patient safety basics (1)
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The Basics of Patient Safety
How You Can Improve the Safety of Patient Care
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The Patient Safety Imperative Recent studies suggest that:
Medical errors occur in 2.9% to 3.7% of hospital admissions.
8.8% to 13.6% of errors lead to death. As many as 98,000 hospital deaths
may occur each year as a result of medical errors.
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The Patient Safety Imperative Recent study - 2% of hospital
admissions have a preventable adverse drug event resulting in: Increased LOS of 4.6 days Increased hospital cost of $4,700 per
admission
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The Public Is Concerned 1997 survey of 1513 US adults:
More than four out of five adults (84%) have heard about a situation where a medical mistake was made
42% said they have been involved in a situation where a medical mistake was made.
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External Groups Involved Beginning in 1997, the Joint
Commission added new patient safety improvement standards
The Leapfrog Group (a payer consortium) is urging health care facilities to adopt safer patient care practices
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Basics of Patient Safety Patient Safety: Actions
undertaken by individuals and organizations to protect health care recipients from being harmed by the effects of health care services.
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Traditional Methods of Protecting Patients From Harm
Well structured systems
Explicit processes
Professional standards of practice
Individual competence reviews
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People Are Set-Up toMake Mistakes
Incompetent people are, at most, 1% of the problem. The other 99% are good people trying to do a good job who make very simple mistakes and it's the processes that set them up to make these mistakes.
Dr. Lucian Leape, Harvard School of Public Health
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Need to Increase Focus on the Human Factors
Studies of adverse patient incidents have heightened our awareness of the need to redesign processes to prevent human errors.
It’s time for organizations to use cognitive ergonomics or human factors analysis to make health care services safer for patients.
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How Can Safety be Improved?
Human errors occur because of: Inattention Memory lapse Failure to communicate Poorly designed equipment Exhaustion Ignorance Noisy working conditions A number of other personal and
environmental factors
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Process Redesign Solutions Make mistakes impossible
Auto-shut off heating devices Circuit breakers Ready-to-administer medications Over-write protected computer disks
Can you think of other mistake-proofing techniques?
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Process Redesign Solutions Design safer processes
Barriers or safeguards can prevent untoward events
X-ray confirmation of tube placement Mandatory repeat-backs Door alarms Surgical site confirmation
Can you think of other barriers or safeguards?
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Process Redesign Solutions Reduce harm caused by mistakes
People must be able to quickly recognize the adverse event and take action
Human interventions Response teams Backups Automation
Can you think of other methods for reducing patient harm?
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Where to Start Consider safety improvement
recommendations made by external groups
Share safety improvement ideas
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Where are Patients at Risk? Focus attention on high-risk
processes Incident reports and other information
are used to identify risk-prone patient care processes
Your help is needed – report incidents and hazardous situations
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Everyone Has a Role inPatient Safety Employees and Physicians Management Administrative and Medical Staff
Leaders
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Take Action to Reduce Risk Reactive: Investigate significant
patient incidents (sentinel events). Proactive: Monitor patient safety
and redesign high-risk processes to prevent a sentinel event from occurring.
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Root Cause Analysis A reactive (after-the-fact) activity
Example of sentinel event:An inpatient received 2 units of the incorrect type of blood. At the time the patient’s blood was drawn for a type/cross match, the sample was mislabeled with another patient's name. The transfusion was given to the patient whose name appeared on the type/cross match lab report, not the patient whose blood was in the lab specimen vial.
Results of the analysis: The root cause of the event was the poorly designed system for labeling laboratory specimens. If not corrected, this problem could cause other incidents.
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Root Cause Analysis Steps
1. Gather the facts.2. Choose team.3. Determine sequence of events.4. Identify contributing factors.5. Select root causes.6. Develop corrective actions &
follow-up plan.
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Common Causes of Medication Related Sentinel Events Lack of staff orientation/training Communication failure Medication storage/access problems Important information not available to
caregivers Staff competency/credentialing problems Inadequate supervision Inadequate/improper labeling Staff distraction
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Proactive Safety Improvement Gather and analyze information
about risk-prone processes Redesign high-risk processes to
reduce the chance of patient harm
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Examining the Safety of Processes Failure mode, effects and criticality
analysis (FMECA) What could go wrong? How badly might it go wrong? What needs to be done to prevent
failures?
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FMECA Steps Flow chart the process Brainstorm potential failures at
each step in the process Determine the criticality of each
failure (frequency x severity x detectability)
Discover what causes critical failures
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Redesign the Process Consider recommendations from
external groups Redesign the process
Eliminate the chance for failure Make it easier for people to do the
right thing Identify/correct the failure before
patient is significantly harmed
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Test the Redesigned Process Conduct another FMECA Perform stress testing Pilot test the process
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Implement New Process Document the process Train people Monitor continuing safety of the
process
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Steps to Improve Safety Basic Tenets of Human Error
Everyone commits errors. Human error is generally the result of
circumstances that are beyond the conscious control of those committing the errors.
Systems or processes that depend on perfect human performance are fatally flawed.
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A Strategic Objective We must redesign our processes
so that simple mistakes don’t end up harming patients Eliminate opportunities for errors Build better safeguards to catch and
correct errors before they reach the patient
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Your Personal Action Plan
“You first have to be the changes you want to see in the world.”
Albert Sweitzer
What can you do to improve patient safety?
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Training ResourceThis presentation is based on “The Basics of Patient Safety”, a guidebook for training health care professionals in the principles and practices of patient safety improvement.
Published by Brown-Spath & Associates. For ordering information call 503-357-9185 or visit our web site: www.brownspath.com