patient safety .by dr.gyanaranjan

Patient Safety In Public Health Care Institutions

A Conceptual Postmortem &

Critical Analysis

By.

Dr.Gyanaranjan Pradhan(PGDHM*) drgyanaranjan@gmail.com

Dr. S.Yasobant (MPH *)

dryasobant@gmail.com

* Pursuing

Clean Care is Safer Care

Content To Be Covered

Objectives of presentation.

What is patient safety?

Public Heath Care Institutions in India.

Patient Safety and India.

Patient Safety In Public Health Care institutions

drgyanaranajan@gmail.com dryasobant@gmail.com

Content to be covered

Conceptual Postmortem of the issue :Factors

Responsible.

Result of Postmortem: Explore Various Dimensions Of Patient safety.

Critical analysis :Frame Work To Increase Patient Safety

Conclusion.

Patient Safety In Public Health Care institutions

drgyanaranajan@gmail.com dryasobant@gmail.com

Objectives of presentation

To know how unsafe our patients are.

Explore the hidden factors of patient safety along with most common factors

How to create a culture of patient safety

Managerial suggestions to overcome

Patient Safety In Public Health Care institutions

drgyanaranajan@gmail.com dryasobant@gmail.com

How much unsafe our patients are?

Number of doctor: 70,0000

Accidental death caused by doctors per year:

120,000 Hence Accident Per

Year/Doctor:17.14 * *Curtsey USA dept. Of Family

Welfare.

Number of gun owners:

80,000,000 Accidental death due to gun

:1500

Hence Accident Per Year Per

Gun:0.001875*

*Curtsey FBI

Doctors Are More Dangerous than Guns In USA…..

Conclusion: Doctors are 9000 times dangerous than Gun

Patient Safety In Public Health Care Institutions

How much unsafe our patients are?

Health Care Industry is one of the Risk Industry….

Fatal Iatrogenic adverse event

Himalaya mountaineering

Chemical Industry

Medical Risk Total

Road Safety

Nuclear Industry

Cardiac Surgery

Micro light aircraft

Very un safe ..... Risk ….. Ultra safe

Railways

Commercial large jet aviation

Charted flight

Blood transfusion

Patient Safety In Public Health Care institutions

What is patient safety? Do no harm 1st corner stone of medicine…

The prevention of errors and consequence adverse effects to patients associated with health care . (WHO)

Health care error : At various level ;At various aspects

From managerial………...To Clinical

Human Cause…………….To Instrumental

Policy Failure ……………...To System failure

Patient Safety In Public Health Care institutions

drgyanaranajan@gmail.com dryasobant@gmail.com

What is patient safety: Various dimensions

Freedom from accidental injury……

Patient Safety In Public Health Care institutions

Health care error

Diagnostic

Treatment

HAI

Medicine error Surgical error

Communication Equipment

Physical enviourment accidents

Transfusion (blood & fluid)

Pri

mary care

23,236 PHC 1,46,026 Sub centre

3,346 CHC

4,400 DHC

242 Medical colleges 205 Dental colleges

Three tier health Delivery model in India A great challenge for patient safety

Patient Safety In Public Health Care institutions

Ref.k.Park20th ed.

India‘s health care paradox For why patient safety is a ”?”

Patient Safety In Public Health Care institutions

Patient Safety and India: legal aspects

Health to all or safe care to all?

No direct legal frame work: Constitution not provide special right to patients.

Sec-304 0f Indian penal code 1860: Space to complain against physician for negligence.

IMC professional etiquette and ethics regulation : Address the issue

Consumer act :Use some time

Patient Safety In Public Health Care institutions

Patient Safety and India : Current scenario Time to think and progress

At corporate /private hospitals: Quite promising but still need more attention to create patient safety as a culture

Our focus public health care institutions: Not only disappointing but also a headache for all stake holders

Over burden the system: By increase visit to hospitals, burden of disease, out pocket and public spending , longer bed occupancy& queue in OPD.

Reduce faith on public health care system and growth of parallel market.

Vision gradually turned in to rhetoric or a utopian appeal-because something lack to

Vision Reality

Patient Safety In Public Health Care institutions

Back ground of study : Just give a overview

Thanks to all who cooperate us

Non-interventional-explorative study design

Total number of public health care institutions cover:

1.Sub-cetre and Anganwadi: 6

2.PHC:6

3.CHC:4

4:DH:3

Patient Safety In Public Health Care institutions

drgyanaranajan@gmail.com & dryasobant@gmail.com

Postmortem of Patient safety Funny but a necessary

Patient Safety In Public Health Care institutions

Public health care Institutions

Overburden

Collapsed

Patient safety venerable

Death of patient safety in these organizations

Why postmortem: Explore the cause

Not a natural death

The death is suspected due to Individual causes :Health care professionals and other

supportive enviourment

System causes : The health care delivery system and

work process

So there is need to find the exact cause

By

Conceptual postmortem

Patient Safety In Public Health Care institutions

The Procedure of postmortem should not be biased

– Patient Safety In Public Health Care institutions

Open eye observation:

Silent data collection

Interacting with various stake holders of system

Secondary data Sources

drgyanaranajan@gmail.com & dryasobant@gmail.com

Findings of Postmortem You may not belief but true

Already well focused :But seems to be a nightmare.

Patient Safety In Public Health Care institutions

Number of issues :Represents interlinking factors

Various dimensions of factors: Multi facet interaction

Most common highlighted causes : Mask the root causes, So difficult to Addressed

drgyanaranajan@gmail.com dryasobant@gmail.com

Current Scenario :We all know Valuable clues towards solution

Patient Safety In Public Health Care institutions

Critical analysis of Findings Not criticism but finding

Patient Safety In Public Health Care institutions

Issue-1:Human Resource: It’s dimensions

Inadequacy and

Inequitable distribution

Lack Competency

related to patient safety

Beehavioural change and poor attitude

towards patient safety

Required some special strategy to address

Critical analysis of Findings Only findings are not enough

Patient Safety In Public Health Care institutions

Issue-2.Work Culture: Various dimensions

Un-supportive Work

enviourment

Lack of team work &

Leadership

Not people Centered

work culture

Required some special strategy to address

Frame work to increase patient safety some hopeful suggestion

Patient Safety In Public Health Care institutions

Create a culture of patient safety in public

healthcare institutions: focus on system issues and individual issues.De-centralization of organizational structure and streamline

the management process.

The administrative power shifted from medicos to medicos specialized in healthcare management.

Allotment of resources and its proper distribution

Patient Safety In Public Health Care institutions

Conclusion Not possible to conclude still we are not achieve the Goal

From Too Much Zeal For The New And Contempt For The Old; From Putting Knowledge Before Wisdom Science Before Art Cleverness Before Commonsense From Treating Patient As a Case And For Making Cure of Disease More Grievous Than The Endurance Thereof ; Good lord Deliver Us By: Robert hutichison

Thanks to all Join Hands Creating a culture of patient safety

Patient Safety In Public Health Care institutions

Special Thanks

To

Prisim-2012

&

You!!!!drgyanaranjan@gmail.com & dryasobant@gmail.com