5. .The paediatrician ordered injection of
vitamin K. The nurse gave the baby injection.
Her parents realized she was no longer
breathing after sometimes. They rushed her
back to the clinic. The baby girl died later
that afternoon.
6. Patient a science that promotes the use of
evidence-based medicine and commonsense
improvements in an attempt to minimize the
impact of human error on the routine delivery
of health services.
Our main aim is “First, Do No Harm”
8. S – Sense the error
A – Act to prevent it
F – Follow Safety Guidelines
E – Enquire into accidents/Deaths
T – Take appropriate measure
Y – Your responsibility
9. An Adverse Event
A near miss
A no harm
Negligence
10. Around 1 in 10 hospitalized patients
experience harm, with at least 50%
preventability
The number of death attributed to medical
error = one jumbo jet crash per day.
Approximately 43 million patient safety
incidences occur every year
Medication errors cost an estimated 42 billion
USD annually
11. Human factor
Inadequate patient assessment
Failure to interpret appropriate test
Error in treatment or operation
Inadequate monitoring
Deficiencies in training
Fatigue
Personal or psychological factor
Lack of recognition of the dangers of errors
12. Poor communication
Inadequate staff level
Disconnected reporting system
Lack of proper handovers
Environment design
Equipment failures
Cost-cutting measures
Inadequate system to report incidents
14. All organizations operating in potentially harmful
environment tends to build up defenses against
potential damage and that these defenses can be
broken down by active failures and latent
condition.
17. International Level :By WHO
“Clean care in safer care” ,
“Safe surgery save lives”
“Patient safety alerts”.
Institution and Hospital Level:
Team working and Training
Using information Technology
Redesigning systems and processes
18. Good communication
Professional behavior and
maintaining fitness to practice
Reporting adverse events and near
misses
Staff communication and the work
environment
Practices to reduce fatigue and
stress.
19. Every year almost
7000 patients die
due to bad
handwritten medical
prescription by
doctors
20.
21. Lean is a set of operating philosophies and
methods that help create a maximum value
for patients by reducing waste and waits
22.
23. Surgery performed on the wrong patient or
side or site
The wrong procedure performed
Failure to communicate changes in the
patient’s condition.
Disagreements about proceeding
Retained instruments or swab
Wrong surgical count
24. The surgical safety checklist identifies
specific checks to be carried out at
three obligatory time points
27. Case example
In OR a nursing student notices that the
surgeon is closing the wound and there is
still a pack inside the patient. The student is
not sure if the surgeon is aware of the pack
and is wondering whether to speak up.
Create an effective learning environment
Safe and supportive learning environments
28. The five “whys”
Statement: The nurse gave the wrong drug.
Why?
Statement: because she misheard the name of
the drug ordered by the doctor.
Why?
Statement: because the doctor was tired and it
was the middle of the night and the nurse did not
want to ask him to repeat the name.
Why?
Statement: because she knew that he has a
temper and would shout at her.
Why?
Statement: because he was very tired and had
been operating for the last 16 hours.
Why?
Because...
29. Healthcare workers may experience a range
of emotions including distress, shame, guilt,
fear and depression
Leads to physical and psychological
disturbances.
Hamper the care of other patients.
30. Schwartz’s Principle of Surgery.
Bailey and Love’s Short practice of
Surgery.
World Health Organization’s Patient
Safety Manual.
Lawal AK, Rotter T, Kinsman L, et al.
Lean management in health care:
definition, concepts, methodology and
effects reported (systematic review
protocol). Systematic Reviews.
2014;3:103. doi:10.1186/2046-4053-
3-103.
Notas do Editor
Hospital in India
The surgeon was over confident and he didn’t checked the imaging reports before the surgery
A couple took their two-week-old baby girl for a routine check-up. Later they found that the injection injected to the baby was injection epinephrine instead of injection vitamin k. and the nurse who injected the medicine was confused because the colour of vials for both medicine was same
Patient safety is a fundamental principle of health care
1 respect for the patient's right to self-determination
2the duty to 'do good‘
the duty to 'not do bad‘
4– to treat all people equally and equitably.
1. An incident which results in harm to the patient
2. an incident that could have resulted in unwanted consequences but did not.
3. An incident that occurs and reaches the patient but results in no injury to the patient.
4 . Care that fails below a recognized standard of care.
The number of death attributed to medical error is the aviation equivalent of one jumbo crash per day. A jumbo can carry maixmum 660 passengers .
After reporting this data interest in patient safety research and programs increased significantly
1 delay or error in daignosis
4 foloow up of the patient
5 experience
6 , due to overload, time pressure
7 eg depression and drug abuse
1 Between health care providers
3 over reliance on automated system
6 due to lack or parts or skilled operators
1931 Unsafe acts or near misses lead to minor injuries and over time to a major injury.
It also assess the risk of near misses Not only by reducing the number of mistakes but increasing the number of defenses set up against the consequences of mistakes, near misses are the best data about the relaibility of safety system. Important to report near misses and adverse events
Reason Hypothesized that
Active failures .. Errors at the ground level 2 latent condition .. Created by the decision taken by higher level or administration. When a adverse event occurs ..not only individual is to be blamed .. Whole system and administration should also be blamed because they are also responsible for creating these loop holes.
Each slice of the cheese is an oppurtunity to prevent an accident .. More the slice fewers the hole .. And there is lees chance of accident to occur.
The centre of the model is human factor ….it is the most flexible factor but it is also the most unpredictable factors because different person have different skill personality attitude . Hardware the device and equipment we use while working. Soft ware means non physical aspect of the system the manuals checklist and computer porgrams 4 the flow of the information to the patient and to the colleagues should not be interrruptted and identical
1Poor communication is a common reason for patients taking legal actions.
4 smooth communication between the staff and healthy environment should be created
Organizations and individuals should manage Practices to reduce fatigue and stress
A doctor many think the pharmacist will understand his regular prescription. But patients may go to another pharmacy and end up with wrong medication.
Prescription are Important in childrens and in patients while prescribing narcotics and anti pshycotic drugs
Based on the Toyota model,
Reduce waste and how to maximize the potential of the available manpower
We cant change the human condition but we can change the condition in which we are working.
Serive in affordable cost
1 failure or late conversion of a difficult laparoscopic procedure into an open one.
2 When we take a step in a surgery for granted and skip it
3 when too much force is used.
1 which is unique to minimal access surgery :misreading of a two-dimensional image
2 , such as with energised dissection modalities, for example, diathermy
3 either at the time of surgery or diagnosed late
All the discussion leads to a question ?
At every level of the medical education patient safety is important
Sometimes the media think that we medical persons are machines not human being. Not only the media but the person at the higher level also think we are machines.