 billion and

$29 billion per year in the USA.

This Cost includes the expense of: • additional care necessitated by the errors

• lost income

• lost productivity

• disability

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Physical and Psychological

Discomfort.

Poor Satisfaction

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Loss of morale

Frustration

Inability to provide best

care

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Work & school

absenteeism

Lower worker productivity

Lower levels of population

health status

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Strategy for Improvement

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Strategy for Improvement

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The USA response to the IOM

Report

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Establish National focus on Patient

Safety

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Establish Mandatory reporting system

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Raising Performance Standards and

Expectation on Safety

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Implement Patient Safety

Culture

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harder to do wrong and

easier to do it right

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Yes, it may be part of human nature to err, but it is

also part of human nature to:

• Create solutions

• Find better alternatives

• And meet the challenges ahead.

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People must be alert and held responsible for their actions. But

when an error occurs, blaming an individual does little to make the

system safer and prevent someone else from committing the same

error.

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The pathway to the

desired Patient Safety

is Quality Performance

in Healthcare Services.

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Healthcare organization should

implement the Patient Safety

goals and required practices

included in the Quality

Standards of Excellence to do its

basic function:

Improve Quality of Life

& Do NO Harm.

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