1. Evolution and transformation of Patient Safety in
to the Modern Health Care System-
Tools & Techniques
Presented by Krish Sankaranarayanan MS, MBA, CPHQ
Senior Safety Officer
Tawam Hospital. UAE

2. Introduction-About me
• Been in healthcare domain for over 24 years.
• Triple Masters degree.
• MS in Patient Safety Leadership from UOI- Chicago.
• Certified Professional in Healthcare Quality (CPHQ)
• Educational consultant- Canadian Healthcare
Association- CQI progarm
• Membership
– Member American College of Healthcare Executives
– Member National Association of Healthcare Quality
– Member American Society for Healthcare Risk Management
– Member American Society of Professionals in Patient Safety
– Vice President of the ACHE Middle East and North Africa Group

3. Disclosure
The presenter has nothing to disclose, nor has
any commercial interest with any of those
information's displayed in this presentation.
2013-8-23 3

4. About Tawam Hospital
• Tawam is a 466-bed tertiary care facility located in the garden city Al
Ain in the middle of the desert, and one among the largest healthcare
facilities in the United Arab Emirates.
• In 2006 the General Authority of Heath Services now called as the Abu
Dhabi Health Services Company PJSC (SEHA) entered in to a ten
year affiliation contract with Johns Hopkins Medicine.
• Tawam Hospital has current status with
• Joint Commission International Accreditation (2006; 2009; 2012),
• College of American Pathology (CAP; 2011) and
• American College of Graduate Medical Education- International (ACGME;
Program Accreditation)
2013-8-23 4

5. I will………

6. Items for discussion
• Ice breaker
– Video: Capt. Chesley "Sully" Sullenberger
• Historical context of Patient Safety
• Lessons from high reliability organization
• Patient Safety definitions
• Patient Safety Organizations
• Why do errors happen?
• Second Victim
• Tools & techniques to improve patient
safety
2013-8-23 6

7. Capt. Chesley "Sully" Sullenberger- Video

9. Hippocratic Oath
5th century BC -Physicians and other healthcare professionals swearing
to practice medicine honestly

10. Florence Nightingale
The founder of modern nursing
1863-―the very first requirement in a Hospital is that it should do the sick no
harm

11. Dr. Ernest Codman
1905 started "end result idea.― Hospital standardization.
Doctors should follow up with all patients to assess the results of their treatment
and that the outcomes actively be made public.

12. How is it that aviation became safer than
healthcare ???

14. High Reliability Organizations
Zero compromise to safety

15. The Annual Toll of Medical Injury
IOM ―To Err is Human‖ (1999)
• 44,000 – 98,000 deaths/year in US due to
medical errors.
• $ 50 billion in total costs.
• 7% of patients suffer a medication error.
• Every patient admitted to ICU suffers an
adverse event.
1 in 3 people say that they or a family member has experienced a medical error at
some point in their lives
180,000 people die each year due to iatrogenic injury in US.
This is equivalent to three fully loaded jumbo- jet crashing every two days.
Most of it where preventable !!!!

16. 1
10
100
1,000
10,000
100,000
1 10 100 1,000 10,000 100,000 1,000,000 10,000,000
Number of encounters for each fatality
Totalliveslostperyear
REGULATEDDANGEROUS
(>1/1000)
ULTRA-SAFE
(<1/100K)
Health
Care
Mountain
Climbing
Driving
Chemical
Manufacturing
Chartered
Flights
Scheduled
Airlines
European
Railroads
Nuclear
Power

18. Why do errors happen in healthcare?

22. Miscommunication- Video

23. That killed him- Video

24. 2013-8-23 24

25. National Quality Forum
List of Never Events-28
• Unintended retention of a foreign body in
a patient after surgery or other procedure
• Surgery performed on the wrong body part
• Surgery performed on the wrong patient
• Wrong surgical procedure performed on a
patient
• Infant discharged to the wrong person
• Stage 3 or 4 pressure ulcers acquired
after admission to a healthcare facility

27. The patients saw an average of 17.8 health
professionals during their hospitalization

28. National Patient Safety Goals
Established in 2003
Established in 2001
Anesthesia Patient Safety Foundation
launched in late 1985
APSF was incorporated as
an association in July 1989
World Alliance for Patient Safety
was launched in 2004
Canadian Patient Safety Institute
Established in 2003
National Patient Safety Foundation
Established in 1997

29. What is Patient Safety?- Definition
• The freedom from accidental injury due to medical
care or from medical error.(Institute Of Medicine)
• The prevention of healthcare errors, and the
elimination or mitigation of patient injury caused by
healthcare errors. (National Patient Safety Foundation)
• The absence of the potential for or occurrence of
health care associated injury to patients. Created by
avoiding medical errors as well as taking action to
prevent errors from causing injury. (Agency for
Healthcare Research and Quality)

30. The biggest hurdle!!!!!!
Reported errors
Not reported

31. We Name, Shame & Blame people
31

32. “The single greatest impediment to error
prevention in the medical industry is that
we punish people for making mistakes.”
(Leape 2009)
Dr. Lucian Leape is a professor at Harvard School of
Public Health, he is a health policy analyst whose
research has focused on patient safety and quality of
care

33. Second Victim-
Eric Cropp story (Video)

34. Eric Cropp story (Video)

35. Common Response After a Medical
Error
The types of suffering are
• Increased anxiety about the future possibility of
errors.
• Loss of confidence in the work they do.
• Some face difficulty sleeping.
• Concern about their reputation as a care giver
• Reduction in their sense of job satisfaction.
• Excellent clinicians may leave the profession
prematurely when involved in a preventable
error.

36. Medical error: the second victim..
• The term second victim was initially coined by Wu in
his description of the impact of errors on
professionals. The doctor who makes the mistake
needs help too.
• In the aftermath of a mistake, it's important the
doctor seek support to deal with the consequences.
Albert W Wu associate professor
School of Hygiene and Public Health and School of Medicine, Johns
Hopkins University, Baltimore, MD
2013-8-23 36

37. System Failure Vs Individual Fault

38. ―Insanity: doing the same
thing over and over again and
expecting different results‖
Albert Einstein
2013-8-23 38

39. Avedis Donabedian
1966 –Structure leading to Process and process leading to Outcome
Whether a procedure or intervention has made a favorable difference.
Structure Process Outcome Paradigm

40. ―Every system is perfectly designed to
achieve the results it gets.‖
Donald Berwick, M.D.
President & CEO of Institute for Healthcare Improvement
2013-8-23 40

41. Not Bad people - But Bad Systems
2013-8-23 41

42. Medical Errors related Behavioral
Choices
Reckless
Behavior
Intentional Risk-Taking
Manage through:
• Remedial action
• Disciplinary action
At-Risk
Behavior
Unintentional Risk-Taking
Human
Error
Product of our current
system design
Manage through changes in:
• Processes
• Procedures
• Training
• Design
• Environment
Console Coach Punish
Manage through:
• Removing incentives for
at-risk behaviors
• Creating incentives for
healthy behaviors
• Increasing situational
awareness

43. How do we prevent errors?
Errors can be prevented by
designing systems that make it
hard for people to do the wrong
thing, and easy for people to do
the right thing.
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44. Critical thinking & System redesign - video

45. Critical Thinking - Video

46. System Redesign- Video

47. System Design- Forcing Function
2013-8-23 47

48. Steps to Minimize Medical Error
Forcing functions & constraints
Automation & computerization
Standardization & protocol
Checklist & double check system
Rules & policies
Education/ Information
Be more careful, be vigilant
Most
effective
Least
effective

49. Tools & Techniques
To prevent medical errors &
Improve patient Safety

50. Accreditation programs
Seeking gold standards
National Accreditation Board for Hospitals
& Healthcare Providers (NABH) is a
constituent board of Quality Council of
India

51. JCIA- Standards
1. International Patient Safety Goals (IPSG)
2. Access to care and continuity of Care (ACC)
3. Patient and Family Rights (PFR)
4. Assessment of patients (AOP)
5. Care of patients (COP)
6. Anesthesia and Surgical care (ASC)
7. Medication management and use (MMU)
8. Patient and Family Education (PFR)
9. Quality Improvements and patient Safety(QPS)
10.Prevention and Control of Infections (PCI)
11.Governance Leadership and Direction (GLD)
12.Facility Management and Safety (FMS)
13.Staff Qualification and Education (SQE)
14.Management of communication and Information (MCI)

52. Patient Safety Goals
1. Identify Patients Correctly
2. Improve Effective Communication
3. Improve the Safe Use of Medications
4. Ensure correct-site, correct-
procedure, correct- patient Surgery
5. Reduce the Risk of Health Care –Associated
Infections
6. Reduce the Risk of Patient Harm Resulting
from Falls

53. Goal 1
Identify Patients Correctly
Use two identifiers
Patient full name, DOB, Medical Record # etc
• Before giving medication
• Before administering blood or blood products
• Before taking blood samples & specimens
• Before doing clinical testing
• Before providing any treatment or procedures

54. Correct Patient Identification

55. Do Not Use
Patient Room Number or Location
to identify the patient
1343

56. Use of technology

57. Goal 2
Improve Effective Communication
• Effective communication, which is
timely, accurate, complete, unambiguo
us, and understood by the
recipient, reduces errors and results in
improved patient safety.

58. Miscommunication- Video

59. The German Coast Guard

61. Improve Effective Communication
• Verbal & Telephonic order
– Write down and ―Read- Back‖
• Communicate critical test results
– Write down and ―Read- Back‖
• Use of SBAR, I PASS BATON- structured form of
communication
• Daily Goals Checklist

62. Verbal & Telephone orders

65. Daily Goals Check List

66. Bridging the hierarchy challenges

67. Goal 3
Improve the Safe Use Of Medications
• Following the Seven Rights
• Storage, labeling and segregation of
High Alert Medication
• Do Not Use dangerous abbreviation
List
• Medication Reconciliation

68. Seven rights to prevent medication
errors
• RIGHT drug
• RIGHT patient (Two Identifiers)
• RIGHT dose
• RIGHT time
• RIGHT route
• RIGHT reason
• RIGHT documentation

69. Improve the Safety of High-Alert
Medications
HIGH ALERT MEDICATIONS :-
Drugs that bear a heightened risk of
causing significant patient harm when
they are used in error. Although mistakes
may or may not be more common with
these drugs, the consequences of an
error with these medications are clearly
more devastating to patients.
(Institute for Safe Medication Practice)

70. Storage, labeling and segregation
• Concentrated Electrolytes are removed
from patient care areas unless clinically
necessary
• Segregated from other medications and
Labeled as "High Alert
Concentrated electrolytes are:
Magnesium sulfate injection
Potassium Acetate injection
Potassium chloride for injection concentrate
Potassium phosphates injection
Sodium Acetate injection
Sodium bicarbonate 8.4% injection
Sodium Chloride for injection, hypertonic (greater
than 0.9% concentration)
Sodium Phosphate injection

71. Storage, labeling and segregation

73. Independent Double Checking- Video

74. Independent double check

75. Medication Reconciliation
• Obtain information on the medications
the patient is currently taking
• Medication orders are compared to the
list of medications taken prior to
admission

76. The Medication Use System
Selection
&
Procuring
Establish
formulary
Monitoring
Assess patient
response to
drug; report
reactions &
errors
Administering
Review
dispensed drug
order; assess
patient &
administer
Preparing &
Dispensing
Purchase &
store drug;
review &
confirm order;
distribute to
patient location
Prescribing
Assess
patient;
determine
need for drug
therapy; select
& order drug
Clinician &
administrators
Physician/
prescriber
Pharmacist Nurse/other health
professionals
All
practitioners, plus
patient &/or
family
Joint Commission. 1998

77. Major Areas for Medication Error
Prescribing
Transcribing
Dispensing
Administering
38% 39%
12% 11%
Medication Errors Reporting Program US

79. Prescribing Errors
Contributing factors:
• Illegible handwriting
• Inaccurate medication history taking
• Confusion with the drug name
• Inappropriate use of decimal points
• Use of abbreviations
• Use of verbal order
Williams DJ. 2007

81. Prescribing Errors….. Example
Name That Drug…
Lipitor 10mg PO QD
Filled Rx: Zyrtec 10mg

82. Prescribing Errors….. Example
Name That Drug…
6 units of regular insulin now
Filled Rx: 60 units

83. Prescribing Errors….. Example
Name That Drug…
Tegretol 300mg BID
Filled Rx: Tegretol 1300mg

84. Dispensing Errors
• Selection of the wrong drug
• Similar appearance or similar
name (look alike sound alike
medication)

85. Dispensing Errors…..Example
look alike sound alike

86. Dispensing Errors…..Example
look alike sound alike

87. Administration Errors
Contributing factors:
• Failure to check the patient’s identity
prior to administration
• Storage of similar preparations in
similar areas
• Noise, interruptions, & poor lighting
Williams DJ. 2007

88. Systems & Technology to prevent
medication errors

89. Tall man lettering to prevent
look alike sound alike drugs

90. Computerized Physician Order Entry
CPOE- with decision support system

91. Automated drug dispenser
Barcode Scanner
bedside medication verification

92. Smart Infusion pumps

93. Goal 4
Ensure correct-site, correct-procedure, correct- patient
Surgery.
• Use a checklist.
• Verify all documents.
• Check equipment needed for surgery.
• Mark the precise site ( involve the
patient ).
• Use "time-out" just before starting a
surgical / invasive procedure.

95. WHO Safe Surgical Checklist- Video

96. How to perform a ―Time-Out‖

97. Goal 4
Reduce the Risk of Health Care –Associated Infections
• Strict hand hygiene before and after contact with
each patient or their environment
• Adequate hand hygiene facilities for staff and
patients
• A clean hospital environment and good hygiene
practice
• Isolation of patients in single rooms, when
necessary, to reduce the risk of infection
• Careful prescription of antimicrobial drugs
• Training on infection prevention and control for all
staff

100. Five moments of hand hygiene

101. Technology support
Sharps disposal box
Hand sanitizer dispenser

102. Antimicrobial Stewardship
• Antibiotic stewardship refers to a set of
coordinated strategies to improve the
use of antimicrobial medications with
the goal of enhancing patient health
outcomes, reducing resistance to
antibiotics, and decreasing
unnecessary costs.
• The Infectious Diseases Society of
America (IDSA)

103. Healthcare Associated Infection-
HAI
• Central line Associated Blood Stream
Infection- CLABSI
• Surgical Site Infection-SSI
• Cather Associated Urinary Tract
Infection-CAUTI
• Ventilator Associated Pneumonia -VAP

104. HAI
• CLABSI
– Attributable mortality: 9-25%
– Attributable cost: $25,000-$45,000
– Of patients who get a bloodstream infection from
having a central line, up to 1 in 4 die.
• CMS Medicare and Medicaid no longer pays
hospital for CLABSI
• CLABSI
– Remove Unnecessary Lines
– Wash Hands Prior to Procedure
– Use Maximal Barrier Precautions
– Clean Skin with Chlorhexidine
– Avoid Femoral Lines

109. Replicating the same for
CLBASI Free Days
109

110. NNU CLABSI Free Days
110

111. PICU CLABSI Free Days
111

112. ICU CLABSI Free Days
112
CUSP Team with the ICU Executive - COO

113. Dangerous enviornment
Spread of infection- Video

115. Goal 6
Reducing the risk of patient resulting from fall
• Falls account for a significant portion of
injuries in hospitalized patients.
• Establish fall-risk reduction program
– Initial assessment of patients for fall risk
during admission
– Reassessment of patients when indicated
by a change in condition or medications
– Implemented fall reduction strategies
– Monitor intended and unintended
consequences of fall risk measures

116. Epidemiology of inpatient falls
• 1235 falls by 1082 pts (3.10 falls/1000 pt
days)
• 89% single fall, 11% more than once
• 40% related to toileting
• Serious injury (laceration requiring
sutures, loss of
consciousness, fracture, SDH) – 6%
• Death – 0.2% (both in patient with more than
1 fall)
Source: Inf Control Hosp Epidem 2005;26:822

117. Falls risk assessment tools
• Morse, STRATIFY, Hendrich II

120. Prevention strategies to reduce patient fall-
video

122. Fall Prevention Strategies
Place fall precautions sign in patient’s room.
Communicate fall risk during hand-off of care
Maintain bed in low position, and put bed rails up.
Assess hourly patient’s need for toileting.
Actively engage patient and family
Lock all moveable equipment before transferring patients.
Do not leave patient unattended for transfers/toileting.
Place patient care articles within reach (call bell, urinal, phone,
water).
Provide physically safe environment (adequate lighting,
eliminate spills, clutter, electrical cords, and unnecessary
equipment).
Evaluate medication profile for fall risk.
Move patient closer to the nursing station for those at High Risk

123. Fall prevention protocols

124. ―If you can’t measure it, you
can’t manage it.‖
Peter Drucker

125. Key Performance Indicators (KPIs)
• Embrace the following :
– People – staff focus
– Service – customer focus
– Quality – excellence in clinical
outcomes and service
– Finance
– Growth – expansion of
services

126. Dashboards
• Powerful graphs
communicating both the
financial and nonfinancial
key performance
indicators
• Designed to translate
vision & strategy into
objectives
• Employees can:
– embrace, achieve,
measure & celebrate.
– focus on annual goals &
long term strategic goals.

127. Color Coded Dashboard

128. Discussions- The End Game

129. Are these initiatives sufficient to prevent &
eliminate Medical Errors and improve Patient
Safety?

130. If not……then how do we get to the ideal
situation??

131. Building a Culture of Safety
2013-8-23 131

132. How to integrate SAFETY in to
the CULTURE of the
organization???
A CUSP Approach
Topic of my next lecture will be

133. I will………

134. Resources-websites
• http://www.iom.edu/
• http://www.npsf.org/
• http://www.ihi.org/explore/patientsafety/pages/default.aspx
• http://www.hopkinsmedicine.org/armstrong_institute/
• http://www.josieking.org/
• https://www.patientsafetygroup.org/main/index.cfm
• http://www.pso.ahrq.gov/
• http://www.patientsafety.gov/
• http://www.safetyleaders.org/

135. References
• How many health professionals does a patient see during an average
hospital stay? N Whitt, R Harvey, S Child
• Waterman AD, Garbutt J, Hazel E, et al. The emotional impact of
medical errors on practicing physicians in the United States and
Canada. Jt Comm J Qual Patient Saf 2007;33:467–76.
• Rossheim J. To err is human—even for medical workers. Healthcare
monster. http://healthcare.monster.ca/8099_en-CA_pf.asp (accessed
21 Jan 2009).
• Green, M.J., Farber, N.J., and Ubel, P.A. Lying to each other. Archives
of Internal Medicine, 2000;160:2317-23.
• Mizrahi, T. Managing medical mistakes: ideology, insularity and
accountability among internists-in-training. Social Science & Medicine,
1984;19(2):135-46
• Hickson, G. B., Clayton, E. W., Githens, P. B., et al. Factors that
prompted families to file medical malpractice claims following perinatal
injuries. JAMA, 1992;267:1359-63.

136. References
• Vincent, C., Young, M., and Philips, A. Why do people sue doctors? A
study of patients and relatives taking legal action.
Lancet, 1994;343:1609-13.
• Witman, A. B., Park, D. M., and Hardin, s. B. How do patients want
physicians to handel mistakes? A survey of internal medicince patients
in an academic setting, Archives of Internal
Medicine, 1996;156(22):2565-69.

137. • http://www.patientsafetyalliance.in/

138. Patient Safety Top Priority
Patient Safety Everyone's Responsibility
Contacts:
Email- ksankara@tawamhospital.ae
Mobile- +971 50 9211649
2013-8-23 138
Thank You