Patient Safety

What is Patient Safety?

“The reduction of risk of unnecessary harm associated with healthcare to an acceptable minimum”

 

Red Threat: External attacks

Blue Threat: Internal analysis; mistakes

Military

Red Threat

Blue Threat
The threat posed to military forces by the enemy (e.g. enemy fire, improvised explosive devices) The threat posed to military forces from friendly fire or mishaps.

Healthcare

Red Threat

Blue Threat
The disease, injury, or condition The threat posed to patients from errors made by healthcare professionals.

 

Patient Safety is the Core to Good Professional Practice of Health Practitioners

 

What is an Adverse Event?

Adverse events are unintended injuries or complications which are caused by healthcare management, rather than by the patient’s underlying disease, which leads to:

  • death
  • disability at the time of hospital discharge or
  • prolonged hospital stay

Examples:

  • Falls
  • Using contaminated blood for transfusion
  • Wrong drugs/dosage
  • Surgical lapse (> scarring, left something inside…)

 

Medical Error Statistics

  1. Medical error affects approximately 10% of hospitalized patients.
  2. Within an Irish context, that equates to approximately 160,000 patients injured every year
  3. An estimation of between 632 to 1,409 deaths in Ireland due to medical error.
  4. Approximately 80% of adverse events in health care are due to human error.

 

The INAES Study (2016)

  • Records examined for 1,574 adult inpatients randomly selected across 8 Irish hospitals
  • 12.2% of admissions were associated with an adverse event
  • Over 70% of events considered preventable
  • 66% resulted in mild-to-moderate harm, 9.9% caused permanent impairment and 6.7% contributed to death
  • Average of 6.1 added bed days (5,550e cost per event)

 

Adverse Events also occur outside the Hospital!

  • 2-3% of General Practice consultations result in an adverse event

 

 

How do we prevent (reduce) Adverse Events occurrence?

  • Notice the causes of adverse events; Observe; Change practices

Patient safety

Junior doctors often an easy target for criticism and it’s often failed to appreciate the important and essential role that they play in the clinical environment and their ability to contribute to improving quality and safety of care

Beginner’s mind- fresh set of eyes- may prompt them to consider practices within an organisation or team that have endured over time but which may not be conducive to safety and quality of care and which should be challenged and remediated

Junior doctors may also benefit from their more recent engagement with the medical curriculum, and may readily identify means of bringing performance or practice in a setting into line with current knowledge of best practice

Further, as junior doctors often work longer hours, and cover shifts that span nights, weekends and public holidays, across almost all areas of patient care within a healthcare system, and typically constitute the frontline of patient care, they may transcend the silos that typically exist within healthcare and have the knowledge and experiences that are vital for informing beneficial change

 

Interns and their Impact on Quality and Patient Safety

Examples:

Intern 38: “My team is hard hitting with a lot of antibiotics… they had gotten into a routine of say ‘here are five antibiotics, they can have them’…we started saying ‘no, that is not the guidelines, it puts them at risk’

Intern 27: “We would have ward rounds going around at 9 which was such a rush so a lot of the time I found myself going back and saying to the patient ‘Did you understand that?’ and a lot of time they didn’t”.

 

Conclusion

  • The threat to patients can never be reduced to zero.
  • Human error is inevitable and ubiquitous.
  • However, error can be reduced through a greater focus on patient safety and the implementation of evidence-based quality improvement initiatives.
  • All healthcare professionals, at all levels, have a role to play in quality and safety