Patient Safety

Dr.Abhimanyu Bishnu

Patient safety is a healthcare discipline that emphasizes the reporting, analysis, and prevention of medical error that often lead to adverse healthcare events.

Systems for therapeutic action designed to preempt/rescue from failure

Workers: teams trained to preempt / rescue from / manage failureR

ec

ipie

nts

of

ca

reMethods: CQI on info, hardware, plant, policy

Methods: CQI on: competence communication, teamwork

Preparation on: illness understanding, accessing care systems, advocacy

A patient safety model of health care Emmanuel et al 2008

Knowledge & Expertise

Patients

•experience of illness• social circumstances•attitude to risk• values• preferences

Clinicians

• diagnosis disease • etiology• prognosis•treatment options• outcome

probabilities

Coulter A Picker Institute 2001

Important:

• understand the multiple factors involved in failures• avoid blaming• practise evidence-based care• maintain continuity of care for patients• be aware of the importance of self-care• act ethically everyday

Human factors

Human factors definition

• the study of all the factors that make it easier to do the work in the right way

• apply wherever humans work

• also sometimes known as ergonomics

Human factors• acknowledges:

○ the universal nature of human fallibility○ the inevitability of error

• assumes that errors will occur

• designs things in the workplace to try to minimize the likelihood of error or its consequences

Human factors design principles

Senses- Vision - Hearing

Psychomotor- Hands

Input Devices- Buttons

Output- Display - Sound

INTERFACE

US Department of Veteran affairs

Human factors

Importance of human factors has been recognized for a long time in:

• aviation

• nuclear power

Importance in health care?• only recently been acknowledged as an essential part of patient safety

• a major contributor to adverse events in health care

• all health-care workers need to have a basic understanding of human factors principles

Health care is increasingly complex

We cope quite well with complexity

• Health-care workers are quite good at compensating for some of the complex and unclear design of some aspects of the workplace

○ equipment

○ physical layouts

Because the human brain is ….

• very powerful

• very flexible

• good at finding shortcuts (fast)

• good at filtering information

• good at making sense of things

Sometimes though our brain is “too clever” …

Are the lines crooked or straight?Optillusions.com

Look at the chartSay the colour of the word, not the word itself

Why is it hard? Optillusions.com

The fact that we can misperceive situations despite the best of

intentions is one of the main reasons that our decisions and actions can

be flawed such that …

Human beings make “silly” mistakes

Regardless of their experience, intelligence, motivation or vigilance, people make mistakes

Traps in health care?

look-alike and sound-alike pharmaceuticals equipment design, e.g. infusion pumps hand-offs and shift of level of care lack of verification during procedures/ medication

Avoidable confusion is everywhere…

US Department of Veteran affairs

Look-alike, sound alike drugs

√

×

Name Confusion- 25% of all medication errors

The context of health careWhen errors occur in the workplace the consequences can be a problem for the patient

○ a situation that is relatively unique to health care

Errors

One definition of “human error” is “human nature”

Error is the inevitable downside of having a brain!

What is an error?

• the failure of a planned action to achieve its intended outcome

• a deviation between what was actually done and what should have been done

Reason

• A definition that may be easier to remember is: ○ “Doing the wrong thing when meaning to do the right

thing.” Runciman

Errors

Mistakes

Skill -based slips and lapses

Attentional slips of action

Lapses of memory

Rule -based mistakes

Know ledge -based mistakes

Reason

Error and outcome

• error and outcome are not inextricably linked: – harm can befall a patient in the form of a complication of care

without an error having occurred

– many errors occur that have no consequence for the patient as they are recognized before harm occurs

Situations associated with an increased risk of error

• unfamiliarity with the task*• inexperience*• shortage of time• inadequate checking• poor procedures

• poor human equipment interfaceVincent

* Especially if combined with lack of supervision

Individual factors that predispose to error

• limited memory capacity• further reduced by:

○ fatigue○ stress○ hunger○ illness○ language or cultural factors○ hazardous attitudes

Fatigue24 hours of sleep deprivation has performance effects

~ blood alcohol content of 0.1%

Dawson – Nature, 1997

Stress and performance

The relationship between stress and performance

Stress level

Area of “optimum”

stress

Low stress Boredom

High stress Anxiety, panic

Perf

orm

ance

leve

l

Yerkes, R. M., & Dodson, J. D. (1908) The relation of strength of stimulus to rapidity of habit-formation.

Journal of Comparative Neurology and Psychology, 18, 459-482

A performance-shaping factors “checklist”

• I Illness• M Medication

–prescription, alcohol & others • S Stress • A Alcohol• F Fatigue• E Emotion

Jensen, 1987

Don’t forget ….

If you’re – H ungry– A ngry– L ateor – T ired …..

HALT

Removing error traps

• a primary function of an incident reporting system is to identify recurring problem areas - known as “error traps” (Reason)

• identifying and removing these traps is one of the main functions of error management

Error traps

Modified from Cook, 1997

Hindsight Bias

Before the Incident

After the Incident

Apply human factors thinking to your work environment

1. Avoid reliance on memory2. Make things visible3. Review and simplify processes4. Standardize common processes and procedures5. Routinely use checklists6. Decrease the reliance on vigilance

Human factors engineering is about designing the workplace and the equipment in it to accommodate for limitations of human performance

Summary

• errors are inevitable

• there are situations that can increase the likelihood of error

○ recognize them for your patient’s sake - and yours!

• attention to human factors principles can lead to a reduction in error or its consequences

Errors

• medical error is a complex issue, but error itself is an inevitable part of the human condition

• learning from error is more productive if it is considered at an organizational level

Examples• order medications electronically

• hand off information

If all of these tasks become easier for the health-care provider, then patient safety can improve.

Systems thinking

A “system”

any collection of two or more interacting parts, or

“an interdependent group of items forming a unified whole”

NPSEF (p. 202)

A “complex system”

many interacting parts

difficult if not impossible to predict the behaviour of the system based on a knowledge

of its component parts

Health care is a complex system

Complexity = increased chance of something going wrong!

Two schools of thought regarding iatrogenic injury

o traditional or person approach* the “old” culture* “just try harder”

o systems approach* the “new look”

You may encounter a bit of both in your “journey”

Person approachsee an errors as the product of carelessness

remedial measures directed primarily at theerror-maker

o namingo blamingo shamingo reassigning

Perspectives on error

An individual failing?Not often the case

o people don’t intend to commit errors only a very small minority of cases are deliberate violations

o won’t solve the problem - it will make it worseo countermeasures create a false sense of security

“we’ve ‘fixed’ the problem” o clinicians will hide errorso may destroy many clinicians inadvertently

the second victim

Systems approach

• Investigate• Analyze• Correct• Prevent

Why investigate?

• the more we understand how and why these things occur, the more we can put checks in place to reduce recurrence

• strategies might include:

– education– new protocols– new systems

Multiple factors usually involved

• patient factors• provider factors• task factors• technology and tool factors• team factors• environmental factors• organizational factors

Reason’s “Swiss cheese” model of accident causation

Example- Acute Respiratory Distress Syndrome (ARDS)

Reason’s - Defences

VA NCPS

Clinical risk management

Why clinical risk is relevant to patient safety • clinical risk management specifically is concerned with improving the

quality and safety of health-care services by identifying the circumstances and opportunities that put patients at risk of harm and acting to prevent or control those risks

4-step process to manage clinical risks

• identify the risk• assess the frequency and severity of the risk• reduce or eliminate the risk• cost the risk

Incident Reporting

Near miss: Process variation which did not affect the outcome but for which recurrence carries a significant chance of serious adverse outcome, eg.patient falls in bathroom but is immediately supported by the accompanying nurse.

Adverse event: Unanticipated, undesirable or potentially dangerous occurrence in a healthcare organization, eg. patient fall resulting in minor bruising; wrong medication resulting in a change of prescription.

Sentinel event: An unexpected event which involves death or serious physical and psychological injuries to a patient or employees, eg. patient fall resulting in internal head injury; patient suicide; infant

abduction;wrong surgery done etc.

Confirmed transfusion reactionsSerious adverse drug events

Medication errorsDiscrepancies between properative and postoperative diagnosis

Adverse events associated with sedation and anaesthesiaInfectious disease outbreaks Equipment- related Incidents

Patient Falls in WardStaff falls in Ward

Needle Stick InjuryComplaints by Patients and / or Relatives

Cancellation of elective surgeryAssault or battery of patients by employees or other persons

Error in consent Adverse Outcome of Procedure

Incidents

Incident monitoring

• involves collecting and analysing information about any events that could have harmed or did harm anyone in the organization

• a fundamental component of an organization’s ability to learn from error

Incident form pathway

Incident Reporting Form

Causes of incidents

• Patient factors• Task and technology factors• Individual factors• Team factors• Work environment factors• Other factors

Root Cause Analysis

Engaging with patients and carers

SEGUE framework ( Northwestern University)

o Set the stageo Elicit informationo Give informationo Understand the patient’s perspectiveo End the encounter

Performance requirements• actively encourages patients and carers to share information• shows empathy, honesty and respect for patients and carers• communicates effectively• obtaining informed consent• shows respect for each patient’s differences, religious and cultural beliefs,

and individual needs• describes and understands the basic steps in an open disclosure process• apply patient engagement thinking in all clinical activities• demonstrates ability to recognize the place of patient and carer

engagement in good clinical management

Gaining an informed consent

• the diagnosis • the degree of uncertainty in the diagnosis• risks involved in the treatment • the benefits of the treatment and the risks of not having the

treatment• information on recovery time• name, position, qualifications and experience of health

workers who are providing the care and treatment• availability and costs of the services required

Harvard framework• preparing• initiating conversation• presenting the facts• actively listening• acknowledging what you have heard• responding to any questions• concluding the conversation• documentation

SPIKESo Sharpen your listening skillso Pay attention to patient perceptionso Invite the patient to discuss detailso Know the factso Explore emotions and deliver empathyo Strategize next steps with patient or family

Robert Buckland

Minimizing infection through improved infection control

What is the urgency?

• We can no longer rely on antibiotics• increased rates of nosocomial infections• infected patients:

– stay longer in hospital– die– treated with more toxic and less effective drugs– prone to surgical site infections

Campaigns to decrease infection rates

• WHO “Clean hands are safer hands” campaign• Centers for Disease Control and Prevention campaign to prevent

antimicrobial resistance in health-care settings• Institute for Healthcare Improvement “5 million lives” campaign

Main causes of infection– person-person via hands of health-care providers patients

and visitors– personal equipment (e.g. stethoscopes, personal digital

assistants) and clothing– environmental contamination– airborne transmission– carriers on the hospital staff– rare common-source outbreaks

Main types of infections

• urinary track infections usually associated with catheters • Surgical site infections• blood stream infections associated with the use of an

intravascular device• pneumonia associated with ventilators • other sites

Burke J Infection control-a problem for patient safety New Eng Journal of Medicine

Main types of infections

Prevention in hospitals

– make sure- visibly clean – increased cleaning during outbreaks– use hypochlorite and detergents

Prevention through handwashing

– how to clean hands– rationale for choice of clean hand practice– technique for hand hygiene– protecting hands from decontaminates– promoting adherence to hand hygiene guidelines

• gloves• aprons• face masks

Protective equipment

• keep handling to a minimum • do not recap needles; bend or break after use• discard each needle into a sharps container at the point of use• do not overload a bin if it is full• do not leave a sharp bin in the reach of children

Safe disposal of sharps

Act to minimize spread of infection

• before contact with each and every patient:– clean hands before touching a patient – clean hands before an aseptic task

• after contact with each and every patient: – clean hands after any risk of exposure to body

fluids– clean hands after actual patient contact– clean hands after contact with patient

surroundings

“My 5 moments for hand hygiene- WHO”

Medication Safety

Medication

• Definition: A chemical substance intended for use in the diagnosis, cure, investigation, treatment or prevention of disease.

Process in Medication

• 1. Prescription• 2. Transcription• 3. Dispensing• 4. Administration &

Documentation

Medication Errors (MEs)• 1. Prescription• 2. Transcription• 3. Dispensing• 4. Administration & Documentation

Wrong Drug (Look alike)

Orders for Vancomycin

Medication Errors

• Please bring these to the notice of the Quality & Clinical Pharmacy deptts. Extremely important. The responsible person fills in an Incident Report..

• Data will be collected and presented at the Quality Steering Committee.

• All such Measures are used as Quality Indicators for evaluating statistically significant improvement.

Prescription• Drugs are ordered in Physician Order Sheet• Document correct date,time and signature.• Write in CAPITALS• Mention – i) Drug name , ii) Dose, iii) Route, iv) Frequency • DISCONTINUE medication with date, time and signature.• Dose changes to be done with date, time and signature.• For discontinued medications cross out drug and after the

last dose given

Contd…• Use standard abbreviations.• Write the date of new medication.• Verbal orders to be used only in

emergency situations e.g. Code Blue.

• Always use leading zeros for decimal points. E.g.

.5 mg Digoxin ------- Incorrect Digoxin 0.5mg PO OD --------

Correct

Contd…

• Orders should be legible, clear and with date, time and signature.

• All antibiotics to be charted in clinical chart.• In case of antibiotic prescribed, no. of days

should be mentioned. E.g. Inj. Cefrom 1gm iv BD ---- day 2 in clinical chart.

Can you read this???

Transcription/ Indenting

Definition: Something written, especially copied from one medium to another as a type written version of dictation, as done in case of indenting a medicine ( copying drug order from drug chart to computer).

Transcription/ Indenting• Always spell check and indent.• Verify correct name, UHID no. and bed no.• Mention allergies in remarks column.• Any doubt regarding medicine to be clarified with

the prescriber.

Dispensing• Medications

dispatched from from pharmacy.

Dispensing• No substitute or opened medication to be

received.• All medications to be received by T/L or

assigned nurse. • Check medications for their dose, expiry and

quantity after receiving.• All medications received should be kept

under lock in bedside of the patient.• Temperature of the fridge for medicine

storage to be maintained at 2-8 degree celsius.

• Narcotics are stored under lock.

Administration

• Process of giving drug used in the diagnosis, treatment, or prevention of a disease or as a component of a medication.

Administration• Always remember: Right patient Right drug Right dose Right route Right time

Right documentation• Self medication is not allowed.• All medications to be known and checked and signed by 2

nurses.• Prepare and label the medications.• In case of antibiotics, a sensitivity test need to be done

before administration.

Contd…• Food drug reaction (FDR) and drug and drug reactions (DDR) should be known.

• All medication dosage, indication, side effects, precautions and route should be known.

• Some high-risk medications are Vancomycin Digoxin IV Phenytoin Chemotherapeutic drugs Theophylline Warfarin Heparin Narcotics IV Iron Morphine Fentanyl Inj Insulin• Some high alert medications are Concentrated electrolytes e.g. KCL, MgSO4,

10% dextrose.

Contd…• Transdermal patches should be dated

and timed on the patch and document.• Remove old patches, clean the

remaining medication from the skin.• Administer all medicines one by one and

observe for 5 minute for any allergy.• Ensure that patient has taken oral

medicine completely.

Contd…• Iron to be started only after test by the

doctor.• Base line investigations for high risk

medications e.g. PTT, ACT for heparin infusion.

• Monitoring of patients getting high risk medications.

Documentation

• Process of transferring data or action into paper or computer record.

Documentation

• Document the medication given with time, signature/name and emp ID no.

• Document the effect of medication if any.• Incident forms to be filled in case of any

medication errors.• If medication is not given on time, it is

considered as medication error.

• Use standard timings for medication administration: OD 10AM,

• HS 10 PM, • TDS OR 8 hrly 6 AM, 2 PM, 10 PM, • BD OR 12 hrly 10am 10pm, OD warfarin 6PM/4PM, BD

diuretics 6AM- 4PM.• QID 6hrly 6AM- 12N - 6 PM – 12MN.• 4 hrly 0200- 0600 – 1000 – 1400 – 1800 – 2200 – 0200.

• For making medication label, write: name of the medication, dilution, dosage, date, time, name and emp no. of the nurse making the medication.

• Record any known allergy.• All medication can be administered with ± 1 hr e.g. If medication is to be

given at 8.00am the nurse can give the medication between 7.00am to 9.00 am and document the exact time of administration like 8.25 am.

Medication Reconciliation• Collect accurate list o f the all possible current

medications• Compare it with the list against

– Admission– Transfer– Discharge

• The prescribes shall document the reconciliation process on the medication reconciliation list document in the comments section.

• Reason for holding, discontinuing or changing dose / frequently

• Any other pertinent medication information.• Nurse shall enquire with the consultant regarding the

use of current medication and these medications if available with patients to be sent to pharmacy for verification.

Home Medication & Self Administration

• No self medication of any kind is allowed in hospital.

.

Adverse Drug Reaction (ADR)

• Definition: Any harm associated with the use of drug at normal dose.

ADR levels

• Level 1 –ADE/ADR occurred but required no change in treatment with suspected drug

• Level 2 –Drug held, discontinued or changed but no antidote or additional

• treatment needed.• Level 3 –Drug held, discontinued or changed AND/OR antidote or

other treatment required. • Level 4 – ADE / ADR required patient transfer to an intensive care

setting• Level 5 – ADE / ADR caused permanent harm to the patient• Level 6 – ADE / ADR either directly or indirectly led to the patient’s

death

ADRs• Document all ADRs on ADR

Form-send to Clinical Pharmacy.• Please report suspected or

confirmed ADRs on ADR Form. Incident Form to be filled for levels 4,5 and 6

Read Back Policy• Read back, verify, document verbal orders• Applicable for; a) Code Blue Situation b) Critical Lab Values: The staff nurse has to read

the value back to confirm and duly sign her name and clock no. and write the name and emp no. of the person who has given the report.

c) Insulin orders: Eg: 29/04/08 6:00am – 40 units – Read back to Dr. -----------, signature, name of the staff and emp no.

Remember• Never leave Medicines unattended.• Lock them in bedside cabinets.• Label all Open In Use Vials.

Patient safety and invasive procedures

The main causes of adverse events associated with invasive procedural and surgical care

• poor infection control methods • inadequate patient management • failure by health-care providers to communicate effectively before, during

and after operative procedures

Requirements• follow a verification process to eliminate wrong patient, wrong side and

wrong procedure• practise operating room techniques that reduce risks and errors ( time-out,

briefings, debriefings, stating concerns)• participate in an educational process for reviewing surgical mortality and

morbidity

Teamwork

A team is….

a distinguishable set of two or more people who interact dynamically, interdependently and adaptively towards a common and valued goal/objective/mission, who have been each assigned specific roles or functions to perform, and who have a limited lifespan of membership.

Eduardo Salas

What types of teams do you find in health care?

Many different teams are found in health care:

o multiprofessional/drawn from a single professiono co-located/distributedo transitory or long standing

How do teams improve patient care?

o teams represent a pragmatic way to improve patient care

o teams can improve care at the level of:o the organizationo the patient – outcomes and safetyo the team as a wholeo the individual team member

What makes for a successful team?

Effective teams possess the following features:o a common purposeo measurable goalso effective leadership and conflict resolutiono good communicationo good cohesion and mutual respecto situation monitoringo self-monitoringo flexibility

Requirements…Practical tips to improve teamwork include:o always introducing yourself to the teamo reading back/closing the communication loopo stating the obvious to avoid assumptionso asking questions, checking and clarifyingo delegating tasks to people not to the airo clarifyng your roleo using objective (not subjective) language

Requirements…

o learning and using people’s nameso being assertive when requiredo if something doesn’t make sense, finding out the other person’s

perspectiveo doing a team briefing before undertaking a team activity and a

debriefing afterwardso when conflict occurs, concentrating on “what” is right for the

patient, not “who” is right

Communication

A number of techniques have been developed to promote communication in health care including:

o SBAR (Situation, Background, Assessment, Recommendation)o call-outo check-backo handover/handoff

In conclusion…………….

Quality & PatientSafety

QUALITY AND PATIENT SAFETY

Thank you!!!

www.powerofteamworkmovie.com