SAFETY ISSUES
IN HEALTH CARE SYSTEM
Is the prevention of
harm caused by
errors.
WHO IS RESPONSIBLE FOR ENSURING
PATIENT SAFETY?
patients;
individual nurses;
nursing educators,
administrators, and
researchers;
physicians
governments including
legislative bodies and
regulators;
professional associations;
and accrediting agencies.
What is errors?
The IOM defines error as “The failure of a
planned action to be completed as
intended(error of execution) or the use of a
wrong plan to achieve an aim(error of
planning).
HUMANE ERROR
“To err is Humane”
“Human beings makes mistakes because the
systems ,tasks and processes they work in are
poorly designed”.
Errors can be prevented with EVERYONES
initiative in the system.
“There comes the role of patient safety”
DIAGNOSTIC ERRORS
Diagnostic errors mean a diagnosis that was
either “wrong, missed, or unintentionally
delayed
Diagnostic errors may also result from system-
related problems, such as equipment failure or
flaws in communication.
FINDING THE RIGHT DIAGNOSIS FOR YOU
Tell your story Well- Be clear,Be complete,Be
accurate
Be a good historian-
Be a Good Record keeper
Be an informed consumer
Take Charge of Managing Your Health
Know Your Test Results
Follow up
Make sure it is the right diagnosis
HEALTHCARE ACQUIRED INFECTION
health care-acquired infection (HAI) is an
infection a person gets while being treated for a
medical condition.
An infection is considered to be an HAI when it
occurs after treatment begins.
The three most common types of HAIs are:
1. Catheter-related bloodstream infections
2. Hospital-acquired pneumonia:
3. Surgical site infections (SSI)
FALLS
are a common cause of injury, both within and
outside of health care settings.
Injuries that result from falls can include bone
fractures, excessive bleeding, or even death.
Patients may be at increased risk of falls if
They have an impaired memory
They have muscle weakness
They are older than 60
They use a cane or walker to help them walk
Medications
MEDICATIONS ERRORS
are when a patient receives the wrong
medication, or when he or she receives the
right medication but in the wrong dosage or
manner.
READMISSIONS
is when a patient needs to return to the
hospital less then 30 days after being
discharged.
Patients can help avoid readmission by making
sure they understand their care plan before
they are discharged from the hospital. They
also need to be sure to follow up on care once
they leave the hospital.
WRONG-SITE SURGERY
means an operation done on the wrong part of
the body or on the wrong person. It can also
mean the wrong surgery was performed.
What should I do if I see an error made in the
hospital?
Talk to someone immediately
Do not wait to report the incident if no one you
know is around.
Discuss the issue in a respectful, yet assertive
manner.
If the error happens to you, talk to a hospital
employee who can investigate and resolve the
problem.
If you do not receive an answer during your stay
or shortly after being discharged from the
hospital, contact the hospital’s customer
service, patient advocacy or patient and family
relations department.
Many hospitals have an established system for
reporting errors, such as a suggestion box or a
hot line. Use these systems. The problem will
not be addressed if it is not reported.
Near miss
is an error that results
in no harm or very
minimal patient harm
(IOM, 2000, p. 87).
Near misses are useful
in identifying and
remedying
vulnerabilities in a
system before harm can
occur.
ADVERSE EVENT
An adverse event is injury to a patient caused
by medical management rather than
underlying condition of the patient.
ADVERSE EVENT ARE CLASSIFIED INTO
FOUR TYPES:
Diagnostic
Error or delay in diagnosis
Failure to employ indicated tests
Use of outmoded tests or therapy
Failure to act on results of monitoring or
testing
TREATMENT
PREVENTIVE
Failure to provide prophylactic
treatment
Inadequate monitoring or follow-
up of treatment
OTHER
ACCIDENT
An accident is an event that
involves damage to a defined
system that disrupts the
ongoing or future output of that
system
Accidents occur when multiple
systems fail and tend to be
unplanned or unforeseen..
Such events maybe may be related to:
Professional practice
Health care products
Procedures and systems,including
prescribing,order, communication,product
labeling,packaging,dispensing,distribution,a
dministration,education,monitoring,and use.
ERROR IDENTIFICATION AND REPORTING
Nurses are on the front line in identifying and
reporting errors. However, many errors are not
reported or go undetected. Providers and
organizations may fear blame or punishment
for mistakes or errors.
DEVELOPING A CULTURE OF SAFETY
Organizations and senior
leadership must drive change to
develop a culture of safety—a
blame-free environment in
which reporting of errors is
promoted and rewarded.
A culture of safety promotes trust, honesty,
openness, and transparency
TEAMWORK and INVOLVEMENT of the patient
contribute to promoting a culture of safety.
PATIENT SAFETY GOAL
Improve the accuracy of patient identification.
Improve the effectiveness of communication
among caregivers.
Improve the safety of using medications
Reduce the risk of health care associated
infections
Accurately and completely reconcile medications
across the continuum of care
Reduce the risk of patient harm resulting to falls
Special emphasis on Dangerous
abbreviations,infection control,”look alike and
sound alike”medications,time outs.
Principle of patient safety
Proper identification of patient and matching to
their care elements.
Prevention of patient handover error and safety
during tranition
Assessing medical accuracy while giving care to a
patient
Performance of correct procedure at correct body
site
Take Appropriate precaitionary measures to avoid
infection
