Improving Patient Safety
Patient safety
• Patient safety is a discipline/system that
emphasizes/focuses on safety in healthcare by
preventing, minimizing, reporting, analyzing errors
and other types of unnecessary harm that often
lead to adverse events for the patient.. The
frequency and magnitude of avoidable adverse
events, often known as patient safety incidents,
experienced by patients was not well known until
the 1990s, when multiple countries reported
significant numbers of patients harmed and killed
by medical errors. Recognizing that healthcare
errors impact 1 in every 10 patients around the
world, the World Health Organization calls patient
safety an endemic concern.
Patient safety
The ethics of
practice
Patient safety
priorities and
risk
management
Patient
safety
Knowledge of
formularies
and
guidelines
Learning from
errors
Reham Al Hakami, Saudi Arabian Girl,
Given HIV-Positive Blood Transfusion
We all make errors!
In healthcare, hospital acquired conditions
may include:
• Transfusion reaction (wrong blood)
• Medication event
• Misdiagnosis
• Hospital-Acquired Infection
• Treatment error
• Delay in treatment
• Wrong site/side surgery or procedure
• Fall with serious injury
Swiss Cheese Model- in patient safety:
Poorly designed processes or
active errors within a well
designed process
Active errors
by individuals
result in
initiating
action(s)
Significant
events or
injuries
“Safety is a Dynamic Non-Event”
Slide concept adapted from
James Reason, Managing the Risks of Organizational Accidents, 1997
Swiss Cheese Model- there are processes and
systems in place to protect human error, not
all systems or processes are designed well. It is
not just one person making a mistake, it is one
team and at any point care, someone has the
options to Question the process and/or
system. If harm reaches a child, all team
member have made a mistake!.
Why Significant Events Happen?
The Swiss Cheese Effect, a model that
explains how human error results in events
of harm, was developed by James Reason, a
psychologist studying events in aviation/
flying. In most everything we do, there are
checks and barriers built designed to help
catch errors and prevent them from
resulting in events. This is called defense-indepth. The slices of Swiss cheese represent
that defense-in-depth.
The healthcare system is designed wherever
possible with defense-in-depth such that single
human
errors
do
not
result
in
harm.
Sometimes, however, those good checks and
barriers fail. Those failures are seen as the holes in
the Swiss cheese. When all our best defenses fail
us, an error that otherwise would have been
caught carries through the holes unstopped and
results in an event.
Safety doesn’t just happen. We have to work to
make it happen. There are two basic approaches
to reduce event rate:
First, reduce the human error rate.
Second, find and fix the holes in the Swiss cheese.
Continuous improvement approaches to system
reliability should be designed to reduce event rate
by 50% in two years.
Types of errors
• Active errors
• Also called sharp end errors – the slips, lapses, or
mistakes that are at the end of the causal chain of
events.
• Latent errors
• Also called system errors or system factors – these are
poor designs that set people up to make mistakes.
• Equipment design flaws that make the human-machine
interface less than intuitive.
• Organizational flaws, such as staffing decisions made for
fiscal/financial reasons which increase the likelihood of
error.
As Humans, We Work in 3 Modes
Skill-Based Performance
“Auto-Pilot Mode”
Rule-Based Performance
“If-Then Response Mode”
Knowledge-Based Performance
“Figuring It Out Mode”
12
Three types of human performance errors
1. Skill-Based Errors
We are doing tasks so routine and familiar that we don’t even have
to think about the task while we are doing it.
Type of Error
Example Error Prevention
Strategy
Slip – act performed wrong
Lapse – act not performed when
required
Stop and think before acting
In our daily life, each person performs 10,000 skill-based acts. This would lead to roughly
30 skill-based errors per day.
1. Skill-Based Errors
Minimal error in this human
performance mode (Skill-Based Errors).
What the human mind wants more
than anything is to minimize mental
effort. This is a coping strategy to deal
with a complex and fast-paced world.
Routine actions in familiar
environments are performed with little
or no thought based on learned skills.
1. Skill-Based Errors
The probability of an error when you are in
skill-based performance is approximately 3
errors for every 1000 actions or 0.3%.
Since this is very reliable and skill-based
performers are experts in the action,
errors are easily identified.
The probability of detecting one’s own
skill-based error is approximately 60%.
Three types of human performance errors
2. Rule-Based Errors
We choose how to respond to a situation using a principle (rule) we
were taught, told or learned through experience.
Type of Error
Used the wrong rule
Misapplied a rule
Choose not to follow the
rule
Example Error Prevention Strategy
Education about the correct rule
Think a second time – validate/verify
Reduce burden/load, increase risk
awareness, improve coaching
2. Rule-Based Errors
Rule-based errors occur in three varieties:
1. Wrong rule errors occur when the wrong answer is learned
as the right answer. For example, the preceptor/trainer trains
the orientee the incorrect method for a task.
2. Misapplication of correct rules occurs when thinking
becomes confused. This is never a knowledge problem; this is a
critical thinking problem.
For example: potassium dose is 1meq/kg – I order 50 meq for
my 50 kg patient. (rule is 1meq/kg up to max of 20meq dose).
3. Non-compliance occurs when the rule is known (and
considered at the time) but a choice is made to do otherwise,
thinking that a better result can be achieved with the same or
less effort. For example, choosing not to label syringes being
used at the bedside or not double checking the patient’s arm
band before administering the medication.
2. Rule-Based Errors
The probability of a rule-based error is
1 in 100 or 1%. The probability of selfdetecting a rule-based error is 1 in 5.
For wrong rule error, teach your
colleague the correct rule.
For misapplication, coach your
colleague on critical thinking skills.
For non-compliance, coach your
colleague by either reinforcing a
professional standard or teaching the
consequences of the non-compliance.
Three types of human performance errors
3. Knowledge-Based Errors
We’re solving problem in a new and unfamiliar situation. We don’t have a
skill for the situation, we don’t know the rules, or no rule exists. So we
come up with the answer by:
• Using what we do know (fundamentals)
• Taking a guess
• Figuring it out by trial-and-error
Type of Error
Example Error Prevention Strategy
We came up with the wrong
answer (a mistake)
STOP and find an expert who/that
knows the right answer
3. Knowledge-Based Errors
Knowledge-based errors occur in choices where
rules do not exist or are unknown to the performer.
This error type is better called “lack of knowledge”
error. Knowledge-based errors are associated with
performers working outside their practice or facing a
very complex case.
The probability of a knowledge-based error is 3 in 10
or 30%. The self-detection probability is only 11%.
3. Knowledge-Based Errors
You will know that you are in knowledge-based
thinking when you start to question what to do next.
This is to be avoided.
The best strategy to prevent knowledge-based error
is not to do it. Change your knowledge-based error
into someone else’s rule-based success.
Presentation
Is Patient Safety Improving?
Maybe, maybe not – but there’s room for improvement
http://www.cnn.com/2016/05/03/health/medical-error-a-leading-cause-of-death/index.html
The culture plays a role in patient safety
Presented by : Manar Khaled
ID : 442000939
Culture
•
Ross, C. (2017, Mar. 20). When Hospital Inspectors are in Town, Fewer Patients Die, Study Says. Boston, MA: STAT. Retrieved from:
https://www.statnews.com/2017/03/20/hospital-inspectors-fewer-patients-die
Event reporting is very important
Culture of blame effects event
reporting
•A barrier to our reporting goals.
•Differences within the hospital,
within departments, and within
divisions or wards.
•Culture doesn’t change
overnight.
•Need to show that reporting
yields positive change.
Presented by : Farah Shabab
ID : 442001382
Creating a culture of safety:
The healthcare workers voices are
very important to improve the safety.
What Is the Communication and
Optimal Resolution (CANDOR) Process?
An approach health care institutions and
practitioners can use to respond in a timely,
thorough (comprehensive), and just way to
unexpected patient harm events.
Presented by : Relam Jamaan Alghamdi
ID : 442001767
What should I report?
A healthcare worker should report anything that harms or
has the potential to harm. This may include incidents,
adverse events, near misses, or unsafe conditions.
1. Incidents and adverse events:
• Any event that reaches a patient, regardless of
whether or not it resulted in harm, is
considered an incident. If that event does result
in harm, it is considered an adverse event.
• Imagine a hospital provider accidentally
prescribes a medication meant for patient A to
patient B. Once the drug reaches patient B, it is
considered an incident. If patient B takes the
drug and suffers some form of harm, this is
considered an adverse event.
Presented by : Razan GhurmAllah
ID : 442002044
2. Near misses
• If an event occurs but fails to reach the patient,
whether by chance or by intervention, this is
defined as a near miss.
• Imagine a provider calls in a prescription to a
pharmacy for an antibiotic to which a patient is
allergic. If the pharmacist identifies the allergy
and notifies the ordering provider to change the
prescription to an alternative, this would be an
example of a near miss.
3. Unsafe conditions:
• If conditions exist that are not related to a
specific patient but increase the risk of an event
occurring, this is considered an unsafe
condition.
• Unsteady chair is an example of an unsafe
condition— faulty equipment is something you
may find in nearly every care setting. Another
example, medications with similar sounding
names and labels stored next to each other, also
present an increased risk of harm occurring.
Presented by : Asmaa Saeed
ID : 442002427
Sentinel (serious) event
• any unanticipated event in a healthcare setting
resulting in death or serious physical or psychological
injury to a patient or patients, not related to the
natural course of the patient's illness. Sentinel events
specifically include loss of a limb or gross motor
function, and any event for which a recurrence would
carry a risk of a serious adverse outcome.
Sentinel (serious) event: examples
• Infant abduction, or discharge to the wrong family.
• Unexpected death of a full-term infant.
• Surgery on the wrong individual or wrong body part.
• Instrument or object left in a patient after surgery or
another procedure.
• Rape in an acute-care setting.
• Suicide in an acute-care setting, or within 72 h of discharge.
• Hemolytic transfusion reaction due to blood group
incompatibilities.
• Radiation therapy to the wrong body region or 25% above
the planned dose.
Presented by : Emtenan Saad
ID : 442002583
Eight recommendations for achieving
Total Systems Safety
1. ENSURE THAT LEADERS
ESTABLISH AND SUSTAIN A
SAFETY CULTURE
2. CREATE CENTRALIZED
AND COORDINATED
OVERSIGHT OF
PATIENT SAFETY
Improving safety requires an
organizational culture that
enables and prioritizes safety.
The importance of culture
change needs to be brought
to the forefront, rather than
taking a backseat to other
safety activities.
Optimization of patient safety
efforts requires the involvement,
coordination, and oversight of
national governing bodies and
other safety organizations.
3. CREATE A COMMON SET
OF SAFETY METRICS THAT
REFLECT MEANINGFUL
OUTCOMES
Measurement is foundational
to advancing improvement.
To advance safety, we need
to establish standard metrics
across the care continuum
and create ways to identify and
measure risks and
hazards proactively.
4. INCREASE FUNDING FOR
RESEARCH
IN PATIENT SAFETY
AND IMPLEMENTATION
SCIENCE
To make substantial
advances in patient safety, both
safety science and
implementation science should
be advanced, to more
completely understand safety
hazards and the best ways
to prevent them.
Eight
recommendations
for achieving
Eight
Recommendations
for Systems
Achieving TotalSafety
Systems
Total
Safety
5. ADDRESS
SAFETY ACROSS THE
ENTIRE CARE CONTINUUM
Patients deserve safe care in
and across every setting.
Health care organizations need
better tools, processes, and
structures to deliver care
safely and to evaluate the
safety of care in various
settings.
6. SUPPORT
THE HEALTH CARE
WORKFORCE
7. PARTNER WITH PATIENTS
AND FAMILIES FOR
THE SAFEST CARE
Workforce safety, morale, and
wellness are absolutely
necessary to providing safe
care. Nurses, physicians,
medical assistants,
pharmacists, technicians, and
others need support to fulfill
their highest potential as
healers.
Patients and families need to
be actively engaged at all
levels of health care. At its
core, patient engagement is
about the free flow of
information to and from
the patient.
8. ENSURE THAT
TECHNOLOGY IS
SAFE AND OPTIMIZED TO
IMPROVE
PATIENT SAFETY
Optimizing the safety benefits
and minimizing the
unintended consequences of
health IT is critical.
Presented by : Reham Ali
ID : 442002627
‫اﻟﻣرﻛز اﻟﺳﻌودي ﻟﺳﻼﻣﺔ اﻟﻣرﺿﻰ ھو ﻣرﻛز ﻣﺳؤول ﻋن‬
‫ﺗﺣﺳﯾن اﻟرﻋﺎﯾﺔ اﻟﺻﺣﯾﺔ واﻟﻣﻣﺎرﺳﺔ اﻟﺻﺣﯾﺔ ﻓﻲ اﻟﺳﻌودﯾﺔ‪،‬‬
‫وﯾﻣﺛل اﻟﻣرﺟﻌﯾﺔ اﻷﺳﺎﺳﯾﺔ ﻓﻲ ﺟﻣﯾﻊ ﻣﺎ ﯾﺗﻌﻠق ﺑﺳﻼﻣﺔ‬
‫اﻟﻣرﺿﻰ‪ ،‬وﻣﺎ ﯾﺗﻌﻠق ﺑﺎﻟﺣد ﻣن اﻷﺧطﺎء اﻟطﺑﯾﺔ‪ ،‬ﺗم إﻧﺷﺎؤه‬
‫ﻋﺎم ‪ 2017‬ﺑﻣﺑﺎدرة ﻣن وزارة اﻟﺻﺣﺔ اﻟﺳﻌودﯾﺔ‪.‬‬
‫‪https://www.spsc.gov.sa/Arabic/Pages/Gallery.aspx‬‬
•The Saudi Patient Safety Center (SPSC) established in 2017, is
the first of its kind in the whole region and fulfills one of the
initiatives of the National Transformation Vision 2030. The
center's mission is to motivate healthcare regulators, payers,
providers, patients, families and communities around patient
safety with the aim of providing healthcare services free from
harm. The SPSC is acting as the main custodian of the Patient
Safety strategy with a focus on giving a voice to the community
and healthcare providers. The center shall be inspired by the
guiding principles of the patient safety strategy as it relates to:
•System orientation
•Capacity building
•Learning from mistakes
•Patient empowerment
•Measurement
•Monitoring and research
•Patient safety culture
•All levels and institutions
•Realistic & motivating expectations
•Sustainability
Presented by : Halah Hamad
ID : 442002831
The End