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B arrualde Eskualdea C om arca Interior TWELVE COMMANDAMENTS FOR PATIENT SAFETY Patient safety is the prevention of adverse events that patients may suffer as a result of their contact with the health system 1 KNOW THAT IS PATIENT SAFETY The purpose of patient safety is to reduce the risk associated risk associated healthcare healthcare 2 KNOW THAT IS RESPONSIBLE FOR PATIENT SAFETY Working in patient safety is to be aware of the risks involved, inform, analyze and establish improvement measures improvement measures to avoid, as much as possible, that patients are reexposed to them 3 CONSIDER WHY ADVERSE EVENTS OCCUR The Reason’s Swiss cheese model shows us how advers events occur: they are caused by system falilures and human system falilures and human errors errors combination 4 UNDERSTAND THAT TO ERR IS INHERENT TO THE HUMAN CONDITION 5 CHANGE THE WAY WE WORK Although we can not change the human condition, we can change the conditions we can change the conditions under wich humans work 6 LEARN FROM MISTAKES Every mistake is an opportunity to improve

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TWELVE COMMANDAMENTS FOR PATIENT SAFETY Patient safety is the prevention of adverse events that patients may suffer as a result of their contact with the health system. 1 KNOW THAT IS PATIENT SAFETY The purpose of patient safety is to reduce the risk associated healthcare. - PowerPoint PPT Presentation

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Page 1: TWELVE COMMANDAMENTS FOR PATIENT SAFETY

Barrualde EskualdeaComarca Interior

Barrualde EskualdeaComarca Interior

Barrualde EskualdeaComarca Interior

Barrualde EskualdeaComarca Interior

TWELVE COMMANDAMENTS FOR PATIENT SAFETYPatient safety is the prevention of adverse events that patients may suffer as a result of

their contact with the health system

1 KNOW THAT IS PATIENT SAFETY The purpose of patient safety is to reduce the risk associated healthcarerisk associated healthcare

2 KNOW THAT IS RESPONSIBLE FOR PATIENT SAFETY

Working in patient safety is to be aware of the risks involved, inform, analyze and establish improvement measuresimprovement measures to avoid, as much as possible, that patients are reexposed to them

3 CONSIDER WHY ADVERSE EVENTS OCCUR The Reason’s Swiss cheese model shows us how

advers events occur: they are caused by system falilures and human errorssystem falilures and human errors combination

4 UNDERSTAND THAT TO ERR IS INHERENT TO THE HUMAN CONDITION

5 CHANGE THE WAY WE WORK Although we can not change the human condition, we can change the we can change the

conditions conditions under wich humans work

6 LEARN FROM MISTAKES Every mistake is an opportunity to improve

Page 2: TWELVE COMMANDAMENTS FOR PATIENT SAFETY

12 CONSIDERER PATIENT SAFETY AS A CHALLENGE TO ACHIEVE IN THE HEALTH SYSTEM The same failures can be The same failures can be repeated with different repeated with different consequences increasinglyconsequences increasingly

11 LEAD AND SUPPORT OUR PROFFESIONALS To develop a Safety Plan is essential to have a Patient

Safety Leader locally and with the commitment of the Organization’s clinical manager, supporting proffesionals for incidents management and facilitating the implementation of the improvement measures

10 IMPROVE COMMUNICATION BETWEEN THE VARIOUS PEOPLE WHO ARE INVOLVED The risk of adverse events decreasses when patients are sufficiently informed about their condition and

the treatment required and when the communication between different health proffesionals involved in their care is proper.

9 SPREAD THE RECOMMENDATIONS SHARING SAFETY LESSONS In the health sector is not possible to achieve the zero risk, so the dissemination of lessons learned is key

to improving health care quality

8 INTEGRATE RISK MANAGEMENT INTO OUR DAILY WORK When we detect a fault, we should try to find out how it happened and

why. Normally the person who detected the error is who has the better information to propose improvement measures to prevent its recurrence.

7 DRIVE FORWARD THE NOTIFICATION Report faults is essential. The reporting of adverse events is a long chain of work including analyze, learn from them, establish corrective actions and, finally, disseminate recommendations for all professionals

Barrualde EskualdeaComarca Interior

Barrualde EskualdeaComarca Interior

Barrualde EskualdeaComarca Interior

Barrualde EskualdeaComarca Interior

1 Notify

2 Analize

3 Learn

4 Propose improvements

5 Disseminate recommendations

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TWELVE COMMANDAMENTS FOR PATIENT SAFETYPatient safety is the prevention of adverse events that patients may suffer as a result of

their contact with the health system

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