Patient Safety Lecture in the Healthcare Settings

Welcome to today's lecture on patient safety. Patient safety is a cornerstone of healthcare quality and a critical aspect of delivering effective and compassionate care. It involves the prevention of errors and adverse effects to patients associated with healthcare. Our goal today is to deepen our understanding of the principles and practices that ensure patient safety and to explore how we can implement these in our daily work to protect our patients.

In this lecture, we will cover key concepts such as identifying and mitigating risks, the importance of communication and teamwork, and the role of a safety culture in healthcare settings. We will also discuss real-life examples and strategies that have proven successful in enhancing patient safety.

By the end of this session, I hope you'll have a clearer insight into how each one of us can contribute to a safer healthcare environment. Let's work together to make patient safety a priority and ensure that every patient receives the highest standard of care.

1. Patient safety Prepared and Presented by Nemer Tawbeh Date: 15/12/2012

2. Outline: 1- Definition of patient safety 2-Patient safety terms: Adverse event, error, sentinel event, near miss, hazard ,retrospective and prospective analysis) 3-RCA: Definition, objectives and example 4-FMEA: Definitions and example 5-Examples of common patient safety incidents 6-The nine patient safety solutions 7- Filling incident/accident form

3. Objectives: 1-Define patient safety 2-Identify all terms used in patient safety 3-Recognize and properly apply tools for identifying and addressing the root causes of critical incidences in organizations (RCA,FMEA) 4-Classify the nine problems of patient safety 5-Identify the difference between incident/accident/near miss 6- Properly and timely filling the relevant forms.

4. Definition of Patient Safety Freedom from accidental injury; Ensuring patient safety involves the establishment of operational systems and processes that minimize the likelihood of errors and maximize the likelihood of intercepting them when they occur.

5. Patient Safety Terms A- Error : An error is the failure of a planned action to be completed as intended (i.e., error of execution) or the use of a wrong plan to achieve an aim (i.e., error of planning). An error may be act of commission or an act of omission

6. Patient Safety Terms B- Near miss : An act of commission or omission that could have harmed the patient but did not cause harm as a result of chance, prevention, or mitigation. C - Sentinel event : An unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof . Serious injury specifically includes loss of limb or function. The phrase, " or the risk thereof " includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome.

7. Patient Safety Terms D- Adverse event : An adverse event results in unintended harm to the patient by an act of commission or omission rather than by the underlying disease or condition of the patient. (This definition makes it clear that the potentially avoidable results of an underlying disease or condition, for example, a recurrent myocardial infarction in a patient who was not given a beta-blocker-an error of omission, should be considered an adverse event)

8. Patient Safety Error: failure of a planned action or use of a wrong plan Adverse Event – commission or omission resulting in unintended harm to a patient Near miss – event caught before harming a patient Sentinel Event – event causing or risking serious injury or death

9. Patient Safety Terms E- Hazard: Anything that can put somebody or something at risk of damage or injury or harm F- R etrospective study: A study in which a search is made for a relationship between one phenomenon or condition and another that occurred in the past (e.g .: the exposure to toxic agents and the rate of occurrence of disease in the exposed group compared with a control group not exposed).

10. Patient Safety Terms G- Prospective Analysis: is a form of risk management to reduce the possibility of future sentinel events, adverse events ,near miss… So it help to identify and prevent problems before they happen

11. Root Cause Analysis (RCA) A- Definition : It a tool for identifying prevention strategies It a process that builds a culture of safety It identifies the root B- Objectives: The goal of RCA is to find out: -what happened? -why did it happen? And why, and why…. -what can you do to prevent it from happening again

12. Root Cause Analysis (RCA) C- Example: The nurse administered metoclopramide to patient when the order was dexamethasone RESPONSIBLE TIME-FRAME ACTIONS RCA PROBLEM -pharmacy -nursing staff immediate -mark the a look alike drug by a specific label to high attention 2 drugs (same form) Look –alike drug Wrong-drug selected

13. Failure Modes and Effects Analysis(FMEA) A- Definition: Systematic, proactive method for evaluating a process to identify where and how it might fail and to assess the relative impact of different failures, in order to identify the parts of the process that are in need of change the most.

14. Failure Modes and Effects Analysis(FMEA) B- Examples: Follow a procedure from A to Z according policy and procedure (blood transfusion process starting when the order is written to sending the empty bag unit to blood bank)

15. Common Patient Safety Problems solution Problem -Cooperate with pharmacist /nursing to clarify all drugs(LASA) by a specific label - Updating pharmacy in case of new LASA -Storing LASA drugs in separate locations Look-alike ,sound alike(LASA) medication names (PHA-LO7 )edition 1 -Use at least two identifiers( e.g name, case nb )to verify a patient’s identity and never use the patient’s room number as an identifier -Same patient name(identify by a red bracelet) Patient identification (NUR-p19) edition 3 The hand-over communication between units should be in details Communication during patient hand- overs -Verification of patient/procedure/site -In case of double organs (mark the site in floor by physician) Wrong site procedures -Labeling the prepared solution with high risk warning label -Physician’s order should include the rate of infusion for these solutions Poor control of high risk medications and concentrated

16. Common Patient Safety Problems solution problem -Always check the five rights of medications when requested , dispensed ,and administered…) Medication Use (prescribed, dispensed, administered..) Policy and procedure:medication manual NUR-M03 EDITION 3 -Single use of all equipments defined in policy and procedures Re-use equipments or catheters (NUR/MO1/55 edition2) -Respect all standard precautions to prevent nosocomials infections Infection control Refers policy admission/transport and transfer of critical ill patients(NUR-PO6 EDITION 4) Critical patient transfer ER---CCU/ICU OR Critical area to radio /or

17. Incident/Accident Form

18. Near Miss Report

19. References 1-Kohn LT, Corrigan JM, Donaldson MS. To err is human: building a safer health system. Washington, DC: National Academy Press; 2000:211 - 2- Davies JM, Hébert P, Hoffman C. The Canadian Patient Safety Dictionary. Ottawa: Royal College of Physicians and Surgeons of Canada; 2009:12 3-Davies JM, Hébert P, Hoffman C. The Canadian Patient Safety Dictionary. Ottawa: Royal College of Physicians and Surgeons of Canada; 2010:54