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Enhancing Patient Safety: Insights from the RISC Initiative (September 2011)

The RISC Patient Safety event, held on September 20th and 22nd, 2011, brought together facilitators and medical students to discuss critical aspects of patient safety in healthcare. Key topics included the definition of patient safety, the causes of medical errors, and practical solutions such as protocols and checklists to enhance safety standards. Participants engaged in various stations that covered surgical preparation, patient handover, recognizing ill patients, and more. The initiative underscores the importance of fostering a safety-oriented culture in medical education and practice.

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Enhancing Patient Safety: Insights from the RISC Initiative (September 2011)

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  1. RISC Patient Safety 20th and 22nd September 2011

  2. Acknowledgements • Facilitators • Adam Figgins • Adrian Hayes • Rosalind Pool • Siobhan Reilly • Poppy Roberts • Chris Roughley • Tommy Salter • Jessica Scott • Sarah Watson • Rebecca Woodside • Dr Vinod Patel, WMS • Institute for Applied Teaching and Learning

  3. Plan • 7:00 – 7:30 Introduction • 7:30 – 7:45 Station 1 • 7:45 – 8:00 Station 2 • 8:00 – 8:30 Refreshments • 8:30 – 8:45 Station 3 • 8:45 – 9:00 Station 4

  4. Evaluation • Consent Form • Questionnaires • Before and After • Interviews • Follow-up • Please complete Before questionnaires now

  5. What is Patient Safety? • The freedom from accidental injury due to medical care or from medical error (Institute of Medicine 2000) • ‘doing the right thing to the right person at the right time, getting it right first time’ (Ambrose, 2009)

  6. Hospitals are Hazardous “If you fly on a plane, you have a one in 10m chance of being killed. If you go into hospital, you have a one in 300 chance – and not from the illness you went in with.” Richard Branson

  7. Hospitals are Hazardous Amalberti et al, 2005

  8. Everyone Makes Mistakes • Why? • Heavy workload • Fatigue • Stress • Shift work • Reliance on memory • Reliance on vigilance • Noise • Distractions • Unnatural workflow Watson, 2010

  9. Swiss Cheese Model Reason, 2000

  10. Medical Error

  11. Medical Error

  12. Medical Error

  13. Medical Error • Just a Routine Operation

  14. Patient Safety Solutions

  15. Patient Safety Solutions • Protocols and checklists • Constraints • Forcing functions • Encouraging function • Discouraging functions • Leadership and Culture

  16. Medical Curriculum • Recommendations • BMA • GMC • WHO • Little formal teaching Walton et al, 2010 • RISC initiative

  17. CHiPS Stations • How to prepare for surgery • How to hand over a patient • How to recognise an ill patient, and what to do about it • How to spot an unsafe clinical event, and what to do about it

  18. RISC Patient Safety • 3rd and 4th year students • 3 grants • 1 publication (in press) • 17 projects • Handover • ED Admissions • Sepsis • Medication Error Audits • Surgical Safety Checklist • iPhone App • Uniforms for Medical Students Get Involved!

  19. Conclusion • Patient safety is important (and interesting) • Medical students can contribute

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