PATIENT SAFETY - “To Err Is Human:

Building a Safer Health System”

Dr. Lallu Joseph

Quality Manager,

CMC Hospital, Vellore

HOSPITALS

“Healthcare Organizations are the most complex organizations to manage”

Peter Drucker

“Running a Hospital isn’t Brain Surgery….

…..Its Harder

How we want the hospitals to be……

How hospitals are……

Source: 2002. IHI. Leape

Medical Error

Source – The Philadelphia Inquirer

PATIENT INTERFACE IN HEALTHCARE

Complex interactions

Many stakeholders involved

Every patient is different

Every situation is different

Highly sensitive and emotional

Errors cannot happen

IC

U

Ward

Swiss cheese model

TEAM WORK IN HOSPITALS

When caregivers work together- benefits for the employees, the patients and the health-care facility

Patients receive thorough care when providers collaborate

Providers can concentrate on their areas of expertise, knowing they are part of a team looking after the whole patient- shared responsibility

Quality of care improves

Hospitals save money with effective team care

TEAMWORK IS ENHANCED BY QUALITY MANAGEMENT AND

ACCREDITATION

Patient safety?????

PREVENTING ERRORS- IPSG

International Patient Safety Goals (IPSG) help hospitals address

specific areas of concern in some of the most problematic areas of

patient safety.

The goals describe evidence and expert based consensus

solutions to these problems

IPSG Goals-Info graphic 2017

Goal 1: Identify patients correctly

ECRI Institute- PSO reviewed 7,600 wrong-patient events

occurring over 32-months- voluntarily submitted by 181 hospitals.

Deep dive report on patient identification errors (News release -

26/Sep/2016 - Preventable, Potentially Fatal Patient Identification

Errors Analysed )

About 9% of the patient identification events led to temporary or

permanent harm or even death.

IDENTIFY PATIENTS

Primary responsibility of healthcare workers- check identity

and match the correct patients with correct care.

Using two identifiers

• UHID No. and Patient full name.

• Additional identifiers- Age of patient and sex

• DO NOT use Room No./Location for identification

Standardize patient identification (ID band colour, Marker)

Incorporate training on identifying patients

Educate and involve the patients on correct identification.

http://www.who.int/patientsafety/solutions/patientsafety/PS-Solution2.pdf

When to identify patients

Before any surgery, minor procedure and treatment

Before administering medications, blood or blood

products

Before taking blood and other specimens for clinical

testing

Before investigations and imaging

Goal 2: Improve effective Communication

Communication failures- major factor in 30 % malpractice cases

examined by CRICO Strategies- research and analysis offshoot of

the company that insures Harvard-affiliated hospitals.

Communication failures linked to 1,744 deaths in five years- US

malpractice study- 1.7 billion dollars as malpractice costs- Feb 2016

A large scale European Commission project has found that handover

communication is responsible for 25% to 40% of adverse events

(2015)

Effective communication situations

Can be verbal, electronic or written

Effective communication is timely, accurate, unambiguous,

complete and understood by the recipient

Patient care orders given verbally are most error prone.

Critical test result reporting is found to be another error prone

Effective Communication in critical

situationsVerbal and telephone order or test result is written down and

read back by the receiver.

Critical value/reports intimation immediately to the treating

team member and documented. Read back to be followed.

Standardized approach to hand-over communication between

staff, change of shift and between different patient care units in

the course of a patient transfer. Suggested elements of this

approach include:

Use of the SBAR (Situation, Background, Assessment, and

Recommendation) technique.

SBAR Tool for Communication

A structured communication technique designed to convey a

great deal of information in a succinct and brief manner.

This is important as we all have different styles of

communicating, varying by profession, culture and gender.

SBAR

S Situation

Concise statement of the

problem

What is going on now

B Background

Pertinent and brief

information

related to the situation

What has happened

A Assessment

Analysis and

considerations of

options

What you found/think is going on

R Recommendation

Request/recommend

action

What you want done

Goal 3: Improve the safety of high-alert

medications

From January 1997 to December 2007, 446 medication-error

sentinel events were reported to TJC’s (the Joint Commission)

sentinel event database.

High-Alert Medications (HAMs) are

Medications involved in a high percentage of errors and/or

sentinel events

Medications that carry a higher risk for adverse outcomes

Look-Alike/Sound-Alike medications (LASA)

HAMs

Performing an independent double-check (IDC) helps ensure safe

administration of HAMs (High Alert Medications).

According to ISMP, IDCs can prevent up to 95% of errors before

they reach the patient.

PREVENTING MEDICATION ERRORS

Look alike & sound alike – separate storage and re-check drug name

High risk – check and verification by a second staff before dispensing

and double check before administration

Concentrated electrolytes – strict control and check for dilution

Avoid storing concentrated electrolytes in patient care areas, unless

clinically necessary

Concentrated electrolytes that are stored in patient care units are

clearly labelled and stored in manner that restricted access.

Loaded syringes to be labelled before loading the next drug – meet the

labelling requirements including dilution

Medicine reconciliation at all transition points - up-to-date list of

medicines patient currently on

15 hospitalised after wrong drug

injected before sterilization

12 Jan 2017, Kamalapur, Ballari district

15 women admitted for tubectomy, for tubectomy

Hospitalised after being injected wrong medicine before the surgery.

Adrenaline administered instead of Atropine sulfate injection

Women felt giddy, began to vomit and felt their hearts race and rushed to Taluk Hospital

Root Cause: LOOK ALIKE MEDICINES

Goal 4: Ensure safe surgery

From 1995 to 2005, the Joint Commission (TJC) sentinel event

statistics database ranked wrong site surgery as the second most

frequently reported event with 455 of 3548 sentinel events (12.8%)

Steps………

ENSURE CORRECT-SITE, CORRECT-PROCEDURE, CORRECT

PATIENT SURGERY

Surgical site marking with active patient involvement throughout

the hospital

Time out for all invasive procedures throughout the hospital

Inside OR- follow sign in, time out and sign out using surgical

safety checklist

Pause before the surgery to make sure that a mistake is not being

made

Doctors operate on wrong leg of 24-

year-old

• June 22, Fortis Hospital, Delhi

• Fractured right foot due to fall in the stair case

• Operated on the healthy left ankle of a 24 year old

• Multiple screws placed on the left ankle

• Temporary cast placed on the fractured foot

Goal 5: Reduce the risk of health care-associated

infections

FACT SHEET WHO - Health care-associated infections

At any given time, the prevalence of health care-associated

infection in developed countries varies between 3.5% and

12%.

Of every 100 hospitalized patients at any given time, 7 in

developed and 10 in developing countries will acquire at least

one health care-associated infection.

At any given time, the prevalence of health care-associated

infection varies between 5.7% and 19.1% in low and middle-income

countries.

Reduce the risk of HAI

SSIs -31% of all HAIs among hospitalized patients (CDC

prevalence study)

15% of patients who get it may die from VAP and 10% critically

ill on ventilator develop VAP(Agency for Healthcare Research

and Quality, CDC)

Approximately 12 – 16 % hospitalized adults will have an

indwelling urinary catheter and each day, patient has a 3%-7%

increased risk of acquiring CAUTI

CLABSIs - prolongation of hospital stay and increased cost and

risk of mortality ( 7 – 21 days)

Recommendations

5 moments of hand hygiene (WHO)

Use hand rub (20 – 30 sec) or hand wash (40 – 60 sec)

Appropriate PPE to be used

Care bundles to prevent HAI (VAP, CAUTI, CLABSI, SSI)

Use proven guidelines to prevent infections that are difficult to

treat

Surveillance and monitoring

continued…….

The organization has adopted or adapted currently published

and generally accepted hand-hygiene guidelines.

The organization implements an effective hand-hygiene

program.

Policies and/or procedures are developed that support

continued reduction of health care-associated infections.

Goal 6: Reduce the risk of patient harm

resulting from falls

Falls and recurrent falls are the leading cause of injury –related

death

1 of 3 people above 65 years fall every year

1 of 5 falls causes a serious injury.

10% of fatal falls for older adult occur in the hospital setting

Fall related hospitalizations in older adults increased 50%

Inpatient fall rates range from 1.7 to 25 falls per 1,000 patient

day

Fall risk management

Daily fall risk assessment and re-assessment as and when required

Side rails should always be up – always!

Safety belt/side rails while transport

Identify slip and trip areas and take necessary action

Roles and responsibilities

Implements a process for the initial assessment of patients for

fall risk and reassessment of patients when indicated by a

change in condition or medications, among others.

Measures are implemented to reduce fall risk for those assessed

to be at risk.

Measures are monitored for results, both successful fall injury

reduction and any unintended related consequences.

BUILDING A SAFETY CULTURE

Top management commitment- Conduct Patient Safety Leadership Rounds

Encourage reporting- Create a Reporting System

Create openness- do not blame or shame

Designate a Patient Safety Officer

Active patient safety committee

Appoint safety champions/ advisors in units

Involve Patients in Safety Initiatives

Re-enact Real Adverse Events from Your Hospital

Simulate Possible Adverse Events

Safety training and awareness

Priority to safety and take safety issues seriously

The patient……

THE SOLE BREAD WINNER OF THE FAMILY,HE IS THE FATHER OF A SMALL KID,SON OF AN OLD FATHER,HUSBAND OF A YOUNG LADY,AND IS NOW YOUR RESPONSIBILITYTO TREAT HIM AND SEND HIM SAFE TO HIS LOVED ONESIMAGINE YOUR OWN THERETAKE CARE OF HIM LIKE YOUR BROTHER

By…..Dr. Lallu Joseph

Thank you.......