Patient safety
Prof.Dr.Chinna Chadayan.N
RN.RM., B.Sc (N)., M.Sc (N)., Ph.D (N).,
Professor,
Adult and Elderly Health Nursing Department,
Enam Nursing College – Savar,
Bangladesh.
1st yr M.Sc (N)
2nd batch
Unit – 17c

Patient Safety Definition
• “Patient safety is the prevention of errors
and adverse effects to patients associated
with health care..”
• Essentially, patient safety is about
constantly working to avoid, manage and
treat unsafe acts within the health care
system.

Patient Safety:
Challenges and Concerns
 Difficulty recognizing errors
 Lack of information systems to identify errors
 Relationship of trust with providers
 Shortages of clinical professionals
 Concern about liability
 Limited capacity on how to use quality
improvement tools such as PDSA
 Culture of patient safety is lacking

Some Reasons Why Errors Occur
processes
 Complexity of health
care work environments
 Lack of consistent
administration practices
 Deferred maintenance
 Clumsy technology
System Factors Human Factors
 Complexity of healthcare Limited knowledge
 Poor application of
knowledge
 Fatigue
 Sub-optimal teamwork
 Attention distraction
 Inadequate training
 Reliance on memory
 Poor handwriting

DEFENSES
Accident
Regulatory
Narrowness
Incomplete
s
Mixed
Procedure Messages
Production
Pressures
Responsibility
Shifting
Inadequate
Training
Attention
Distraction
s
Deferred
Maintenanc
e
Clumsy
Technology LATENT
FAILURES
Goal Conflicts
and Double
Binds
Trigger
s
The
World

The “Swiss Cheese” Theory
of System Error
After J. Reason
Patient receives
wrong
medication, and
has a respiratory
arrest
Different medications
stored in look alike bags
No warning labels
on dangerous
medications
Nurse staff
shortage
Nurse
prepares to
administer a
medication
Unanticipated
increase in
patient
volume/severity

Patient Safety
 Active Failures
 highly visible errors with immediate consequences
 Latent Failures
 may be hidden for years and generally rooted in
organizational culture
 takes the right set of circumstances for the error to
become visible or known

The Anatomy of
Errors in Healthcare
Blunt End of the System
Sharp end
of the
System
Organizational Factors -
culture, policies,
procedures, regulations
Environmental Factors -
equipment, staffing,
resources, constraints
Human Factors - clinical
competency, communication
skills, problem solving skills

Culture of Safety
Indicate the extent to which you agree with following
statements. Scoring: strongly disagree, neutral, agree,
strongly agree.
1. Senior management provides a climate that promotes
patient safety
2. If people find out that I made a mistake, I will be
disciplined.
3. My supervisor/manager says a good word when he/she
sees a job done according to established patient safety
procedures
4. Discussion around major events focuses mainly on
systems-related issues, rather than focusing on the
individual(s) most responsible for the event.

Behaviors
 Human error – inadvertent action: doing other than what should
have been done.
Manage through change in processes, procedures and training.
 At risk behavior: behavioral choice that increase risk where risk
is not recognized or is believed to be justified.
Manage through increase awareness, and providing incentives
for healthy behaviors and disincentives for risky behaviors.
 Reckless behavior: consciously disregard substantial and
unjustifiable risk.
Manage through Remedial and punitive action.

Responsibilities of Governing
body to enhance patient safety
 Setting aims
 Getting data
 Establishing and monitoring system-level
measures.
 Change the environment, policies and
cultures.
 Learning.
 Establish executive accountability.

International Patient Safety Goals

International Patient Safety Goals
 Goal 1 Identify Patients Correctly
 Goal 2 Improve Effective Communication
 Goal 3 Improve the Safety of High-Alert
Medications
 Goal 4 Ensure Correct-Site, Correct-
Procedure, Correct-Patient Surgery
 Goal 5 Reduce the Risk of Health Care-
Associated Infections
 Goal 6 Reduce the Risk of Patient Harm
Resulting from Falls

Nursing Theory in
Patient Safety

Thank u