Session 1: Importance of
Patient Safety
Mohamad-Ali Hamandi
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Patients
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3
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Patient Safety
Freedom from accidental
injury
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Medical Error
The most common adverse errors affecting patients include:
medication and transfusion errors 
infections 
complications of surgery (including wrong-site surgery) 
suicide 
restraint-related injuries 
falls 
burns 
pressure ulcers 
misidentification 
wrong diagnosis or treatment 
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Exposing the Problem
The December 1999 Institute of Medicine
(IOM) report, found that 48,000 to 98,000
people die yearly due to medical errors.
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Errors
95% of errors are not the result of
carelessness or lack of concern.
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Who Commits Errors?
The worst errors are sometimes
made by the best doctors and
nurses.
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Errors
Even though error is not a popular
problem in health care, if not
critically tackled, it will get worse in
the future (Leape et al, 1991).
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Surgical safety is a serious public
health issue
Harvard School of Public health •
Involvement:
About 234 million operations are done –
globally each year
A rate of 0.4-0.8% deaths and 3-16% –
complications means that at least 1 million
deaths and 7 million disabling complications
occur each year worldwide
THE HIGH RISK ENVIRONMENT OF HEALTH CARE
“THE PERFECT SET UP FOR MAKING MISTAKES”
dangerous
equipment
use of invasive devices
potent chemicals
high risk, irreversible
KCl
procedures
potent body fluids
look-alike, sound-alike
drugs, chemicals, fluids
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potent drugs
infectious
environment
Prof. Rene T. Domingo
www.rtdonline.com
THE HIGH RISK ENVIRONMENT OF HEALTH CARE
“THE PERFECT SET UP FOR HIDING MISTAKES”
disease can
mask medical error
collegial silence
incoherent, inarticulate patients
IR
punitive culture
hierarchical
culture
ADMINISTRATOR
MANAGER
MANAGER
dual management
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incomplete, error-prone
documentation
MED. DIRECTOR
MANAGER
MANAGER
multiple handoffs
most errors are
near misses, slight effects
Prof. Rene T. Domingo
www.rtdonline.com
10 Facts on Patient Safety
World Health Organization
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Fact 1
Patient safety is a serious global public •
health issue.
In 2002, WHO Member States agreed on a •
World Health Assembly resolution on
patient safety.
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Fact 2
Estimates show that in developed countries •
as many as one in 10 patients is harmed while
receiving hospital care.
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Fact 3
In developing countries, the probability of •
patients being harmed in hospitals is
higher than in industrialized nations.
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Fact 4
At any given time, 1.4 million people •
worldwide suffer from infections acquired
in hospitals.
Hand hygiene is the most essential •
measure for reducing health careassociated infection and the development
of antimicrobial resistance.
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Fact 5
At least 50% of medical equipment in •
developing countries is unusable or only partly
usable.
This leads to substandard or hazardous •
diagnosis or treatment that can pose a threat
to the safety of patients and may result in
serious injury or death.
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Fact 6
In some countries, the proportion of injections given •
with syringes or needles reused without sterilization
is as high as 70%. This exposes millions of people to
infections.
Each year, unsafe injections cause 1.3 million deaths, •
primarily due to transmission of blood-borne
pathogens such as hepatitis B virus, hepatitis C virus
and HIV.
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Fact 7
Surgery is one of the most complex health •
interventions to deliver.
More than 100 million people require surgical •
treatment every year for different medical reasons.
Problems associated with surgical safety in •
developed countries account for half of the
avoidable adverse events that result in death or
disability
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Fact 8
The economic benefits of improving patient •
safety are Compelling
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Fact 9
Industries with a perceived higher risk such as •
aviation and nuclear plants have a much better
safety record than health care.
There is a one in 1, 000,000 chance of a traveler •
being harmed while in an aircraft.
In comparison, there is a one in 300 chance of a •
patient being harmed during health care.
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Fact 10
Patients' experience and •
their health are at the
heart of the patient
safety movement.
The World Alliance for •
Patient Safety is working
with 40 champions – who
have in the past suffered
due to lack of patient
safety measures – to help
make health care safer
worldwide.
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What was done since IOM
Report?
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World Alliance for
Patient Safety
In 2004, WHO's World Alliance for
Patient Safety set up to address
problem of Patient Safety in Member
States
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http://whqlibdoc.who.int/publications/2011/9789241501958_eng.pdf
13 action areas of WHO 2012-onwards
13. Medical Checklists
6. Solutions to Improve Patient
Safety
1. First Global Patient Safety
Challenge:
Clean Care is Safer Care
7. High 5s
2. Second Global Patient Safety
Challenge:
Safe Surgery Saves Lives
3. Patients for
Patient Safety
4. International
Patient Safety
Classification
5. Reporting and
Learning
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Catalyse
Catalyse
countries’
countries’
action
action toto
achieve
achieve
safety
safety ofof care
care
12. Safety
Prize
11. Education
for
Safer Care
8. Technology for
patient safety
9. Knowledge
Management
10. Eliminating
blood stream IV line
infection
Example of Hi Five
Developing SOPs:
Concentrated Injectable Medicines •
Medication Accuracy at Transitions in Care •
Correct Procedure at the Correct Body Site •
Communication Failures during Patient Handovers •
Addressing Health Care-Associated Infections •
What is this tool that addresses the
10 objectives?
JCI 2014 Patient Safety Goals
Highlight
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Patient Identification
Goal 1:
Improve the accuracy of patient
identification.
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Improve Communication
Goal 2:
Improve the effectiveness of communication
among caregivers.
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Medication Safety
Goal 3:
Improve the safety of using medications.
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Clinical Alarms
Goal 6:
Reduce the harm associated with clinical alarm
systems.
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Health Care-Associated Infections
Goal 7:
Reduce the risk of health care-associated
infections.
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Reduce Falls
Goal 9:
Reduce the risk of patient harm resulting
from falls.
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Risk Assessment
Goal 15:
The organization identifies
safety risks inherent in its
patient population.
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What about
safety
culture?
Culture and Safety
Culture
is the shared values and beliefs of
the individuals in the organization
Behaviors
Outcomes
What is a culture of safety?
Components of a safety culture include:
Commitment to safety as the primary priority •
Availability of the necessary resources •
Incentives, and rewards for safety •
Openness about errors and problems •
Commitment to organizational learning •
Unity, loyalty, and teamwork among staff •
Non Punitive Environment •
Understand Systemic Problems that
Harm Patients
DEFENCES
Procedures
Physical barriers
Training
THE GAPS
Culture
Disease manage
protocols missing
or not actioned
Patient
harmed
Poor compliance, poor
supplies
Inadequate knowledge, lack
of training opportunities
No clear leadership, no
cohesive team structure
Organizational Culture Continuum
Pathologic
Bureaucratic
Generative
Execute the
messenger
Follow the rules
Learning
organization