patient safety in healthcare; developing patient safety culture by reporting adverse events and near...
TRANSCRIPT
LOGO
Dr.D.VENODEN, MEDICAL ADMINISTRATOR, MoH, Sri Lanka
CONTENTS
Introduction to patient safety
Classification of hospital accidents
Evolution of patient safety culture
Elements of safety culture
Types of Medical errors
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WHAT IS PATIENT SAFETY?
Patient safety is defined as the prevention and
reduction of adverse outcomes (Alahmadi,2009)
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Learning from the
mistake is the key to
improve patient safety
PATIENT SAFETY – GLOBAL SCENARIO
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PATIENT SAFETY – GLOBAL SCENARIO
12.9% of admissions to public hospital in
New Zealand is associated with a hospital
adverse event.
10% of such admissions in UK
7.5% of such admissions in Canada
2.5 billion of Euros are spent yearly for
compensation due to mistakes in hospitals
in Italy
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ADVERSE EVENTS
ADVERSE EVENT
PREVENTABLE ADVERSE EVENT
An injury caused by medical management rather than the
underlying condition of the patient
An adverse event attributable to an error
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ERROR AND NEAR MISS
ERROR
NNEAR MISS
Failure of a planned action to be completed as intended (i.e., error of
execution) or the use of a wrong plan to achieve an aim (i.e. error of
planning)
An unplanned event that did not result in injury, illness, or damage – but had
the potential to do so. Only a fortunate break in the chain of events prevented
an injury, fatality or damage
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ERRORS AND ADVERSE EVENTS
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NEVER EVENTS AND NEGLIGENCE
NEVER EVENTS
Failure to meet standard practice of an average qualified physician
practicing in the specialty in question
NEGLIGENCE
Serious, largely preventable patient safety incidents that should not
occur if the available preventative measures have been implemented by
healthcare providers
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HOSPITAL ACCIDENTS
Active failureIt is related to errors of procedures or treatment at
the site of the action
Latent failureIt is related to design failure, building failure and
regulatory and procedure failures.
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Active vs. latent error
Active errors occur at the level of the frontline operator
their effects are felt almost immediately
Latent errors Not under the direct control of the operator
poor design, incorrect installation, faulty
maintenance, bad management decisions,
and poorly structured organizations
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LATENT FAILURE SWISS CHEESE MODEL
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LATENT FAILURE SWISS CHEESE MODEL
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Multi-Causal Theory “Swiss Cheese” diagram (Reason, 1991)
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STAGES IN THE DEVELOPMENT OF AN ACCIDENT OR INCIDENT
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What is safety ‘culture’?
The safety culture of an organisation is the product
of individual and group values, attitudes,
perceptions, competencies and patterns of
behaviour that determine the commitment to, and
the style and proficiency of, an organisation’s
health and safety management.”
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All based on our
mental processes, beliefs, knowledge, and values
What we
think
Culture is learned,
not biologically inherited
What we doWhat we produce
= the outcomes
Adapted from Reason
WHAT IS SAFETY CULTURE
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KEY CHARACTERISTICS OF SAFETY CULTURE…
Mutual trust
Shared perceptions
on the importance of
safety
Confidence in the efficacy of
preventive measures
Safety culture
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EVOLUTION OF PATIENT SAFETY CULTURE
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@SAFE_QI
The Model for Safety Culture
• No time for safety or investment into improvementPathological
• Safety occurs in response to an incidentReactive
• Safety is driven by management systems and imposed on the workforceBureaucratic
• There is value placed in safety with continually improving systemsProactive
• The ideal, where safety is an integral part of everyday life in all staffGenerative
Hudson P. Applying the lessons of high risk industries to health care
Qual Saf Health Care 2003
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ELEMENTS OF SAFETY CULTURE
Element of safety
culture
Characteristics
Reporting culture Staff have confidence in the local
incident reporting system and use it to
notify health care managers of incidents
that are occurring, including near misses.
Barriers of incident reporting should be
identified and removed:
- Staff are not blamed and punished when
they report incidents
-They receive constructive feedback after
an incident reporting
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ELEMENTS OF SAFETY CULTURE
Element of safety
culture
Characteristics
Informed culture Those who manage and operate the
systems have current knowledge on the
factors that determine the safety of the
system
Open culture Staff feel comfortable discussing
patient safety incidents and raising
safety issues with both colleagues and
senior managers
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ELEMENTS OF SAFETY CULTURE
Element of safety
culture
Characteristics
Just culture Staff, patients and carers are treated
fairly, with empathy and consideration
when they have been involved in a
patient safety incident or have raised a
safety issue
Learning culture The organization
-Is committed to learn safety lessons
- Communicates them to colleagues
- Remembers them over time
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TYPES OF ERRORS
SYSTEM ERRORS
(LATENT)
Heavy work load/fatigue
Incomplete/unwritten
policies
Inadequate
training/supervision
Inadequate maintenance
of equipment/department
Communication
HUMAN
MISTAKES(ACTIVE)
Action slips or
failures(e.g. picking up
the wrong syringe – due
to anxiety, fatigue etc)
Cognitive failure(e.g.
memory lapses, mistakes
through misreading a
situation)
Violations( deviations
from the standard
procedures)
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TYPES OF MEDICAL ERRORS
Medication errors: Errors which occur at any
point in the medication usage chain. It can occur
at ordering stage, transcribing stage, dispensing
stage or administering stage.
Surgical errors – specific to surgery-wrong site
surgery, retained sponges and instruments.
Diagnostic errors
Human factors and errors at the person-machine
interface
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TYPES OF MEDICAL ERRORS
Transition and hand off errors
Team work and communication errors
Hospital acquired infections
Other complications of health care
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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
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HOW TO PROMOTE PATIENT SAFETY
Improve the system of incident and accident
reporting
Carrying out root cause analysis (RCA) and
Human failure mode effect analysis (HFMEA)
Creating safety culture in hospitals
Increase attention is to be paid to the importance
of a well trained, well-rested workforce to patient
safety
Availability and involvement of more supervisors
and efforts to encourage trainees to admit their
limitations and call for help.
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HUMAN FAILURE MODE EFFECT ANALYSIS
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HOW TO PROMOTE PATIENT SAFETY
Regulations and Accreditations are powerful
tools to promote patient safety
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LOGO