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The Basics of Patient Safety. How You Can Improve the Safety of Patient Care. 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.

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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

  • Gather the facts.

  • Choose team.

  • Determine sequence of events.

  • Identify contributing factors.

  • Select root causes.

  • 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 Resource

This 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


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