Patient Safety is a health care discipline that emerged with the evolving complexity in health care systems and the resulting rise of patient harm in health care facilities. It aims to prevent and reduce risks, errors and harm that occur to patients during provision of health care.

1. PATIENT AND STAFF SAFETY
MANAGEMENT
DR.ANJALATCHI MUTHUKUMARAN
VICE PRINCIPAL
ERA COLLEGE OF NURSING
ERA UNIVERSITY , LUCKNOW 226003

3. WHAT IS SAFETY
• S – Sense the error
• A – Act to prevent it
• F – Follow Safety Guidelines
• E – Enquire into accidents/Deaths
• T – Take appropriate remedial measure
• Y – Your responsibility

5. WHY SAFETY NEED IN HOSPITAL
• Hospital is a people intensive place
• Provide services to sick people round the clock 24
hours daily 365 days a year.
• People have a free access to enter any part of the
hospital any time for advice and treatment
• The hospital atmosphere is filled with emotions,
excitement, life & happiness, death & sorrow
• Since hospital operates under continuous strain, it
gives rise to irritation, confrontation, conflicts &
aggression, threatening the life of hospital staff &
hospital properties

8. PATIENT SAFETY INITIATIVE
• WHA” INITIATIVE
• • Jan 2002 – Executive Board discuss patient safety
• • May 2002 – resolution adopted by 55th World Health Assembly
• • May 2004 – WHA support establishing World Alliance for Patient Safety
• • October 2004 – launch of the World Alliance and Forward Programme by DG of
WHO
• • December 2005 – first progress report of the Alliance
• WHO/WORLD ALLIANCE FOR PATIENT SAFETY
• Co-ordinate, spread and accelerate improvements in patient safety worldwide
• WHO Patient Safety was created to facilitate the development of patient safety
policy and practice across all WHO Member States and to act as a major force for
patient safety improvement across the world. Our mission
• The mission of WHO Patient Safety is to coordinate, facilitate and accelerate
patient safety improvements around the world by:
• •being a leader and advocating for change;
• •generating and sharing knowledge and expertise;
• •supporting Member States in their implementation of patient safety actions. Our
vision
• •Every patient receives safe health care, every time, everywhere.

9. World Alliance For Patient Safety:
Ten Action Areas
• Global Patient Safety Challenges : Solutions to improve
• 1. Clean Care is Safer Care patient safety
• 2. Safe Surgery Saves Lives High 5s WHO Project
Patients for Patient Safety Catalyse Technology for
Patient Safety Research for Patient Safety countries’
action to achieve Knowledge Management
International safety of care Special projects:
Classification for - Education Patient Safety (ICPS) -
Radiotherapy - Rewarding excellence - When things go
wrong Reporting & - Vincristine sulphate Learning

10. HIGH 5s WHO PROJECT
• A High 5s Steering Group was established in 2006 to determine the overall
architecture of the initiative. The project is being implemented in three phases.
The first phase (2006-2008), initiated in late 2006, has involved the identification
of five evidence-based solutions for patient safety and the development of a
Standard Operating Protocol (SOP) for each solution.
• The solutions are:
• Managing Concentrated Injectable Medicines;
• Assuring Medication Accuracy at Transitions in Care;
• Communication During Patient Care Handovers;
• Improved Hand Hygiene to Prevent Health Care-Associated Infections; and
Performance of Correct Procedure at Correct Body Sites
• The second phase (2008 -2010) identify a lead technical agency in each
participating country to coordinate the High 5s initiative at the country level.
• Impact will be measured using the following tools:
• Root cause analyses of indicator events and other adverse events Patient safety
indicators Cultural assessments Economic impact indices.
• The third phase (2010-2011) Over time, the project will encourage participating
countries to use their established relationships with other countries

11. PATIENT SAFETY INITITIVE
• •Patients know that their ailments may not always be cured, but
they don’t expect to be inadvertently harmed during their medical
care.
• • The “blame and train” approach to medical errors and close calls
doesn’t work well.
• • human factors engineering techniques tease out root causes of
medical errors and close calls.
• • Playing the Blame Game: An Ineffective strategy for improving
patient safety
• • Preventing inadvertent harm to patients requires use of human
factors engineering principles.
• • In other high hazard jobs such as airplane flying and running
nuclear reactors, systems have been developed to minimize risks
based on the science of human factors engineering. There fore
concept of Patient safety has been derived from Aviation industry.

12. SHARED SAFETY BEHAVIORS AVIATION
& MEDICINE
• • Broaden dimensions
• • human factors engineering
• • fatigue & stress management
• • effective communication
• • shared awareness
• • teamwork
• • Countermeasures
• • briefings, debriefings
• • workload distribution
• • cross-monitoring
• • graded assertiveness
• • checklists

14. SURGICAL SAFETY
1. Consent of the patient/ relative in writing
2. Proper identification of patient, name wrist band
3. Proper identification mark of parts to be operated
4. Pre- anesthetic check-up
5. Anesthetic Safety
6. Ensure no foreign body left inside
7. Safety measures from ward to OT & coming back (Safety check list)
8. Prevention of surgical wound infections
9. Use of Surgical safety proforma in all operations
10. Check Safety code if available DNR Purple Falls Risk Yellow Allergies Red
(Red for Allergy Alert, yellow for Fall Risk, and Purple for Do Not Resuscitate).
WHO SURGICAL SAFETY CHECKLIST
 The primary benefit of the checklist may be to engage the medical team.
 By using the checklist, we may be gaining the ability to open
communication by the medical team, to encourage teamwork behaviors,
& to develop discipline in the team.
 Reducing sentinel error

16. INSTALLATION HAZZARDS
• 1. Regular checking of equipments
• 2. Proper earthling to avoid shock
• 3. Regular maintenance & repair
• 4. Training of nurses & technical staff
• 5. How do you control hazards?
• • Preventing inadvertent harm to patients requires use
of human factors engineering principles.
• 6. The “hierarchy of hazard control:”
• • Eliminate hazard
• • Guard against hazard
• • Train to avoid hazards
• • Warn against hazards

17. NEW DEVICES
• Acceptance, safety inspection, compatibility,
education, procedures, and appropriate
purchasing documents (including loan
agreements).
• When in doubt, have CE (Certified
Equipment)check, supply chain management
.(SCM),

18. WHY REPORTING MEDICAL DEVICE
PROBLEMS
• • Prevent future problems and protect patients, staff,
families, and visitors
• • Achieve performance improvement goals
• • Assist Risk Management with claims or litigation
• • Provide information to manufacturers and/or Food
and Drug Administration
• • Publicize report for the general good of patients and
health care providers
• • Effect changes in policies and procedures of
procurement

19. WHEN TO REPORT
• When you think a device has or may have
caused or contributed to any of the following
outcomes (for a patient, staff member or
visitor):
• – Death
• – Serious injury
• – Minor injury
• – Close calls or other potential for harm

20. INDIVIDUAL’s ROLE
• Identify actual and potential problems,
adverse events, close calls with medical devices
• Report the problem or adverse event to your
supervisor, according to policy and procedure
• Make sure your report includes details
• Remove the device, keep all affected items,
save the packaging

21. ELECTRICAL SAFETY
• 1. Safety fuses with each equipment
• 2. No loose wires or connection
• 3. Properly plugged and fixed
• 4. If short circuit call electrician
• 5. Electricity back up battery/ generator
• 6. Use of CVT/UPS

22. FIRE SAFETY
• Use Fire proof material for construction.
• Have Fire Exit in all Buildings.
• Smoke detectors and water sprinklers on the
roof of all Floors.
• Fire Extinguishers in all areas.
• Fire Hydrants in all buildings.
• Training in Fire management

23. BLOOD SAFETY
• 1. Proper grouping & cross matching
• 2. Tests of HIV, Inf. hepatitis & VDRL
• 3. Proper leveling of group, name of the patient
• 4. Control of mismatch reaction
• 5. Standard operating procedure
• 6. Screening against HIV, Hepatitis. VD, Malaria.
• 7. Inform adverse reaction to BB

24. SANITATION- INFECTION CONTROL-
BMW DISPOSAL
• Sanitation BMW HAI Disposal
• • Proper segregation & transportation of biomedical wastes
• • Sanitation & hygiene of different parts of hospital to avoid
infection
• • Use of sterile procedures
• • Safety in use of incinerator, autoclave, shredder, needle
destroyers and proper disposal of biomedical waste.
• • Formation of hospital infection control committee
• • Investigation of all hospital infections
• • Use of proper antibiotics in right doses in right time
• • Reorientation of Resident doctors & Nursing staff

25. LABORATORY SAFETY
• •Avoid needle prick & spilling of blood
• • Safety measures in Radiology & Radiotherapy
departments
• • Safety norm guide lines for different areas of
hospitals.
• • Regular pest control measures
• • Care in handling acids, reagents, inflammable
substances.
• • BMW segregation and disposal

26. WHO IS RESPONSIBLE
• NURSE -DOCTOR
• PATIENT- NURSE
• PATIENT -DOCTOR

27. PATIENT INVOLVEMENT
• • Individual Advocacy – In doctor & hospital visits
– Share information
• • Create lists of health problems, previous
operations, etc.
• • List or bring all medications, supplements, and
vitamins – Get information
• • Ask questions about treatments, medications,
etc.
• • Research illnesses and treatments – Bring an
Advocate – Know what to do before leaving
• • Ask about medications and future
appointments

28. PREVENT MEDICAL ERRORS BY PATIENT
A. MEDICINES
• 1. Make sure that all of your doctors know about
every medicine you are taking. This includes
prescription and over-the-counter medicines and
dietary supplements, such as vitamins and herbs.
• 2. Bring all of your medicines and supplements to
your doctor visits. Your medicines can help you
and your doctor talk about them and find out if
there are any problems.
• 3. Make sure your doctor knows about any
allergies and adverse reactions you have had to
medicines.

29. ERRORS BY PATIENT
• 4. When your doctor writes a prescription for you, make sure you can read it.
• 5. Ask for information about your medicines in terms you can understand—both
when your medicines are prescribed and when you get them: •What is the
medicine for? •How am I supposed to take it and for how long? •What side effects
are likely? What do I do if they occur? •Is this medicine safe to take with other
medicines or dietary supplements I am taking? •What food, drink, or activities
should I avoid while taking this medicine?
• 6. When you pick up your medicine from the pharmacy, ask: Is this the medicine
that my doctor prescribed?
• 7. If you have any questions about the directions on your medicine labels, ask if
"four times daily" means taking a dose every 6 hours around the clock or just
during regular waking hours.
• 8. Ask your pharmacist for the best device to measure your liquid medicine.
Special devices, like marked syringes, help people measure the right dose.
• 9. Ask for written information about the side effects your medicine could cause. If
you know what might happen, you will be better prepared if it does or if
something unexpected happens.

30. B. HOSPITAL STAYS
• 10. If you are in a hospital, consider asking all health
care workers who will touch you whether they have
washed their hands. Hand washing can prevent the
spread of infections in hospitals.
• 11. When you are being discharged from the hospital,
ask your doctor to explain the treatment plan you will
follow at home.
• •About your new medicines,
• •When you can get back to your regular activities.
• •Continuing old medicines before your hospital stay.
• •When to come back to the hospital for check up

31. C. SURGERY
• 12. If you are having surgery, make sure that you,
your doctor, and your surgeon all agree on exactly
what will be done. Surgeons are expected to sign
their initials directly on the site to be operated on
before the surgery.
• 13. If you have a choice, choose a hospital where
many patients have had the procedure or surgery
you need. Research shows that patients tend to
have better results when they are treated in
hospitals that have a great deal of experience
with their condition.

32. D. OTHER STEPS
• 14. Speak up if you have questions or
concerns.
• 15. Make sure that someone, such as your
primary care doctor, coordinates your care.
• 16. Make sure that all your doctors have your
important health information.
• Learn about your condition and treatments by
asking your doctor and nurse and by using
other reliable sources.

33. PATIENT INVOLVEMENT
• Patient Representative
• – In health care organizations
• – Work to improve safety at the organization
and individual unit level
• – Serve on committees and boards
• – Assist on rounds and here patient
greivences
• – Support staff and families

34. • Patient Participant/Activist
• – Participate on state and regional coalitions and
organizations and/or
• – Serve nationally
• – Advocate for public reporting and accountability of
hospital and health system performance
• – Volunteer, make donations, work with fund- raising
• – Be aware of state and national legislation, contact
legislators

35. • • Patient Advocate
• – For friends and family
• – Willingness to go with the patient to
appointments, be with them in the hospital and
clinics
• – Listening and taking notes
• – Speak up when necessary to clarify an issue and
to ask a question
• – Question when something does not seem right
in the hospital, nursing homes, clinics, etc.

36. PREVENT MEDICAL ERRORS BY
MEDICAL STAFF
• Communication & coordination deficits drive errors
• Application of Aviation Safety concepts & skills are
being introduced in healthcare
• Strong Correlation between Teamwork results in:
• •Improved Patient Outcomes
• •Patient Satisfaction
• •Staff Satisfaction
• •Reduced Errors
• •Reduce malpractice claims
• •Reduce ‘Blame culture’

37. TWO-CHALLENGE RULE
• It is your responsibility to assertively voice your
concern at least two times to ensure that it has
been heard
• The member being challenged must acknowledge
• Provide supporting information with second
challenge
• If the outcome is still not acceptable use ‘CUS’
Concern, Un comfortable , Stop Take a stronger
• course of action “Empower any member of the
team to “stop the line” if he or she senses or
discovers an essential safety breach.”

38. EFFECTIVE COMMUNICATION
• Communication Breakdowns Contributing Factor in 43% of adverse
surgical events
• Pivotal Factor in 65% of Sentinel Events (3,000 events 1995-2005)
(Joint Commission on Accreditation of Healthcare Organizations.
(2006)
• Primary contributing factor in adverse events 70-80% of root cause
analysis (National Center for Patient Safety(2006).
• Root Cause Analysis Database)
• Common in:
• •Medical errors
• •Medical malpractice cases
• •Adverse surgical events
• •Adverse medical events
• •Sentinel events

39. ADVERSE INCIDENT REPORTING
• Complete and submit
• Notify Risk Management
• Drug controller notification if Medical Device
or Medication
• Begin Root Cause/Intensive analysis to
examine process changes that may prevent
future events
• Take preventing measures for future near miss.

40. PEER REVIEW
• Monitor and improve physician care of patients
• Accomplish by:
• •Open, non-punitive discussion
• •Review and discuss alternatives
• •Disseminate to ALL physicians
• •Monthly review schedule Move towards: review previous
48 hour record (Code Blue)
• •Could this event have been prevented?
• •Were signs of deterioration missed?
• Elevated BP,
• dropping BP Elevated HR,
• dropping HR Elevated RR

41. HEALTH EXECUTIVE’S ROLE
• Set Culture
• Accountability
• Measures
• High Reliability/Redesign
• Communication and Teamwork
• Professional Development
• Reliability principles: simplification
,standardization ,relation of humans to the work
,environment