2. Patient Safety Definition
• Healthcare
organizations
including hospitals
were founded to give
care to those who
need it and to keep
patients safe.
• It is generally agreed
upon that the
definition of patient
safety is…
3. What is Patient Safety?
The absence of the potential for patient
harm
Involves all Employees/Contract workers, All
job descriptions
Involves all Departments
Time frame: 24/7
4. A model of patient safety
1. Those who work in health care.
2. Those who receive health care or have
a stake in its availability.
3. The infrastructure of systems for
therapeutic interventions (health-care
delivery processes).
4. The methods for feedback and
continuous improvement.
5. Methods: CQI on
info, hardware,
plant, policy
Systems for therapeutic
action designed to
Recipients of care
preempt/rescue from failure
Preparation on:
illness
understanding, Workers: teams
accessing care trained to preempt /
systems, rescue from /
advocacy manage failure
Methods: CQI
on: competence
communication,
A patient safety model of health care Emmanuel et al 2008
teamwork
8. Traps in health care?
• look-alike and sound-alike
pharmaceuticals
• equipment design
○ e.g. infusion pumps
9. Removing error traps
• a primary function of an incident
reporting system is to identify
recurring problem areas - known as
“error traps” (Reason)
• identifying and removing these traps
is one of the main functions of error
management
Error traps
10. What is being done to make healthcare
organizations safe for patients?
• Joint Commission on Accreditation for
Healthcare Organizations (JCAHO) first
established patient safety goals in 2002.
• Each year those goals are re-evaluated
and revisions are published.
• When healthcare organizations are
accredited, they are given report cards and
graded on their compliance with meeting
the goals.
11. National Safety Goals
• Improve the accuracy of patient
identification.
• Improve the effectiveness of
communication among caregivers.
• Improve the safety of using medications.
12. National Safety Goals
• Reduce the risk of healthcare associated
infections.
• Accurately and completely reconcile
medications across the continuum of
care.
• Reduce the risk of patient harm resulting
from falls.
14. Clean care is safer care
Communication policy
Patient identification
Medication safety
Notification of critical lab
results
Safe blood transfusion
Patient fall
Incident reporting and
management
15. Medical Officers
Paramedics
Pharmacists
PPKs
Allied health
professionals
HSS
WHO SHOULD KNOW?
16. Reduce medical error
Improve patient safety
Requirement for
Accreditation
Protect from litigation
Patient’s right
WHY???
17. What else is being done to promote
patient safety?
• Committees to
investigate all aspects
of patient safety.
• Employee training on
proper lifting and
transfer techniques
which benefit both
employees and
patients.
18. What else is being done to promote
patient safety?
• Policies for safe disposal
of contaminated articles
and sharps
– Syringes
– Needles
– Blades
19. What else is being done to promote
patient safety?
• Frequent Fire and Disaster drills
• Inspection and maintenance of all
equipment…
– Hospital beds
– Patient Lifting equipment
– Gas containers
– Infusion pumps
– Monitoring equipment
20. What can employees do to promote
patient safety?
• Report any potentially dangerous patient
situation to your supervisor.
• Know about and participate in performance
improvement processes in your
department or unit.
• Take your annual mandatory training
seriously; it will help you to identify safety
issues.
21. What can employees do to promote
patient safety?
• Don’t take “shortcuts”.
• Use check lists.
• Ask co-workers to complete double
checks.