HEALTH SAFETY CONCERN

WORLDWIDE COMPARISON TO

KURDISTAN REGION IRAQ

Hawler Medical University

By:

Raveen Ismael Abdullah

B.Sc in Nursing

Supervised By:

Dr. Hamdiya Mirkhan

Dr.Viyan Afan

16th July 2017

Contents

Objectives .................................................................................................................................. 1

Error identification ..................................................................................................................... 2

Classification of medical errors .................................................................................................. 2

Purpose of Error Reporting ........................................................................................................ 2

Error reporting process .............................................................................................................. 3

Patient Safety Concerns worldwide in 2017 .............................................................................. 3

Most common Patient Safety Concerns within Kurdistan region hospitals .............................. 3

Electronic health Record (Data integrity) .................................................................................. 4

Record-keeping .......................................................................................................................... 5

Guidelines for record-keeping: .................................................................................................. 5

Principles of record-keeping ...................................................................................................... 6

Alarm hazards ............................................................................................................................ 7

Mix-Up of IV Lines Leading to Misadministration of Drugs and Solutions ................................ 8

Inadequate Reprocessing of Endoscopes and Surgical Instruments ......................................... 9

Ventilator Disconnections Not Caught because of Miss set or Missed Alarms ......................... 9

Opoids Administration ............................................................................................................... 9

Inability of Managing patient violence and communicate professionally ............................... 10

Five principles to reduce safety concerns and increase safety of patients ............................. 10

Principle 1. Provide Leadership ........................................................................................................ 10

Principle 2. Respect Human Limits in Process Design....................................................................... 11

Principle 3. Promote Effective Team Functioning ............................................................................ 11

Principle 4. Anticipate the Unexpected ............................................................................................ 11

Principle 5. Create a Learning Environment ..................................................................................... 11

Conclusion................................................................................................................................ 12

Recommendations for eliminating common errors within KRI ............................................... 12

References ............................................................................................................................... 13

1

Introduction

Health care services are provided to patients in an environment with complex interaction among many

factors, such as the disease process itself, clinicians, technology, policies, procedures, and resources; Any

condition, practice, or violation that causes a big probability of physical harm, property loss, and/or

environmental impact called safety concern .

Patient safety is defined as “freedom from accidental injury” caused by medical care, such as harm or death

attributable to adverse drug events, patient misidentifications, and health care associated or health care–

acquired infections(1).

Error identification determines the potential threats to patient safety; it improves healthcare system through

improving patient safety, and minimizing death rate through improving the system.

Worldwide For the second year in a row, in 2017health information technology (IT) tops the list of patient

safety concerns for Healthcare Organizations (2).

While in Kurdistan region there is no documented data for prioritizing the major safety concerns within

KRI health system due to lack of evaluation system and unavailability of contentious reporting errors.

Objectives

Identifying worldwide health safety concerns comparison to KRI in term of safety concerns.

Discussing the process of reporting safety concerns.

Principles of developing healthcare system through establishing annual programs of error identifications

within KRI hospitals.

2

Error identification

1. Morbidity and Mortality.

2. Retrospective chart review.

3. Reporting systems for serious accidents and important “near misses''.

Classification of medical errors

Purpose of Error Reporting

1. Improve the management of an individual patient

2. Identify and correct systems failures.

3. Prevent recurrent events.

4. It helps in providing a safe environment for patient care.

5. Provide a record of the event.

6. Obtain immediate medical advice and legal counsel

3

Error reporting process

1. Date when the report is made

2. Method of reporting (written or visual/oral )

3. Date, time and place of the event

4. Personal details of those involved

5. A brief description of the nature of the event or disease.

Patient Safety Concerns worldwide in 2017

1. Information management in EHRs (electronic health records)

2. Unrecognized patient deterioration.

3. Implementation and use of clinical decision support.

4. Test result reporting and follow-up.

5. Patient identification (name and personal information).

6. Opioid administration and monitoring in acute care.

7. Behavioral health issues in non behavioral-health settings.

8. Management of new oral anticoagulants.

9. Inadequate organization systems or process to improve safety and quality.

Most common Patient Safety Concerns within Kurdistan Region Hospitals

The below safety concerns been identified through evaluating a sessetem, nodocumented data were available.

1. Alarm hazards: inadequate alarm configuration

2. Data integrity: incorrect or missing data

3. Inability of Managing patient violence and communicate professionally.

4. Mix-up of IV lines leading to misadministration of drugs and solutions

5. Ventilator Disconnections Not Caught because of Miss set or Missed Alarms

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6. Failure to conduct independent double checks independently

7. Opioid-related events

8. Inadequate reprocessing of endoscopes and surgical instruments

9. Inadequate patient handoffs related to patient transport

10. Medication errors related to pounds and kilograms

Electronic health Record (Data integrity)

Electronic health records (EHRs) may enhance the safety of patient care, but emerging evidence suggests

that they also produce new, unique risks. These risks can emerge due to poor system design and usability,

ineffective implementation of the system by the health care organization (HCO), or improper use of the

system. While some of the risks may not be apparent to users in a complex health care environment, they

have significant implications for patient safety. Even when a problem is detected, it may be difficult to

determine its origin in a complex, distributed clinical computing environment. Despite calls for greater

attention to EHR-related safety risks, most HCOs and providers have limited awareness of these problems.

To achieve the transformational benefits promised by pioneering EHR designers and developers, HCOs

must ensure that health information technology–related patient safety is an organizational priority. They

can facilitate this by “securing commitment from organizational leadership and refocusing the

organization’s clinical governance structure to facilitate measurement and monitoring of EHR-related

safety risks.” Developing an organizational culture that is amenable to proactively detecting, fixing, and

learning from EHR-related safety concerns are critical.

In most HCOs, systematic approaches for identifying EHR-related safety concerns are underdeveloped.

Safety concerns are broadly defined as “patient safety events that reached the patient, regardless of whether

harm occurred; near misses or close calls, which are patient safety events that did not reach the patient; and

unsafe conditions, which are circumstances that increase the probability of a patient safety event.” Incident

reporting by end users remains the primary mechanism by which HCOs learn about these concerns, but this

method only captures events that have already occurred and has limited value in more real-time

identification of safety concerns.

Furthermore, awareness of EHR safety concerns is often lacking due to the distributed nature of EHRs and

the lack of feedback to end users regarding the consequences of their actions. Thus, there is a compelling

need to increase awareness of these “hidden” safety problems and to develop new, proactive strategies to

identify EHR-related safety concerns.

5

Safety huddles could potentially be useful for learning proactively about EHR-related safety concerns.

These short, routine debriefings are designed to engage frontline clinical and administrative staff in

discussions about existing or emerging safety and performance issues.

Safety huddles and safety briefings have been associated with increases in reporting of safety concerns and

improvements in patient outcomes. For example, after the introduction of safety huddles in one of the

largest US health care systems, reports of safety events increased by 40%. A Veterans Health

Administration study found that initiation of checklist-guided preoperative briefings led to significantly

higher rates of antibiotic use and deep venous thrombosis prophylaxis(3).

Record-keeping

There are many reasons for keeping records in health care such as:

1. To compile a complete record of the patient’s/client’s journey through services

2. To enable continuity of care for the patient/client both within and between services.

The records we keep in health care need to be clear, accurate, honest and timely (meaning they should

be written as near as possible to the actual time of occurrence of the events they describe).

Different means of record-keeping are used in health care settings. Some workplaces use hand-written

records, others have moved to computer-based systems, and many use a combination of both.

Guidelines for record-keeping:

1. Know how to use the information systems and tools in your workplace

2. Protect, and do not share with anyone, any passwords or ‘Smartcards’ given to you to enable you to

access systems

3. Make sure written records are not left in public places where unauthorized people might see them and

that any electronic system is protected before you sign out.

6

We should be aware that apart from being clear, accurate, honest and timely about what we write, we

also need to be careful. This means we have to ensure that nothing we write is, or could be interpreted as

being:

1. Insulting or abusive.

2. Prejudiced.

3. Racist, sexist, ageist or discriminatory in any way.

Principles of record-keeping

The overall principles of record-keeping, whether you are writing by hand or making entries to electronic

systems, can be summed up by saying that anything you write or enter must be honest, accurate and non-

offensive and must not breach patient confidentiality.

The following steps should be considered regarding record keeping for decreasing errors:

1. Handwrite legibly and key-in competently to computer systems

2. Sign all your entries

3. Make sure your entries are dated and timed as close to the actual time of the events as possible.

4. Record events accurately and clearly – remember that the patient/client may wish to see the

record at some point, so make sure you write in language that he or she will understand.

5. Focus on facts, not speculation.

6. Avoid unnecessary abbreviations – as you’ll find, the health care system uses many

abbreviations, but not all workplaces use the same definitions: for instance, ‘DNA’ means

‘deoxyribonucleic acid’ in some places, but ‘Did Not Attend’ (meaning a patient/client who does

not show up for an appointment) in others – avoid abbreviations if you can!

7. Record how the patient/client is contributing to his or her care, and quote anything he or she has

said that you think might be significant.

8. Do not change or alter anything someone else has written, or change anything you have written

previously; if you do need to amend something you have written, make sure you draw a clear

line through it and sign and date the changes.

9. Never write anything about a patient/client or colleague that is insulting or derogatory.

7

Alarm hazards

Caregivers rely on medical device alarms to inform them about changes in the patient’s status or

circumstances that could adversely affect the patient’s care.

When this warning system fails or is ineffective, patients can be harmed as evidenced by numerous

reports of alarm-related deaths and serious injuries. Strategies for reducing alarm hazards often focus

on alarm fatigue condition that can lead to missed alarms as caregivers are overwhelmed by, distracted

by, or desensitized to the numbers of alarms that activate. Alarm-related adverse events which can

involve missed alarms or unrecognized alarm conditions can often be traced to inappropriate alarm

configuration practices. Thus, healthcare facilities should be encouraged to examine alarm

configuration policies and practices in their alarm improvement efforts, if they have not done so

already.

Alarm configuration practices include, for example: determining which alarms should be enabled,

selecting the alarm limits to use, and establishing the default alarm priority level. Selections are

typically based on the particular needs of each care area and the acuity of the patients in that care area,

along with the physiologic condition of each specific patient.

Inappropriate alarm configuration practices that is, the selection of values or settings that are

inappropriate for the circumstances of the patient’s care could lead to caregivers not being notified

when a valid alarm condition develops, or caregivers being exposed to an excessive number of alarms,

specifically ones that sound for clinically insignificant conditions (e.g., those that don’t require a staff

response).

Examples of inappropriate alarm configuration practices include:

1. Failing to reset the medical device to the default alarm limits when a new patient is connected to the

device. In this circumstance, the alarm limits used for the previous patient will be used for the new patient.

2. Choosing inappropriate alarm limits for monitored parameters (e.g., heart rate, SpO2) Limits that are set

too wide will prevent an alarm from activating until after the patient’s condition has deteriorated. Limits

that are too narrow, on the other hand, can lead to excessive alarm activations, thus burdening staff with

alarms for conditions that are not clinically significant (leading to alarm fatigue).

8

Mix-Up of IV Lines Leading to Misadministration of Drugs and Solutions

IV infusions need to be administered to a single patient a common occurrence in healthcare.

If a medication or IV solution is delivered to the wrong infusion site, or at the wrong rate, the consequences

can be severe. There are several ways this can happen.

For example: The infusion line could be connected to the wrong fluid container. This will lead to the wrong

fluid being delivered to the patient or to the fluid being delivered at the wrong rate or via the wrong

administration route.

Not surprisingly, the opportunity for error is compounded when there are multiple lines and fluid

containers. One study found that the likelihood of an adverse drug event increased by 3% for each

additional IV medication being administered(4) .

Factors that contribute to infusion-line confusion include the following:

The number of infusion lines present. Intensive care patients and patients undergoing surgical

procedures can have 12 or more infusion lines at once. Also, for “piggyback” infusions, two infusion lines

(primary and secondary) and two fluid containers are associated with a single large-volume pump or pump

channel.

The variety of administration routes. Although pumps are primarily used to deliver fluids and

medications intravenously, they are also used for epidural, subcutaneous, and arterial infusions. Thus, the

potential exists for an infusion intended for one route to be mistakenly delivered through another.

Difficulties in visually discerning one line from another. The tangle of infusion lines can make it

difficult to visually trace a line from the fluid container to the patient. This issue is exacerbated when the

tubing is obscured by the patient’s gown or bed covers.

Infusion pumps’ inability to tell one line from another. That is, no automated method exists for

associating an infusion pump or pump channel with the correct fluid container and route of delivery.

9

Inadequate Reprocessing of Endoscopes and Surgical Instruments

Endoscope reprocessing is particularly challenging because these devices have narrow, hard-to clean

channels. Moreover, the process involves many steps often model-specific that need to be followed

diligently to ensure that the device is safe for subsequent use.

Investigating endoscope reprocessing failures and to help the facility institute a more effective process

is vital. Factors that can contribute to the improper cleaning of instruments include the intricacy of the

instruments (e.g., devices with narrow channels or movable parts to disassemble), lengthy or

incomplete manufacturer instructions for cleaning, time pressures placed on reprocessing staff, and

insufficiently trained personnel, to name a few.

Ventilator Disconnections Not Caught because of Miss set or Missed Alarms

Ventilators are critical life-support devices that deliver positive-pressure breaths to patients who

require total or partial assistance to maintain adequate ventilation. A complete or partial disconnection

at any point along the breathing circuit the pathway that conveys gases between the ventilator and the

patient could quickly lead to anoxic brain injury and ultimately could be fatal.

To prevent such outcomes, ventilators incorporate sensors and alarms to warn caregivers when a

disconnection occurs, whether it be the complete separation of one breathing circuit component from

another or a partial disconnection that allows gases to leak from the circuit. To be effective, however,

such alarms must be set to appropriate levels and must be heard when they sound.

Opoids Administration

Patients receiving opioids such as morphine, hydro morphone, or fentanyl are at risk for drug-induced

respiratory depression, which can lead to anoxic brain injury or death. Some patients can deteriorate from

normal to insufficient respiration in a few minutes, so spot-checking every few hours may not be adequate

for reliably detecting opioid-induced respiratory depression.

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Inability of Managing patient violence and communicate professionally

In today’s health care environment, great demands are placed on each health care professional to

provide the best quality of care efficiently, safely, and cost-effectively to optimize patient care

outcomes. Many administrators and nurse managers recognize that effective inter professional

communication and collaboration through teamwork is needed to create a safe patient care environment.

Collaboration and teamwork among staff nurses and other disciplines in the health care setting is so

critical to optimizing patient care safety and outcomes that it is a priority for most health care

administrators, directors, and managers(5).

While communication is at the heart of everything we do in our society. It’s central to our learning, our

work and our leisure interests. But it’s particularly important in health care, where patients/clients can

feel vulnerable, alone and frightened, and where you’ll be working with colleagues in the health care

team who rely on good communication to help them deliver safe, coordinated and effective care(6).

Five principles to reduce safety concerns and increase safety of patients

(1) Providing leadership.

(2) Respect for human limits in the design process.

(3) Promoting effective team functioning.

(4) Anticipating the unexpected.

(5) Creating a learning environment.

Principle 1. Provide Leadership

1. Make patient safety a priority corporate objective.

2. Make patient safety everyone's responsibility.

3. Make clear assignments for and expectation of safety oversight.

4. Provide human and financial resources for error analysis and systems redesign.

5. Develop effective mechanisms for identifying and dealing with unsafe practitioners.

11

Principle 2. Respect Human Limits in Process Design

1. Design jobs for safety.

2. Avoid reliance on memory.

3. Use constraints and forcing functions.

4. Avoid reliance on vigilance.

5. Simplify key processes.

6. Standardize work processes.

Principle 3. Promote Effective Team Functioning

1. Train in teams those who are expected to work in teams.

2. Include the patient in safety design and the process of care.

Principle 4. Anticipate the Unexpected

1. Adopt a proactive approach: examine processes of care for threats to safety and redesign them

before accidents occur.

2. Design for recovery.

3. Improve access to accurate, timely information.

Principle 5. Create a Learning Environment

1. Use simulations whenever possible.

2. Encourage reporting of errors and hazardous conditions.

3. Ensure no reprisals for reporting of errors.

4. Develop a working culture in which communication flows freely regardless of authority

gradient.

5. Implement mechanisms of feedback and learning from error

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Conclusion

Errors occur in all industries. Some industrial accidents involve one or a few workers. Others affect entire

local populations or ecosystems. In health care, events are well publicized when they appear to be

particularly egregious for example, wrong-site surgery or the death of a patient during what is thought to be

a routine, low-risk procedure. Generally, however, accidents are not well publicized; indeed, they may not

be known even to the patient or to the family. Because the adverse effects may be separated in time or

space from the occurrence, they may not even be recognized by the health care workers involved in the

patient's care.

Designing safe systems requires an understanding of the sources of errors and how to use safety design

concepts to minimize these errors or allow detection before harm occurs.

Safety systems can be both local and organization wide. Local systems are implemented at the level of a

small work group—a department, a unit, or a team of health care practitioners. Such local safety systems

should be supported by, and consistent with, organization-wide safety systems(7).

Recommendations for eliminating common errors within KRI

1. Establish a policy describing care-area-specific standard alarm configuration practices. If a policy

already exists, assess the policy for completeness and clinical relevance.

2. Before implementing a new system or modifying an existing one, assess the clinical work flow to

understand how the system is (or will be) used by frontline staff, and identify inefficiencies as well as

any potential error sources.

3. For all instances in which multiple IV infusions need to be administered to a single patient nurse must

Physically trace each infusion from the fluid container, and verify that the patient connector is attached

to the correct administration site; label each infusion line with the name of the drug or solution being

infused.

4. Emphasize to reprocessing staff and end users that instruments and devices must be thoroughly

cleaned before they can be disinfected or sterilized.

5. Training and contentious education for medical staff.

6. Reporting system and follow up should be activated.

13

References

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2011 Jun 1;127(6):1199–210.

2. ECRI’s 2017 Top 10 Patient Safety Concerns [Internet]. Medscape. [cited 2017 Jul 15].

Available from: http://www.medscape.com/viewarticle/877231

3. Menon S, Singh H, Giardina TD, Rayburn WL, Davis BP, Russo EM, et al. Safety

huddles to proactively identify and address electronic health record safety. J Am Med Inform

Assoc. 2017 Mar 1;24(2):261–7.

4. Top 10 Health Technology Hazards for 2015 - Top_10_2015.pdf [Internet]. [cited 2017

Jul 15]. Available from: https://www.ecri.org/Documents/White_papers/Top_10_2015.pdf

5. Amos, M., Hu, J., & Herrick, C. A. The impact of team building on communication and

job satisfaction of nursing staff. Journal for Nurses in Staff Development. 2005;21(1).

6. rcn. Communication [Internet]. First Steps. [cited 2017 Jul 10]. Available from:

http://rcnhca.org.uk/top-page-001/

7. America I of M (US) C on Q of HC in, Kohn LT, Corrigan JM, Donaldson MS. Creating

Safety Systems in Health Care Organizations [Internet]. National Academies Press (US); 2000

[cited 2017 Jul 15]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK225188/