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 is the importance of risk management and patient safety?
Clinical Significance – Risk management requires each provider to be aware of the inherent risk and benefits of care of the patient and a goal among all providers to “first do no harm”. Working together as a team will improve patient outcomes and mitigate risks.
What are the components of patient safety?
Use the Patient Safety Component (PSC) to access modules that focus on process measures and events associated with medical devices, surgical procedures, antimicrobial agents used during the provision of healthcare, and multidrug-resistant organisms.
What is the importance of risk protection?
Importance of Risk Management – No individual can predict risks accurately in this dynamic environment, but organizations need to prepare for an uncertain and volatile future. Organizations are becoming ever so cautious about learning from past mistakes.
Implementation of a robust risk management plan will help an organization build policies and procedures around avoiding potential threats and measures to minimize their impact if it occurs. It is crucial for any business to know the nature and extent of risk it is prepared to take the level of risk it can tolerate and communicate the same to its employees at all levels of management. This enables limited control all over the organization. The ability to understand risks enables the organization to make confident business decisions. It protects the organization from the risk of unexpected events that can cause it a financial and reputational loss. P lanning and developing structures to address potential threats improves the odds of becoming a successful organization.
Thus the practice of risk intelligence and risk management is seen increasing in many industries.
What is the importance of need of safety management?
A good health and safety management system can help minimise risk and protect against accidents in the workplace. It is not acceptable for anyone to be hurt or fatally injured at their place of work. Implementing a health and safety system can help to reduce accidents and boost morale within the business.
What are the benefits of risk management for patients?
As a health service, our objectives relate both to our day-to-day mission to provide, the highest quality health and social care services for the population of Ireland and to our longer term ambition that these services and the experience of those waiting for, or who are receiving care, become demonstrably better.
- Risk is the ‘effect of uncertainty on objectives ‘,
- In the context of the HSE and its services, it is any condition, circumstance, event or threat which may impact the achievement of objectives and/or have a significant impact on the day-to-day operations.
- This also includes failing to maximise any opportunity that would help the HSE or service meet its objectives.’ Each one of us unconsciously and naturally manage risks every day, in our homes, as we travel and at work.
Risk management simply provides us with a structured approach to anticipate the threats that could occur, assists us in identifying the most effective way to manage those threats and gives us the means by which we can measure how successful we have been in our efforts.
To support you in delivering on your commitments in relation to managing risk, the Enterprise Risk Management Policy and Procedures 2023 is intended to be a practical resource for all healthcare workers, including clinicians and managers, with the aim of supporting you as you navigate the many uncertainties you face in your roles.
Read the Risk Management Documentation
What are patient safety indicators?
The Patient Safety Indicators (PSIs) are a set of measures that screen for adverse events that patients experience as a result of exposure to the health care system. These events are likely amenable to prevention by changes at the system or provider level.
What is the difference between safety and quality of care?
Quality healthcare means doing the right thing — for the right patient, at the right time, in the right way — to achieve the best possible results. Patient safety practices protect patients from accidental or preventable harm associated with healthcare services.
What are three 3 risk factors that may affect the health of the person?
Understanding Health Risks Improve Your Chances for Good Health Risks are all around us. A nearby sneeze may raise your risk for catching the flu. Obesity boosts the odds you’ll get diabetes. Smoking increases your risk for many cancers. And if you pay attention to news headlines, you may worry that you’re at risk for food poisoning, Zika infection, shark attacks, and more.
How can you know which health risks apply to you? Health risks can sometimes be confusing, but they’re important to understand. Knowing the risks you and your family may face can help you find ways to avoid health problems. It can also keep you from fretting over unlikely threats. Knowing the risks and benefits of a medical treatment can help you and your doctor make informed decisions.
“Understanding health risks is key to making your own health care decisions,” says Dr. William Elwood, a psychologist and behavioral scientist at NIH. “It gives you perspective on potential harms and benefits, so you can make smart choices based on facts and not fears.” A health risk is the chance or likelihood that something will harm or otherwise affect your health.
Risk doesn’t mean that something bad will definitely happen. It’s just a possibility. Several characteristics, called risk factors, affect whether your health risks are high or low. Your personal health risk factors include your age, sex, family health history, lifestyle, and more. Some risks factors can’t be changed, such as your genes A substance inherited from your parents that defines features such as your risk for certain diseases.
or ethnicity. Others are within your control, like your diet, physical activity, and whether you wear a seatbelt. When you see health statistics, consider the types of people being described. If they’re not similar to you, or if the category is very broad, then your risks may be different.
A general statement like “More than half of Americans over age 45 will develop heart disease at some point” is based on statistical averages across the entire U.S. population. If you’re younger than 45, your heart disease risk will generally be much lower. The more risk factors you have—such as smoking, high blood pressure, or diabetes—the greater your risk.
Exercise and a healthy diet, on the other hand, can make your chance of developing heart disease lower than for most other people. “In many ways, our perception of risk is irrational,” says Elwood. “We sometimes worry over something that’s extremely unlikely, like Ebola in the U.S.
- And we ignore steps we can take to prevent what’s much more likely to harm us, like heart disease or colon cancer.” Talking about health risks can seem intimidating.
- Even doctors sometimes have trouble with risk concepts.
- That’s why NIH supports research to improve how medical staff and others communicate health risks and prevention strategies to patients and the public.
“Math in general is hard for a lot of people. Yet math is often hidden in everyday activities that affect our health,” says Dr. Russell Rothman, a physician and scientist at Vanderbilt University in Nashville. Rothman’s research focuses on helping people understand and work with numbers, so they can reduce their risks for diabetes and excess weight, including childhood obesity.
Studies show that the way we hear and understand health statistics can be influenced by how the numbers are described, or how they’re “framed.” Different descriptions can affect how clear the information is and also what emotions it stirs. For example, the statement: “More than 20% of Americans will eventually die of cancer” might sound less scary from a different perspective: “Nearly 80% of Americans will not die of cancer.” The same information might seem clearer described as a ratio: “More than 1 in 5 Americans will eventually die of cancer.” Research shows that pictures or diagrams are often the most understandable—for instance, showing 5 human figures with 1 in a different color.
To understand the potential risks or benefits of a medical treatment or behavior change, it helps to focus on a math concept called “absolute risk.” Absolute risk is the chance of something happening, such as a health problem that might arise over a period of time.
- For example, a disease might affect 2 in 100 middle-aged men over their lifetimes.
- If a certain drug lowers their risk for the disease to 1 in 100, the drug has reduced their absolute risk by 1 person in 100, or 1%.
- Another way to think of it is that you’d need to treat 100 people with this medicine to prevent just 1 additional person from getting the disease.
Often, however, you might hear numbers that use a related concept called “relative risk.” Relative risk compares the absolute risks of one group to another. In the example above, you could also say that the drug reduced the risk of disease by 50%, since 1 is half of 2.
Looking at relative risk alone, you may mistakenly think that the drug is highly effective. “Many times, the relative risk sounds much greater than the absolute risk, which can be confusing,” Rothman explains. When you hear numbers about risk, it’s best to focus on the absolute risk. Health risks can be especially hard to grasp when emotions run high, such as when people are faced with a serious illness.
One recent NIH-funded study found that people with advanced cancer tended to expect better outcomes and longer survival times from treatment than their doctors did. Most patients didn’t realize that their outlook differed from their doctors. Such misunderstandings might affect whether patients choose to undergo harsh treatments.
- Communication is a 2-way street,” says the study’s lead researcher, Dr. Ronald M.
- Epstein of the University of Rochester Medical Center in New York.
- For effective discussions to occur, doctors must provide encouragement and answers.
- And patients have to ask important questions.” Epstein and colleagues are developing methods to help doctors and patients have realistic discussions about topics such as emotions, treatment choices, and likely outcomes.
“We’ve shown it’s possible to improve the conversations. It helps if patients come prepared with 3 or 4 big-picture questions to ask their doctors,” Epstein says. For people with advanced cancer, questions might include: How will treatment affect my quality of life? What’s the average survival time for this type of cancer? “It can feel scary to ask those kinds of questions.
Sometimes you don’t really want to know the answers, or you have mixed feelings,” Epstein says. “Doctors can help by opening the door to conversation. They can say, ‘Tell me what’s on your mind. Do you have any questions?'” Such open conversations can help patients and their families make more informed health decisions.
Start by talking with your doctor about your health risks. Ask how you can reduce your risks. And look to trustworthy websites—like NIH’s —for reliable health information. : Understanding Health Risks
What is the ethical principle for patient safety?
Jeanne Merkle Sorrell, PhD, RN, FAAN Jeanne Sorrell is former Senior Nurse Scientist, Nursing Research and Innovation, at the Cleveland Clinic in Cleveland, OH, and Professor Emerita, George Mason University in Fairfax, VA. She earned a BSN from the University of Michigan in Ann Arbor, MI, a MSN from the University of Wisconsin in Madison, WI, and a PhD from George Mason University. Her scholarly interests focus on philosophical inquiry, writing across the curriculum, qualitative research, and ethical considerations in healthcare.
Patient safety experts at Johns Hopkins have calculated that more than 250,000 deaths per year in the United States are caused by medical errors ( McMains, 2016 ). In 2013, the Centers for Disease Control and Prevention (CDC) ranked the top three causes of death as heart disease, cancer, and respiratory disease.
In 2016, researchers at Johns Hopkins found that medical errors replaced respiratory disease as the third leading cause of death ( Makary & Daniels, 2016 ; McMains, 2016 ). In international comparisons of deaths that are considered preventable by timely and effective healthcare, data showed that the United States had the highest number of preventable deaths in comparison to nine other countries, with France and Australia being the lowest ( Nolte & McKee, 2011 ).
How can nurses help to address this problem by shaping a culture of safety in healthcare? Keep reading for some helpful, safety-promoting suggestions. Students in the Advanced Clinical Nursing class that I taught were assigned to write a paradigm case-a story that reflected an ethical dilemma that they had experienced in their clinical practice.
It was made clear that they needed to write something they could share with others, as we would set aside class time to read their stories aloud. With 22 students gathered in a circle in the classroom, Sarah * prefaced the reading of her story by confiding that she had read it to her husband before class.
He asked her whether she really thought she should share the story openly. She replied, “Yes.” Sarah’s story: “Do no harm.” This ethical principle has guided my nursing practice for almost 30 years. As a young nurse I was taught the 5 rights of medication administration.
- As an oncology nurse, I am painfully aware that many of the chemotherapy agents that I administer have the potential to cause death if not administered properly.
- Some time has passed now since I made a mistake that could have easily cost my patient her life.
- Today I share my story to help us think about what we can do to reduce the possibility of errors in our practice.
The day that Mrs. May * received more than twice the dose of chemotherapy that had been ordered for her was not just any day. It was very close to Christmas. I was feeling especially excited because after being a registered nurse for over 25 years, I had finally completed my Bachelors of Science in Nursing.
- I was proud of my accomplishment and had received many compliments and best wishes for continued professional success. Mrs.
- May had been a patient in our practice for more than a year following a diagnosis of cancer, but I had not met her.
- I introduced myself and administered the chemotherapy.
- Afterward, Mrs.
May went directly to see her physician and her chart went with her, so I did not have a chance to record the medications that I had given. At the close of the day, I realized that I had never charted on Mrs. May’s record, so I retrieved her chart. As I looked at the dose of medication the oncologist had written, I felt a lump forming in my throat.
- I knew for a fact that I had mixed and administered two and a half times that amount.
- The medication was new to me.
- I remembered reconstituting 4 vials.
- I knew that I had given 250 mg instead of the 100 mg.
- That had been ordered.
- My heart began to race.
- I went back through the chart and realized that the dilution of the drug had been written where I had become accustomed to seeing the dose of the drug.
Since the drug was under the same classification as another that I administered regularly, I didn’t question that this might be too high a dose. Immediately, I went to the nurse manager to tell her what had happened. I knew that if Mrs. May died, there was a good chance that I would not ever be allowed to practice nursing again.
- Instead of giving me a reprimand, my manager said, “Let’s make sure that you truly gave that much of the drug.
- You are always so careful.” Together we went through the trash and found the 4 boxes.
- My heart sank.
- I kept thinking, “This lady is going to die and it is right at Christmas time.” Today, I still remember the kindness that was bestowed on me that day.
When I told the oncologist about my terrible error, he stated that he had ordered a lower dose of the medication for Mrs. May than normal for a patient with her condition, as she had a life expectancy of only 6 months to a year and didn’t want to live with serious side effects from the chemotherapy.
- The oncologist said that she would be very, very sick for about a month but would not die from the overdose.
- He would treat her aggressively with agents to increase her cell counts so that she would have enough reserve to keep her counts from going down to zero.
- The next morning Mrs.
- May came to the clinic.
I arrived early to tell her how very sorry I was. She said that her oncologist had told her if I had not come forth and told him of the mistake, she might not have lived. She trusted the doctor that she would not die from the error. I am happy to say that Mrs.
May is still alive today. She certainly was a very sick lady for the next 2 weeks. One day she said to me, “I will not lie to you. I have never felt this bad in my life, but I will make it.” Yes, Mrs. May made it. Her tumor decreased to one half its original size in about a month. Almost 2 years after this incident, Mr.
and Mrs. May were able to enjoy an international vacation together. I talk with Mrs. May whenever she comes to the clinic and she always gives me a hug and reassurance that she is okay. Was I unbelievably fortunate? Yes. Can a medication error happen to even the most careful and conscientious nurse? Yes.
- Am I even more conscious of my ethical obligations to provide safe care? Yes.
- This incident has changed my life.
- I share my story with other nurses with the hope that it will cause them to think, “If it could happen to her, it could happen to me.” Sarah read this story ** to my class a number of years ago but I still remember vividly how I felt after she finished.
The classroom was totally silent. Many of us were fighting back tears. A classmate reached over to put her arm around Sarah’s shoulder, a silent acknowledgement of support and admiration for the courage that Sarah had shown in sharing such a personal story.
- I think probably everyone in that room still remembers the moment when we each realized, “It could happen to me.” Medical errors are not typically caused by a negligent or incompetent healthcare professional.
- Instead they are often the result of a breakdown in processes that guide delivery of patient care ( Bonney, 2014 ).
Sarah was a competent, careful, and caring nurse, but variances in the usual process of care set up a situation for error. The medication was new to Sarah and was ordered in a format that led to confusion of dose versus dilution. Medication orders should be written in clear and consistent formats so that the person administering the drug can readily understand the appropriate dose.
Also, the chart was removed from the clinic setting before Sarah had a chance to record the medication administration. Access to the order on the medical record while administering the medication provides an important safety check to ensure the correct dose is both administered and recorded. Many potential and actual medical errors fall within the sphere of nursing practice ( Lachman, 2007 ).
Thus nurses have an ethical obligation to help prevent and manage medical errors. The remainder of this column will discuss ethical principles related to medical errors for nurses to consider, along with recommendations that can help to shape a culture of safety for the prevention of medical errors.
Ethical issues related to medical errors can be categorized around four ethical principles: autonomy and right to self-determination; beneficence and nonmaleficence; disclosure and right to knowledge; and veracity ( Bonney, 2014 ). Each of these principles will be discussed below. Autonomy and Right to Self Determination Concepts of autonomy and right to self determination acknowledge patients’ rights to make their own choices and to take actions based on their personal views and perceived benefits.
Healthcare providers have an ethical obligation to inform patients about their ongoing plan of care, including if a medical error has occurred. If Sarah had not informed others of her error, Mrs. May would not have been able to make appropriate decisions about the treatment that she needed as a result of the error.
- Healthcare providers are also obligated to assist patients in making decisions, as the physician did in his care of Mrs. May.
- The physician’s honest discussion with Mrs.
- May about the medication error and potential adverse effects helped her to maintain trust in those caring for her and follow their instructions for treatment so that she could minimize harm from the error.
Beneficence and Nonmaleficence The principles of beneficence and nonmaleficence direct healthcare providers to do what is best for patients and avoid harm. This may create moral conflicts for healthcare providers in terms of balancing projected benefits with possible risk for the patient.
Although there is a range of severity in errors, they all cause harm – to the patient, to the person who made the error, and/or to the system ( Kalra, Kalra, & Baniak, 2013 ).Healthcare providers should take necessary steps to minimize the harm caused by an error. Sarah may have thought that informing Mrs.
May of the error would cause unnecessary worry and suffering but had she not informed others of her error, Mrs. May would not have received important treatments to offset potential harm. Disclosure and Right to Knowledge Healthcare providers have an ethical obligation to disclose information that patients need for informed decision making.
The patient’s bill of rights calls for full disclosure of a medical error ( Ghazal, Saleem, & Ariani, 2014 ). Fortunately, in Sarah’s situation healthcare providers disclosed the information needed to help Mrs. May make decisions about her care, thus respecting her autonomy and decreasing the potential for harm.
Every institution needs clear and detailed policies for disclosure of information about medical errors. Veracity The principle of veracity requires healthcare personnel to provide comprehensive, accurate, and objective information in a manner that helps patients understand the information.
Telling the truth about medical errors helps to establish trust. Healthcare providers’ careful communication with Mrs. May helped to establish a sense of trust that can be seen in the mutual respect that Sarah and Mrs. May shared years after the unfortunate incident. Communication researchers suggest that the ways healthcare providers ‘story’ their mistake experiences can help to understand medical errors ( Noland & Carmack, 2015 ).
Storytelling shifts thinking from ‘rational and scientific’ patterns to reflective thought that calls forth a detailed context surrounding the experience. Sarah’s story illustrates the importance of context as she remembers why she did not record the medication she had administered to Mrs.
- May. She remembers the lump forming in her throat when she realized her error, her fear of losing her nursing license, her gratitude for the kindness of her nurse manager and the physician, and the trust that Mrs.
- May had in her healthcare providers, even after the error.
- Reflective thinking helps to uncover beliefs, values, and knowledge embedded in the experience ( Noland & Carmack, 2015 ).
Storying an experience of a medical error helps the narrator and ‘listeners’ to come to know, understand, and make sense of the experience. The prevention of medical errors within an organization requires systematic management strategies. Healthcare providers need education to understand the importance of reporting medical errors.
Researchers in a study of 289 Canadian nurses working in long-term care noted that participants had different definitions of what constitutes harm with a medical error; their perceptions of harm influenced whether they reported the error ( Wagner, Damianakis, Pho, & Tourangeau, 2013 ). Because of busy working conditions, these nurses prioritized which errors to report.
One participant stated, “If it’s caused no harm, it’s no big deal!” (p.3). Participants indicated overwhelmingly that they would like to receive continuing education to help them learn how to handle the ‘after effects’ of error occurrence. Nurses in all settings need education and training to develop a shared definition of harm and understand the process for reporting errors.
- Although fear of litigation is often cited as a barrier to disclosure by healthcare providers, there is no established link between willingness to disclose medical errors and the risk of litigation ( Bonney, 2014 ).
- Sarah’s story revealed multiple factors that contributed to her error, such as a new medication and a system event that delayed recording the medication.
The culture of the organization, however, supported ‘reporting’ of her error. A ‘blame culture’ is a major source of medical errors ( Kalra et al., 2013 ). Organizations must create an environment where healthcare providers feel supported in reporting, disclosing, and discussing errors.
Considerable research in recent years has focused on disclosure of medical errors but has lacked interdisciplinary dialogue ( Hannawa, Beckman, Mazor, Paul, & Ramsey, 2013 ). Research is needed that incorporates disciplinary perspectives of professionals in healthcare, law, communication, and ethics to help healthcare providers understand and implement ethical practices for prevention and management of medical errors.
The American Nurses Association (ANA) defines a Culture of Safety as a work culture in which healthcare providers at all levels of the organization are committed to core values and behaviors that emphasize safety over competing goals ( ANA, 2016 ). Literature related to medical errors suggests that most medical errors are preventable ( Bonney, 2014 ).
- The categories listed in the Box below reflect important ways that nurses can contribute to prevention and management of medical errors ( Noland & Carmack, 2015 ; Zikhani, 2016 ).
- As the largest group of healthcare professionals, over 3 million strong, registered nurses are in a unique position to lead initiatives that promote a culture of safety ( ANA, 2016 ).
Box. Strategies for Prevention and Management of Medical Errors Rules and Policies. Involve nurses in the development of clear and detailed policies for creating a safer environment in their organization. Communication. Convey messages promptly and clearly.
Handoff tools, such as SBAR or task debriefing, are effective ways to reduce communication failures. Checklists, Reminders, and Double Checks. Design checklists and similar tools to reduce medical errors, especially in situations where errors tend to occur. Simplification, Standardization, and Organization.
Break down and standardize procedures and organize care-implementation processes into simple steps. Computerization and Automation. Identify best practices for using technologies, such as healthcare informatics, to promote efficiency and accuracy and avoid errors.
- Forcing Function.
- Devise procedures that make it almost impossible for errors to occur.
- For example, prevent an individual from entering a wrong medication into the computer or starting a process without submitting a completed checklist.
- Sharing Stories of Errors.
- Encourage students and practitioners to tell their stories of medical errors, rather than hiding errors out of fear, and to listen to stories from others.
Knowing how others have handled mistakes, or wish they had handled them, can help other staff prevent and/or manage healthcare errors. Notes : *Sarah and Mrs. May are pseudonyms used to protect the privacy of individuals involved in this story. **This story is adapted from the chapter, Do no harm, as reported in the book Defining moments: The courage to be,
- The book was part of a class project and self-published by Jeanne Sorrell.
- The copyright date for this book is May 2001 and the copyright is held by Jeanne Sorrell.
- Jeanne Merkle Sorrell, PhD, RN, FAAN Email: [email protected] Jeanne Sorrell is former Senior Nurse Scientist, Nursing Research and Innovation, at the Cleveland Clinic in Cleveland, OH, and Professor Emerita, George Mason University in Fairfax, VA.
She earned a BSN from the University of Michigan in Ann Arbor, MI, a MSN from the University of Wisconsin in Madison, WI, and a PhD from George Mason University. Her scholarly interests focus on philosophical inquiry, writing across the curriculum, qualitative research, and ethical considerations in healthcare.
What is the most common cause of patient safety?
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.