Topic presentation

1. Presenter: Dr. Annush Tha
Moderators: Dr. Davendra Shrestha/ Dr. Puspa Raj Koirala
Department of Surgery
Pokhara Academy of Health Sciences
2077/05/16

2. Objectives
• Introduction to patient safety
• Importance of human factor in patient care
• Patient safety incidents/adverse events
• Understanding patient safety incidents
• Patient safety strategies and solutions
• Surgeon’s role in patient safety
• Newer concepts of approaches to safety
• Quality improvements and measures

3. Patient safety
• Patient safety is the avoidance of unintended or unexpected harm to
people during the provision of health care.(NHS)
• Patient safety is a discipline in the health service sector that applies
the method of safety science towards a goal which is to achieve a
reliable health service delivery system.
• Patient safety is also an attribute of the health care system that
minimizes events and impacts, and maximizes recovery from side
effects
• (Emanuel et al., 2008)

4. Patient safety
• “The absence of preventable harm to a patient during the process of
health care and reduction of risk of unnecessary harm associated with
health care to an acceptable minimum”
• An acceptable minimum refers to the collective notions of given
current knowledge, resources available and the context in which care
was delivered weighed against the risk of non-treatment or other
treatment.(WHO)

5. Human Factors
• “The study of the interrelationship
between humans, the tools they work
with and the environment in which
they work”
• The red circle contains those actions or
omissions that impact performance.
These actions impact on practice.
• The outer circle contains factors that
influence care (for better or worse).

6. SHELL concept

7. Patient safety incidents/adverse
• “To Err is Human: Building a Safer Health System “reports
• 44000 and 98000 preventable deaths annually due to medical error in
American hospitals and 7000 preventable deaths related to
medications alone (IOM of he National Academy of Sciences,1999)

8. WHO
• 1/10 patients receiving care will suffer preventable harm
• Medical error would rank 3rd as leading cause of death in US
• 134 million adverse events occur each year in hospitals in LMICs,
contributing to 2.6 million deaths annually due to unsafe care
• Medication errors cost an estimated 42 billion USD annually

9. Patient safety incidents
An adverse event Results in harm to the patient(due to medical
management)
A near miss Incident could have resulted in unwanted consequences
but did not either by change or through timely intervention
preventing the event from reacing the patient
A no-harm event Incident occurs and reaches the patient but results in no
injury to the patient
Sentinel event An unexpected occurrence involving death or serious
physical or psychological injury

10. Medical complexity Health System Human factors
Factors contributing to patient Safety

11. Human Factos
Inadequate patient
assessment-delay or error in
diagnosis
Error in performance of
operation, treatment and test
Inadequate monitoring ,
follow-up
Deficiency in training or
experience
Fatigue , overwork, time
pressures
Inability to recognize the
dangers of medical errors
System factors
Poor communication between
healthcare providers
Less Staffs, uncoordinated
handovers
Disconnected reporting
systems
Environment design,
infrastructures , drug
similarities
Equipment failures, unskilled
operators
Inadequate systems to report
and review patient safety
incidents
Medical
Complexities
Advanced and New
technologies
Potent drugs , side
effects and
interactions
Working
environments –
ICU, Operating
theatres , CCU

12. Most important factor leading to patient safety incident
• Inadequate communication between healthcare staff or medical staff
and their patients or family members –Ranks highest in frequency

13. Patient safety incidents
• Error viewed on two ways
• 1.Person Approach
• 2. System Approach
Person Approach
To err is human - .i.e Humans are fallible
Error of commission- Doing wrong
Error of omission- Failure to act
Error of Execution- Doing the right thing incorrectly

14. The System Approach
• Health system add complex organizational structures to human
fallibility—increases the potential for error substantially
• Most error/events rarely have single isolated cause
• Search for why system failed than who made the mistake

15. Heinrichs’s Safety Pyramid (1931)
Near misses provide
the best data about
the reliability of the
safety system

16. Reason’s Swiss cheese model
All organizations operating
in potentially harmful
environments tend to build
up defenses against
potential damage and that
these defenses can be
broken down by active
failures and latent
conditions
Active failure- acts commited by those at ground level
Latent Condition: decisions taken at a higher level within organization

17. Strategies for patient safety
• “WHO SAVE LIVES: Clean your Hands campaign”
• “WHO Guidelines for Safe Surgery 2009”

19. Strategies in resource rich countries
• Regulating and licensing of physicians and health care institutions
• Developing and adopting policies for patient safety and quality
improvement
• Providing patient safety education programs
• Instituting nation clinical audits
• Reporting(and learning from) adverse events
• Setting up agencies to resolve concerns about the practice of doctors
by providing case and incident management services

20. • In resource poor countries patient safety issues are more acute due to
lack of resource and face different challenges
• Institutions which foster team work, makes maximal use of
information technology and are prepared to align their systems and
processes learning from the patient safety events will provide best
patient safety system

21. Patient safety and the Surgeon
• Coal-face errors surgeons can commit:
Diagnostic and management errors
Resuscitation errors
Prophylaxis errors
Prescription/parenteral administration errors
Situation awareness, identification and teamwork errors
Technical and operative errors

22. Surgeons responsibility and patient safety
Preoperative
From entry in ER/OPD
• Assessment and
diagnosis
• Pre-anaesthetic check-
up
• Making sure patient is
fit for surgery
• Benefits outweighs risks
Intraoperative
From operation
theatre
• Inductions
• Operative procedures
• Reversal
Postoperative
From postoperative
ward
• Anticipate the
complication and
initiate prompt
management
Discharged

23. Situation awareness- Identifying teamwork
errors
• OR- “the most complex political, social and cultural structures that
exist, full of ritual, drama, hierarchy and too often conflict”
• Chances of making errors high
• Errors cannot be prevented individually
• Prevent errors by workplace preparedness and incorporating
defenses in processes involved by identifying teamwork errors with
vigilance and better communication

24. “Safe Surgery Saves Lives”-WHO
• Standard safety protocol in Operating Theatre- Ensures safety and
minimizes the patient safety events
• Surgical safety checklist identifies –checks to be carried out at three
obligatory time points
• Majority of surgical errors(53-70%) occurs outside operation theatre,
before or after surgery—Dictates the need to improve the entire
surgical pathway

25. SIGN IN TIME OUT SIGN OUT

26. Never or serious reportable events
• Identifiable and preventable errors in medical care
• Serious in consequences for patients (harms always)
• Indicates a real problem in safety and credibility of health care facility
Surgery performed in wrong patient or body part
Wrong surgical procedure
Retained foreign objects (swab, instruments)

27. Newer concepts of approaches to safety
• Safety I
Approach to patient safety predicated on identifying errors after
the event and aims to prevent them from occurring or recurring in
future
• Safety II
Approach to perform successful procedure than correcting errors
along the surgical pathway
Ensure Proactive and error free procedure

28. Quality improvement(QI)
• “Designing or redesigning health care processes and systems in
response to a quality gap in order to ensure more efficient, safe,
timely, effective, patient-centered and equitable care”
• Improvements come from the intentional actions of staff equipped
with the skills and data needed to bring about changes in patient care
either directly or indirectly
• Requires substantial and sustained commitment of time and resource

29. Donabedian model for QI

30. Scottish Improvement Hub for QI
Discovering (define Aims
and Vision)
Exploring (define present
state and visualize future
state)
Designing (process to
reach future state)
Refining ( testing change,learining
from data and identify benefits)
Introducing (Putting into the
practice to bring change)
Spreading (Show improvement
and disseminate information)
Closing (Capturing and
sustaining the learning)

31. Six-sigma methodology for QI

32. Consequences of patient safety events
Increased morbidity
hospital stay costs mental
and psychological trauma
mortality
Loss of credibility,legal
issues cancellation of
licence
Physical assaults
Destroys career
Loss of trust, legal cases,
compensations,
vandalisation of property

33. Take home messages
• Patient safety should be the core interest in health care delivery
system which is affected by human and intuitional factors
• Communication breakdown ranks 1st in causation of patient safety
events
• Move towards doing procedure right than correcting errors
• Proceed forward with Quality improvements and sustain the best
evidence based practice methods
• Avoid legal conflicts and vicarious liability issues with utmost care of
patient form admission to discharge

34. References
• Bailey and love’s Short practice of Surgery 27th edition
• Schwartz’a Principles o surgery 10th edition
• The third WHO Global Patient Safety Challenge: Medication Without
Harm
• Crossing the global quality Chasm :Improving Health Care
Worldwide (2018)

35. Thank You