The occurrence of adverse events due to unsafe care is likely one of the 10 leading causes of death and disability in the world (1). In high-income countries, it is estimated that one in every 10 patients is harmed while receiving hospital care (2). The harm can be caused by a range of adverse events, with nearly 50% of them being preventable (3). Each year, 134 million adverse events occur in hospitals in low- and middle-income countries (LMICs), due to unsafe care, resulting in 2.6 million deaths (4). Another study has estimated that around two-thirds of all adverse events resulting from unsafe care, and the years lost to disability and death (known as disability adjusted life years, or DALYs) occur in LMICs (5). Globally, as many as 4 in 10 patients are harmed in primary and outpatient health care. Up to 80% of harm is preventable. The most detrimental errors are related to diagnosis, prescription and the use of medicines (6). In OECD countries, 15% of total hospital activity and expenditure is a direct result of adverse events (2). Investments in reducing patient harm can lead to significant financial savings, and more importantly better patient outcomes (2). An example of prevention is engaging patients, if done well, it can reduce the burden of harm by up to 15% (6).
Patient Safety is a health care discipline that emerged with the evolving complexity in health care systems and the resulting rise of patient harm in health care facilities. It aims to prevent and reduce risks, errors and harm that occur to patients during provision of health care.
- A cornerstone of the discipline is continuous improvement based on learning from errors and adverse events.
- Patient safety is fundamental to delivering quality essential health services.
- Indeed, there is a clear consensus that quality health services across the world should be effective, safe and people-centred.
In addition, to realize the benefits of quality health care, health services must be timely, equitable, integrated and efficient. To ensure successful implementation of patient safety strategies; clear policies, leadership capacity, data to drive safety improvements, skilled health care professionals and effective involvement of patients in their care, are all needed.
What are patient safety principles?
1. Introduction – The World Health Organization defines patient safety as the absence of preventable harm to patients and prevention of unnecessary harm by healthcare professionals, It has been reported that unsafe care is responsible for the loss of 64 million disability-adjusted life years each year across the globe.
Patient harm during the provision of healthcare is recognized as one of the top 10 causes of disability and death in the world, Regarding the financial consequence of patient harm, a retrospective analysis of inpatient harm based on data collected from 24 hospitals in the USA showed that harm-reduction strategies could reduce total healthcare costs by $108 million U.S.
and generate a saving of 60,000 inpatient care days, Additionally, the loss of income and productivity due to other associated costs of patient harm are estimated to be trillions of dollars annually, The burden of practice errors on patients, their family members, and the healthcare system can be reduced through implementing patient-safety principles based on preventive and quality-improvement strategies,
Patient-safety principles are scientific methods for achieving a reliable healthcare system that minimizes the incidence rate and impact of adverse events and maximizes recovery from such incidents, These principles can be categorized as risk management, infection control, medicines management, safe environment and equipment, patient education and participation in own care, prevention of pressure ulcers, nutrition improvement, leadership, teamwork, knowledge development through research, feeling of responsibility and accountability, and reporting practice errors,
The nurses’ role is to preserve patient safety and prevent harm during the provision of care in both short-term and long-term care settings, Nurses are expected to adhere to organizational strategies for identifying harms and risks through assessing the patient, planning for care, monitoring and surveillance activities, double-checking, offering assistance, and communicating with other healthcare providers,
Is patient safety a nursing concept?
5.2 Basic Safety Concepts Open Resources for Nursing (Open RN) Safety is a basic foundational human need and always receives priority in patient care. Nurses typically use Maslow’s Hierarchy of Needs to prioritize urgent patient needs, with the bottom two rows of the pyramid receiving top priority.
- See Figure 5.1 for an image of Maslow’s Hierarchy of Needs.
- Safety is intertwined with basic physiological needs.
- Consider the following scenario: You are driving back from a relaxing weekend at the lake and come upon a fiery car crash.
- You run over to the car to help anyone inside.
- When you get to the scene, you notice that the lone person in the car is not breathing.
Your first priority is not to initiate rescue breathing inside the burning car, but to move the person to a safe place where you can safely provide CPR. Figure 5.1 Maslow’s Hierarchy of Needs In nursing, the concept of patient safety is central to everything we do in all health care settings. As a nurse, you play a critical role in promoting patient safety while providing care. You also teach patients and their caregivers how to prevent injuries and remain safe in their homes and in the community.
Safe patient care also includes measures to keep you safe in the health care environment; if you become ill or injured, you will not be able to effectively care for others. Safe patient care is a commitment to providing the best possible care to every patient and their caregivers in every moment of every day.
Patients come to health care facilities expecting to be kept safe while they are treated for illnesses and injuries. Unfortunately, you may have heard stories about situations when that did not happen. Medical errors can be devastating to patients and their families.
- Consider the true patient story in the following box that illustrates factors affecting patient safety.
- The Josie King Story In 2001, 18-month-old Josie King died as a result of medical errors in a well-known hospital from a hospital-acquired infection and a wrongly administered pain medication.
- How did this preventable death happen? Watch this video of her mother, Sorrel King, telling Josie’s story and explaining how Josie’s death spurred her work on improving patient safety in hospitals everywhere.
- What factors contributed to Josie’s death?
- How could these factors be resolved?
Read more about the The event described in the Josie King story is considered a “never event.” are adverse events that are clearly identifiable, measurable, serious (resulting in death or significant disability), and preventable. In 2007 the Centers for Medicare and Medicaid Services (CMS) discontinued payment for costs associated with never events, and this policy has been adopted by most private insurance companies.
- Surgical or procedural event, such as surgery performed on the wrong body part
- Product or device, such as injury or death from a contaminated drug or device
- Patient protection, such as patient suicide in a health care setting
- Care management, such as death or injury from a medication error
- Environmental, such as death or injury as the result of using restraints
- Radiologic, such as a metallic object in an MRI area
- Criminal, such as death or injury of a patient or staff member resulting from physical assault on the grounds of a health care setting
What are the four major risks to patient safety?
4 Top Patient Safety Risks in Ambulatory Care A watchdog group has identified the top four risks for patient safety at ambulatory care settings, according to a, Ambulatory care facilities such as physician offices and outpatient clinics are the most widely used settings in U.S.
Healthcare, according to the published last week. Ambulatory care settings provide a wide range of services to patients such as consultation, diagnosis, and interventions. “As healthcare delivery shifts from hospitals to ambulatory care settings, it can be challenging to coordinate care among various clinicians, systems, and facilities, raising the potential for errors that put patients at risk.
Reducing and eliminating adverse events in an outpatient environment will require an unprecedented commitment to collaboration and coordination,” Marcus Schabacker, MD, PhD, president and CEO of the, said in a prepared statement.
- The watchdog group is based in Plymouth Meeting, Pennsylvania.
- According to the ECRI Institute PSO (patient safety organization) report, the top four risks for patient safety at ambulatory care settings are diagnostic testing errors, medication events, falls, and security incidents.
ECRI Institute PSO examined more than 4,300 ambulatory care patient safety events from December 2017 to November 2018. Diagnostic testing errors accounted for the most events (47%), followed by medication safety events (27%). Highlights of the findings and recommendations are below.
What is the simple definition of patient safety?
The simplest definition of patient safety is the prevention of errors and adverse effects to patients associated with health care. While health care has become more effective it has also become more complex, with greater use of new technologies, medicines and treatments.
- Health services treat older and sicker patients who often present with significant co-morbidities requiring more and more difficult decisions as to health care priorities.
- Increasing economic pressure on health systems often leads to overloaded health care environments.
- Unexpected and unwanted events can take place in any setting where health care is delivered (primary, secondary and tertiary care, community care, social and private care, acute and chronic care).
Every 10th patient in Europe experiences preventable harm or adverse events in hospital, causing suffering and loss for the patient, their families and health care providers, and taking a high financial toll on health care systems. Safety is part of the quality agenda and therefore a dimension of the quality culture, requiring broad commitment from both the organization and the community.
developing active networks of patients and providers;sharing experiences;learning from failure and pro-active risk assessment;facilitating effective evidence-based care;monitoring improvement;empowering and educating patients and the public, as partners in the process of care.
The diversity in the WHO European Region’s 53 Member States is reflected in wide disparities in health systems’ development, funding mechanisms and resources. Varying paces of socioeconomic growth and changes in demography and lifestyle practices have resulted in widening gaps in life expectancy between groups of countries, and sometimes within countries.
At the same time, expectations of health system performance are mounting, challenging its readiness to change and adjust to technological development and emerging health threats. Evidence has shown that to maintain and increase the health status of their populations, countries in the European Region must strengthen their health systems in terms of addressing patient safety and quality of care.
The 2008 Tallinn Charter: Health Systems for Health and Wealth renewed the concerted political commitment of its Member States to strengthen the quality agenda.
What is the most common cause of patient harm?
Unsafe use of medication harms millions and costs billions of dollars annually – Unsafe medication practices and medication errors are a leading cause of avoidable harm in health care systems across the world. Globally, the cost associated with medication errors has been estimated at US$ 42 billion annually, not counting lost wages, productivity, or health care costs.
Why are patient safety indicators important?
The Patient Safety Indicators (PSIs) provide information on potentially avoidable safety events that represent opportunities for improvement in the delivery of care. More specifically, they focus on potential in-hospital complications and adverse events following surgeries, procedures, and childbirth.
What are the 6 international patient safety goals?
What are the International Patient Safety Goals? –
Goal One: Identify patients correctly. Goal Two: Improve effective communication. Goal Three: Improve the safety of high-alert medications. Goal Four: Ensure safe surgery. Goal Five: Reduce the risk of health care-associated infections. Goal Six: Reduce the risk of patient harm resulting from falls.
Goal One: Identify patients correctly. Wrong patient errors are common. Therefore, the purpose of this IPSG is to reliably identify the individual as the person for whom the service or treatment is intended and to match the service or treatment to that individual.
The JCI recommend using at least two identifiers to identify patients such as name or date of birth (DOB). Identifiers such as room number or location should not be used. Ensuring effective patient identification practices may seem a cumbersome practice but in actual fact, patient identification errors can happen in any aspect of the patient’s journey and can result in negative outcomes for patients.
This is why is it crucial that effective patient identification practices are part of everyday routine practices. Goal Two: Improve effective communication. This IPSG highlights the importance of effective communication when verbally communicating patient care orders, reporting critical diagnostic results and during handovers of patient care.
- Ensuring that patient data is communicated accurately and understood by the recipient is critical to reduce errors and improve patient safety.
- To support this, it is recommended that verbal and telephone orders should be written down when received and read back to the individual providing the information.
The hospital should have a consistent and complete handover process for transitions within the hospital. Goal Three: Improve the safety of high-alert medications. The objective of this IPSG is to improve patient safety whilst administering High Alert Medications (HAMs).
- All medications can be dangerous when used inappropriately, but HAMs have the potential to cause harm that is likely to be more serious when they are given in error.
- To support the reduction of medication related patient safety incidents, hospitals should maintain a list of what they consider HAMs and make sure relevant clinical staff know what is on the list.
The hospital also needs to have a process in place to minimise confusion around Look-alike/sound-alike (LASA) medications. Goal Four: Ensure safe surgery. Significant patient injury and adverse events can result from wrong-site, wrong-procedure, and wrong-patient surgery.
- These events can occur from ineffective communication, lack of processes and lack of patient involvement in the site marking.
- This is an ongoing concern for hospitals.
- To help minimise these adverse events from occurring, hospitals should use multiple strategies when identifying the correct patient, correct procedure, and correct site.
Goal Five: Reduce the risk of health care-associated infections. Effective infection prevention and control practices are critical to reducing the spread of health care–associated infections. This has been a major concern for patients and health care practitioners, particularly over the last two years during the COVID-19 pandemic.
The focus of this IPSG is on hand hygiene and requires the hospital to adopt and implement an evidence-based hand-hygiene guideline throughout the hospital to reduce risk of health care-associated infections. Goal Six: Reduce the risk of patient harm resulting from falls. Falls are the cause of lots of injuries to patients and can occur in both inpatient and outpatient settings.
There are multifactorial reasons as to why people are risk of falls, for example healthcare setting, patient history, medications, visual impairments etc. Hospitals should have a process for assessing and reassessing patients for falls risk and implement measures to reduce falls risks for patients.
What is the first step to ensure patient safety?
The first step to ensure patient safety is the careful observation of patient behavior. uniforms may be work in nonwork settings if they have not been stained with bodily fluids from patients. class A fire extinguishers should never be used on fires that involve flammable liquids.
How can you protect patient identity?
4.1.2. Technical Considerations – Data holders employ three main technical methods of ensuring the privacy and security of patient data: anonymization, encryption, and pseudonymization:
- Anonymization is the practice of removing information that is identifiable to an individual or that may enable an individual’s identity to be deduced. This is a viable option in some data use situations (e.g., conducting a research study that does not require patient followup), but not an option in others (e.g., maintaining comprehensive health records for patients in an EHR). It is also not a reversible process—once identifiers are removed from data, they cannot be reinserted.
- Encryption involves applying a mathematical calculation or algorithm to transform a patient’s original data (plain text) into coded data (cypher text). In order to read the cypher text, a user or system must have access to a key that decrypts the data back into plain text. This is an attractive option because it does not involve deleting or removing patient data, and because the coded data is not in a readable format if it falls into the wrong hands. However, encryption requires robust data management policies and resources to be implemented successfully.51
- Pseudonymization is a more sophisticated approach to patient privacy protection. It involves two steps: depersonalization, in which identifiable data are separated from other clinical data and stored in a separate location, and pseudonymization, in which a unique identifier is generated and applied to the depersonalized data set. The unique identifier, or pseudonym, does not change for a given patient over time, and is not derived from any identifiable attributes of the patient. Pseudonymization can be reversible, if the relationship between the pseudonym and the identifiable data is maintained in a secure way and can facilitate re-identification of the patient under specific circumstances (e.g., a trusted third party maintains the relationship, and only discloses that relationship if the requestor has knowledge of a particular key or password). Pseudonymization can also be irreversible, if a situation arises in which the relationship between the pseudonym and the identifiable data is not maintained, and re-identification is not possible.52, 53
What is patient safety culture?
Defining patient safety culture – Organisational culture is a set of values, expectations, formal and informal practices, and behaviours that define the unique corporate environment. Culture is deeply ingrained in the fabric of organisational life; it determines how the organisation conducts its business, treats its employees, evaluates its leaders, serves its customers, and handles productivity and performance.1 A common interpretation of culture is ‘the way things are done around here’.
Safety culture is the aspects of organisational culture that relate to health and safety management. It is defined as ‘a product of individual and group values, attitudes, perceptions, competencies and patterns of behaviour that determine the commitment to, and the style and proficiency of an organisation’s health and safety management’.2 Patient safety culture is focused on the aspects of organisational culture that relate to patient safety.
It is defined as a pattern of individual and organisational behaviour, based upon shared beliefs and values that continuously seeks to minimise patient harm, which may result from the process of care delivery.3
What are the errors in healthcare?
Introduction – A medical error is a preventable adverse effect of medical care, whether or not it is evident or harmful to the patient. Among the problems that commonly occur during providing health care are adverse drug events and improper transfusions, misdiagnosis, under and over treatment, surgical injuries and wrong-site surgery, suicides, restraint-related injuries or death, falls, burns, pressure ulcers, and mistaken patient identities.
How can medical errors be prevented?
- If you are having surgery, make sure that you, your doctor, and your surgeon all agree on exactly what will be done. Having surgery at the wrong site (for example, operating on the left knee instead of the right) is rare. But even once is too often. The good news is that wrong-site surgery is 100 percent preventable. Surgeons are expected to sign their initials directly on the site to be operated on before the surgery.
- If you have a choice, choose a hospital where many patients have had the procedure or surgery you need. Research shows that patients tend to have better results when they are treated in hospitals that have a great deal of experience with their condition.
How many patient safety standards are there?
Essential National Requirements for Patient Safety – The Essential National Requirements for Patient Safety is a list of 20 national standards for hospitals. They are deemed to be basic conditions that must be fully observed to ensure patient safety and protection against healthcare related errors.
- Any hospital shall not be able to receive national accreditation from CBAHI without producing evidence on its full compliance with all such requirements at the time of the survey visit.
- This list shall not be final and may be increased or decreased based on how firmly healthcare institutions adhere to it.
The main sources of such requirements are the results of hospital evaluations during previous years and the history of serious medical errors reported to the Ministry of Health, and the outcomes of medical research related to patient safety all over the world.
How many steps are there to patient safety?
Your guide to patient safety Seven steps to patient safety describes the steps that NHS organisations need to take to improve safety. They provide a checklist to help you plan your activities and measure your performance in patient safety.
How many patient safety indicators are there?
The Patient Safety Indicators (PSIs) are a set of 26 indicators (including 18 provider-level indicators) developed by the Agency for Healthcare Research and Quality (AHRQ) to provide information on safety-related adverse events occurring in hospitals following operations, procedures, and childbirth.
What are the top 3 patient safety issues?
Many healthcare concerns will follow us into the new year, some we have carried for decades and some that have become more threatening thanks to the COVID pandemic. Among all the many lists of top concerns, three remain consistent: Staffing shortages, capacity, and healthcare-associated infections.
What are human factors in patient safety?
Flexible study – Distance / blended learning options enable you to fit studying around working life Patient Safety is an essential part of health and social care that aims to reduce avoidable errors and prevent unintended harm. Human Factors looks at the things that can affect the way people work safely and effectively, such as the optimisation of systems and processes, the design of equipment and devices used and the surrounding environment and culture, all of which are key to providing safer, high quality care.
This course focuses specifically on Human Factors within the Health and Social Care sectors with the aim of helping health and social care professionals to improve performance in this area. The PgCert provides you with the skills to apply Human Factors to reduce the risk of incidents occurring, as well as to respond appropriately to health, safety or wellbeing incidents.
Through the study of Human Factors, you will be able to demonstrate benefit to everyone involved, including patients, service users, staff, contractors, carers, families and friends. The PgDip extends your insights and capabilities, providing you with a deeper understanding of the philosophy, theories, science and application of Human Factors within Health and Social Care sectors.
- This will be achieved by addressing Human Factors principles for both management and physical elements of the systems that you work within.
- The PgDip will also provide you with an in-depth critical understanding of research methodology and methods for use within Health and Social Care settings.
- Together, these elements will help you to develop the necessary skills to undertake your MSc dissertation project or evaluation of a project-based change.
Upon completion of the MSc, you will have achieved a comprehensive understanding of the subject area and be able to undertake a critical evaluation of Human Factors in your workplace and elsewhere. You will have developed your reflexive ability to undertake Human Factors research and to deliver achievable Human Factors solutions.
What is human factors and why is it important to patient safety?
Human factors are those things that affect an individual’s performance. A human factors approach is key to safer healthcare. It will become part of the core curricula of all health professionals. Training needs to be co-ordinated along interprofessional lines.
What are 4 key elements or factors that promote trust in a nurse by patients and relevant stakeholders?
Showing respect and caring – An important element of a lasting professional relationship is respect. The GPhC standards state that cultural diversity and the right for patients to hold their own values and beliefs must be respected. Pharmacists and healthcare professionals have an obligation not to allow any personal prejudices they may hold to detract from providing the highest quality patient care.
- Professional boundaries must also be maintained at all times; if these are crossed, patients may lose trust and confidence in pharmacists, healthcare professionals and the profession,
- Every patient deserves to be treated with dignity and respect, and by encouraging patients to deliberate and make choices through shared decision-making, patient autonomy is upheld,
Being compassionate, spending appropriate time with patients, demonstrating active listening, and helping to advise and resolve the patient’s problems will all contribute to building a trusting, respectful relationship. Pharmacists and healthcare professionals have a moral obligation to build trust with patients and represent their profession in a trustworthy manner.
- It is important to remember that trust is a fragile concept; once interpersonal trust is lost, it can be difficult to rebuild,
- The GPhC’s ‘Consultation on standards for pharmacy professionals’ contains many standards that are important for the development and maintenance of trusting relationships with patients.
Specifically, the requirements: to provide patient-centred care; to communicate effectively; to maintain, develop and use your professional knowledge and skills; to behave in a professional manner (specifically to be trustworthy and act with honesty and integrity); and finally, to respect and maintain patients’ confidentiality/privacy,
Under often difficult and stressful working conditions, pharmacists and healthcare professionals should strive to raise standards so that every opportunity to interact with, or on behalf of, patients helps towards building and maintaining trust. Reading this article counts towards your CPD You can use the following forms to record your learning and action points from this article from Pharmaceutical Journal Publications.
Your CPD module results are stored against your account here at The Pharmaceutical Journal, You must be registered and logged into the site to do this. To review your module results, go to the ‘My Account’ tab and then ‘My CPD’. Any training, learning or development activities that you undertake for CPD can also be recorded as evidence as part of your RPS Faculty practice-based portfolio when preparing for Faculty membership.