What Does Patient Safety Have to Do with Medical Errors?

1. What Does Patient Safety Have to Do with Medical Errors? DR. NADIA AL-KANDARYHead of Pathology Section Kuwait Ministry of InteriorForensic Medicine Department

2. As part of our extensive program and with CPD hours awarded based on actual time spent learning, credit hours are offered based on attendance per session, requiring delegates to attend a minimum of 80% of a session to qualify for the allocated CPD hours. • Less than 80%attendance per session = 0 CPD hours • 80% or higherattendance per session = full allotted CPD hours • Total CPD hours for the forum are awarded based on the sum of CPD hours earned from all individual sessions. • Conflict of Interest • The speaker(s) or presenter(s) in this session has/have no conflict of interest or disclosure in relation to this presentation. ME Forum 2019 Orientation

3. Medical Errors – the New View MEDICAL ERRORS ARE SYMPTOMS OF DEEPER TROUBLE

5. DO YOU REMMEBER PATIENT: X Y Z?

6. Medical Errors Is a preventable adverse effect of care, whether or not it is evident or harmful to the patient. Medical Malpractice • Occurs when a hospital, doctor or other health care professional, through a negligent act or omission, causes an injury to a patient • Elements of 4 “D’s “: - Duty. - Deviation. - Direct Causation. - Damage.

7. Measuring Medical Errors in Health Care • CDCP relies on death certificate. • CDCP doesn’t consider ME as a cause of death.

8. Achieving a 99% level of quality meansaccepting a 1% error rate

9. Medical Malpractice claims are dealt with atthe Forensic Medicine Authority. • By evaluating : - Access patient clinical records. - External and Internal examination (Autopsy).

10. Delayed or missed diagnoses Medication errors Wrong side surgery Wrong patient surgery Equipment failure Patient identity Transfusion errors Mislabeled specimen Patient falls Laboratory errors Radiology errors Procedural error Lost, delayed, or failures to follow up reports Retention of foreign object following surgery Contamination of drugs, equipment Intravascular air embolism Failure to treat neonatal hyperbilirubinemia Stage lll or lV pressure ulcers acquired after admission Wrong gas delivery Retention of foreign body Medical Errors

11. 5 common patient safety rules we see being violatedby hospitals • Patient information and labeling • Poor Communication • Not following up on a test that was ordered. • Not consulting with the appropriate specialist. • Relying on other staff

12. Strategies to reduce medical errors • Adopt a structure for handoff conversations

13. Strategies to reduce medical errors • Following protocol is crucial to prevent mistakes.

14. Strategies to Reduce Medical Errors • Get pharmacists more directly involved in patient treatment.

15. Strategies to Reduce Medical Errors • Work to reduce infections.

16. Strategies to Reduce Medical Errors • Avoid diagnostic error.

17. Strategies to Reduce Medical Errors • Make electronic health records (EHR) systems

18. Strategies to Reduce Medical Errors • Proper reporting system for errors

19. Strategies to Reduce Medical Errors • A balanced workload

20. A Culture of Safety 31,033 Pilots, Surgeons, Nurses and Residents Surveyed* *Sexton JB, Thomas EJ, Helmreich RL, Error, stress and teamwork in medicine and aviation: cross sectional surveys. BrMedJour, 3-18-2000.

21. Association Between Evening duty and Higher Mortality Rates in the Pediatric Intensive Care UnitYeseli Arias, Doublas S. Taylor, and James P. MarcinPediatrics 2004; 113: 530-534

22. CONCLUSION “…there are some patients we cannot help, there are none we can harm...” --Dr. Ken Stahl