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Dr. Shailendra.V.L. MBBS, DA, MD Specialist Anesthesiologist Director Patient Safety Al Bukariya general hospital

Introduction to patient safety department

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Page 1: Introduction to patient safety department

Dr. Shailendra.V.L.MBBS, DA, MD

Specialist AnesthesiologistDirector Patient Safety

Al Bukariya general hospital

Page 2: Introduction to patient safety department

Patient safety is a new healthcare discipline that emphasizes the reporting, analysis, and prevention of medical error that often leads to adverse patient outcomes.

Recognizing that healthcare errors impact 1 in every 10 patients around the world, the World Health Organization calls patient safety an endemic concern.

3 May 2023 2

Page 3: Introduction to patient safety department

Less than one death per 1,00,000 encounters Commercial airlines Nuclear power generation Off shore oil rigs

One death in 1,000 – 1,00,000 encounters: Motor vehicle driving Chemical manufacturing

More than one death per 1,000 encounters Bungee jumping Mountain climbing Health care

3 May 2023 3

Page 4: Introduction to patient safety department

Hospital is a people intensive place.

Provides services to sick people round the clock – 24 hours a day & 365 days a year.

People have a free access to enter the hospital any time for advice & treatment.

Hospital atmosphere is filled with emotions, excitement, happiness, death & sorrow.

3 May 2023 4

Page 5: Introduction to patient safety department

Institute of Medicine, USA found in a study:Medical error injures 1 in 25 hospital

patientsKills about 44,000 to 98,000 every yearMedical errors costs USA billions of dollors

each year.

3 May 2023 5

Page 6: Introduction to patient safety department

1. Not willful negligence but systemic flaws.

2. Inadequate communication.3. Wide-spread process variation.4. Patient ignorance.

3 May 2023 6

Page 7: Introduction to patient safety department

1. Individual made: errors due to human factor in the process ( wrong calculations of drugs, not following the 5 rights of medications)

2. System made: holes in the system that allows to slip through ( no clear & detailed policy & procedures, no double checking systems )

3. Environmental made: the dangers that come from the setting of the hospital & the material & equipments used ( no fire exit doors, worn out power cables )

3 May 2023 7

Page 8: Introduction to patient safety department

“ To err is humane ” Human beings make mistakes because

the systems, tasks & processes always have room for improvement.

Every error has a root cause & every cause has a solution.

Errors can be prevented with every one’s initiative in the system.

Here comes the role of the patient safety department

3 May 2023 8

Page 9: Introduction to patient safety department

“We cannot change the human condition, but we can change the conditions under which humans work ”

3 May 2023 9

Page 10: Introduction to patient safety department

…………………is our jobIndividual accountability &

Vigilance is important, but its not enough!!!!!

To build a culture of safety, we have to work as a team.

TEAM WORK

3 May 2023 10

Page 11: Introduction to patient safety department

1. Sentinel event:1. Unexpected incident involving death or

serious physical or psychological injury or the risk thereof.

2. Near miss:1. An event or situation that could have

resulted in an accident, injury or illness but did not, either by chance or timely intervention.

3. Adverse health care event:1. Any variation in the processes leading to

unsafe situations in everyday working life.3 May 2023 11

Page 12: Introduction to patient safety department

1. Errors & system failures repeated.2. Action of known risks is very low.3. Detection system is in their infancy.4. Many events are not reported.5. Blame culture is alive & active.6. Defensiveness & secrecy 7. Few examples of successful

improvements.8. Very low awareness of patient & staff

safety.3 May 2023 12

Page 13: Introduction to patient safety department

3 May 2023 13

Page 14: Introduction to patient safety department

Dr.Shailendra.V.L.Director Patient SafetyPager # 140

Dr.Taimoor RajaAssistant Director Patient Safety

Mrs. Manar MehamoodPatient Safety Co-odinatorPager # 188

Page 15: Introduction to patient safety department

1. Detection of safety issues.2. Preventive & corrective actions.3. Processes to reduce risks.

3 May 2023 15

Page 16: Introduction to patient safety department

1. OVR / self reporting.2. Safety oriented Leadership Walk

Rounds.3. Communication / education.4. MOH – Patient safety standards

monitoring.5. Promoting patient safety culture.

Page 17: Introduction to patient safety department

It is an atmosphere of mutual trust in which all the staff members can talk freely about safety problems & how to solve them, without fear of blame or punishment.

3 May 2023 17

Page 18: Introduction to patient safety department

1. Support team work & respect others.2. Share lessons learnt.3. Encourage use of communication.4. Take a proactive approach to error.5. Study & learn from our mistakes.6. Share information about safety with

others.

3 May 2023 18

Page 19: Introduction to patient safety department

3 May 2023 19

Page 20: Introduction to patient safety department

Voluntary reporting of process variation by all health care workers

Non punitive (no disciplinary action taken)

To improve the quality of services To prevent recurrence of same errors Used to plan strategies to prevent same

error repeating again

Page 21: Introduction to patient safety department
Page 22: Introduction to patient safety department
Page 23: Introduction to patient safety department
Page 24: Introduction to patient safety department

This is a multi disciplinary team that takes a proactive approach to patient safety.

It provides coordination & oversight to advance an organizations safety program & implement safety-related policies & procedures.

3 May 2023 24

Page 25: Introduction to patient safety department

3 May 2023 25


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