Pharmacology: WHO Patient Safety

PATIENT SAFETY Curriculum Guide

• Comprehensive program for implementation of patient safety education in
medical schools worldwide
• Patient safety is a new discipline
Why was the curriculum developed?
• Health care actually harms patients
• Health care system is complex
• Doctors & other health care professionals are expected to work while
managing the complexities
• Study on 693 medical trainees found that knowledge on patient safety is
limited & trainees were unable to self-assess their own knowledge
deficiencies in patient safety
Limitations of Patient Safety Education on Medical Curricula
• Lack of recognition that patient safety education is essential
• Medical educators are unfamiliar with the curricula
• Knowledge that originates outside medicine
• Teacher/ expert student relationship
Association for Medical Education
• Integrate patient safety education throughout undergraduate course
• Build foundation knowledge & skills for medical students that will better
prepare them for clinical practice
• WHO World Alliance for Patient Safety aims to implement patient safety
worldwide
• Patient safety is everyone’s business
PATIENT SAFETY PRINCIPLES

Patient Safety
Definition:
 A discipline in the health sector that applies safety science methods
towards the goal of achieving a trustworthy system of health-care
delivery, it minimizes the incidence & impact of and maximizes
recovery from adverse events
 A health care discipline that aims to prevent & reduce risks, errors &
harm that occur to patients during provision of healthcare
 Freedom, for a patient, from unnecessary harm or potential harm
associated with healthcare
• World Health Assembly resolution on patient safety because they need to
reduce the harm & suffering of a patient & their families
• Economic benefits of improving patient safety
• Additional hospitalization, litigation costs, infections acquired in hospitals,
lost income, disability & medical expenses
Relationship with Patients
• Significant numbers of patients are harmed d/t their health care –
permanent injury • Safe & effective care depends on the patient disclosing their experience
• Poor information & understanding about the harm of the illness, their social circumstances, their attitudes to the risk involved
• Errors & system failures do not happen at the same time and their values & preferences for how they wish to be treated
• Studies show that most adverse events are preventable • Important aspect of patient safety is honesty to patients.
• Cornerstone: continuous improvement based on learning from errors & Avoid Blaming When Error Occurs
adverse events
• Medical students support each other & health professionals when they are
Important safety issues: involved in an adverse event
• Health-care associated infection • Mortality & morbidity meetings or peer review forums
• Injuries d/t surgical & anesthesia errors • Students irrespective of level of training & education must appreciate the
importance of reporting their own errors
• Medication safety
• Injuries d/t medical devices Practice Evidence-Based Care
• Unsafe injection practices & blood products • They should be aware of the role of the guidelines & appreciate how
• Unsafe practices for pregnant women & newborns important it is to follow them
Four Domains of Health Care: • Common guidelines & protocols
1. Those who work in healthcare Maintain Continuity of Care for Patients
2. Those who receive health care or have a stake in its availability • Health care system is made up of many parts that interrelate to produce
3. The infrastructure of systems for therapeutic interventions a continuum of care for patients & families
4. The methods for feedback & continuous improvement
• Understanding the journey that patients make through the HC system is
Definition of Adverse Events & Errors necessary to understand how the system can fail
• Adverse Events – an incident which results in harm to a patient Student Awareness of the Importance of Self-Care
• Error – failure to carry out a planned action as intended or application of • Students should be responsible for their own well-being and that of their
an incorrect plan peers & colleagues
Understand the Multiple Factors Involved in Failures • Medical students should be encouraged to have their own doctor & be
aware of their own health status
• The 5 “whys” is a method used to keep discussions about causes focused
on the system rather than the people Act Ethically Everyday
1. The nurse gave the wrong drug. Why?
2. Bec she misheard the name of the drug ordered by the doctor. Why? • Always ask permission
3. Bec the doctor was tired and it was in the middle of the night & the • Patient cooperation in educational activities is entirely voluntary
nurse did not want to ask him to repeat the name. Why? • The decision not to participate will not compromise their care
4. Bec she knew that he was known to have a temper and would shout • Verbal consent is sufficient in most educational activities
at her. Why? • “Would you mind if these students ask you about your illness and/or
5. Bec he was very tired & had been operating for the last 16 hours. examine you so that they can learn more about your condition?”
Why?
IMPORTANCE OF PATIENT SAFETY IN MEDICAL PRACTICE
& HEALTH CARE
Why do students need patient safety education?
• Must be prepared to practice safe health care
• Students are future leaders in health care
• They should be knowledgeable and skillful in their application of patient
safety principles & concepts
• Student themselves can be role models
• Practice their knowledge & skills for the patients benefit alone

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 Pharmacology: WHO Patient Safety

What is Human Factors & Why Is It Important to Patient Safety? Being an Effective Team Player
• Human factors/ergonomics are used to describe interactions between • Team members have specific roles and interact together to achieve a
three interrelated aspects: common goal
o Individuals at work • Teams make decisions
o The task at hand • Teams possess specialized knowledge & skills
o The workplace itself • Teams embody a collective action arising out of task interdependency
• Human factors is an established science that uses many disciplines to
understand how people perform under different circumstances Team Types:
• Study of the interrelationship between humans, the tools & equipment they Core Teams Doctors
use in the workplace and the environment in which they work Coordinating Team Nursing coordinators
• Use evidence-based guidelines to design ways to make it easier to safely Contingency Teams Code Blue Team
& efficiently do things Ancillary Services
• Human-human interactions • Human beings are distractible Support Services Orderlies
• Human-machine interactions – strength & a weakness Administration Higher ups
• Teamwork • Two factors with the most
• Organizational culture important impact are fatigue
What makes a successful team?
• About understanding human & stress
limitations designing • Apply human factors thinking • Common purpose
workplace and the equipment to your work environment • Measurable goals
we use to allow for variability • Avoid reliance to memory • Effective leadership
in humans and human • Make things visible • Effective communication
performance • Review and simplify processes • Good cohesion
• Human beings are not • Standardize common • Mutual respect
machines processes and procedures
• Humans are unpredictable and • Communication for HC Teams
Routinely use checklists
unreliable • Decrease reliance on vigilance SBAR Referral
• Humans are very creative, • Situation – what is going on • I am calling about Mrs. Joseph
self-aware, imaginative & with the patient? in rm 251. She is having new
flexible in their thinking • Background – what is the onset shortness of breath
Understanding Systems & The Impact of Complexity on Patient Care clinical background? • 62 y.o. female day 1 post op
• Any collection of two or more interacting parts or an interdependent group • Assessment – what do I think from abdominal surgery. No
of items forming a unified whole is the problem? comorbids
• Health care professionals need to have an understanding of the nature & • Recommendation – what • Breath sounds are decreased
complexity in HC would I do to correct it? on the right. Would like to r/o
pneumothorax
• Don’t blame the individuals involved
• Health Care is complex because: • I feel strongly the patient
should be assessed now
- The diversity of tasks
- Diversity of patients & staff
- Huge number of relationships between patients, career, staff, etc. Communication for HC Teams
- Vulnerability of patients
- Implementation of new technology
- Increased specialization of health-care professionals
Traditional Approach
• Blame the HC worker directly involved in the patient care
• Very natural & unhelpful & counterproductive
• Natural tendency is to limit reporting
• HC worker as the “second victim”
System Approach
• Examine organizational factors that underpin dysfunctional health care & Understanding & Learning From Errors
accidents/errors rather than focus on the people who are associated with
or blamed for the blunders or negligence • Planned sequences of mental & physical activities that fail to achieve their
intended outcoumes
• Move away from blaming to understanding
• Errors may occur by doing the wrong thing (commission) or by failing to do
• Improve the design of the system so as to prevent errors from occurring or the right thing (omission)
to minimize their consequences
• Errors occur because of the two main types of failures:
• Elements of the System: - Either actions do not go as intended
- Patient & provider factors - Intended action is the wrong one
- Task Factors
- Technology & tool factors
- Team factors
- Environmental factors
- Organizational factors

Characteristics of High Reliability Organizations

• Preoccupation with failure
• Commitment to resilience
• Sensitivity to operations
• A culture of safety

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 Pharmacology: WHO Patient Safety

Understanding & Managing Clinical Risk Patient Safety & Invasive Procedures
• Four Step Process • Main types of adverse events associated with invasive procedural care:
1. Identify the risk 1. Poor infection control methods
2. Assess the frequency and severity of the risk 2. Inadequate patient management
3. Reduce or eliminate risk 3. Failure by health care providers to communicate effectively
4. Assess the costs saved by reducing the risk or costs if risk eventuates • Verification process
Incident Reporting Actual incidents & “near miss” • Practice OR techniques that reduce risks & errors (time-out, briefings &
Sentinel Events Unexpected occurrence involving debriefings)
death or serious physical or • Participate in an educational process for reviewing surgical morbidity &
psychological injury mortality
• Role of complaints in improving health care Improving Medication Safety
• Coronial investigation
Side Effects A known effect other than the primarily intended
• Role of fatigue & fitness to practice Adverse Reaction Unexpected harm arising from a justified action
• Stress & mental health problems Failure to carry out a planned action as intended
• Work environment & organization Error
or application of an incorrect plan
• Supervision Adverse Event Incident that results in harm to patient
• Communication Topics
Fitness-to-practice requirements: Steps in Using Medication
• Are they competent? • Prescribing
• Are they practicing beyond their level of experience & skill? • Administration
• Selecting the right students to study medicine is the 1st step in making sure • Monitoring
that the people who are choosing medicine as a career have the
What are some ways to make medication use safer?
professional attributes for safe & ethical practice
Introduction to Quality Improvement Methods • Use generic names
• Tailor prescribing to individual patients
• Learn & practice thorough medication history taking
• Know which medication are high risk & take precautions
• Know the medications you prescribe well
• Use memory aids
• Communicate clearly
• Develop checking habits
• Encourage patients to be actively involved
Safe Practice Skills for Medical Students to Develop
• Prescribing
• Documentation
• Use memory aids
• Learn & practice drug calculations
• Perform a medication and allergy history
• Monitoring side effects
Engaging With Patient & Carers Remember the Fiver “R”s
• Modern health care should be patient centered • Right Drug
• Every consumer has the right to know what it means to be a patient, and • Right Dose
to receive helpful information about the quality of care they will receive • Right Route
• Inclusion of open disclosures • Right Time
• Informed Consent • Right Patient
- What the patient should know? Summary
o The diagnosis
o Degree of uncertainty in the diagnosis • Patient safety is essential to prepare students to practice safe health care
o Risks involved in the treatment • Economic benefits in improving patient safety
o Risks VS Benefits • Patient safety is everyone’s business
o Options • HCS is made of many parts that interrelate to produce a continuum of care
o Competence of HC workers for the patients & families
o Costs
• Humans are unpredictable & unreliable but flexible
• Cultural Competence
• Don’t blame humans, investigate the different aspects of the system.
- Knowledge, skills & attitudes that a HC worker needs in order to provide
adequate and appropriate HC services to all people in a way that
respects and honors their particular culture
- Be aware and accept cultural differences
- Be aware of one’s own cultural values
- Recognize that people from different cultural backgrounds have different
ways
- Recognize that cultural beliefs impact on how patients perceive their health
• SPIKES
Step 1 Setting Proper setting
Proper perception of the
Step 2 Perception
patient
Step 3 Invitation Invite patient & family
Know the options available for
Step 4 Knowledge the patient; family will ask
questions
Step 5 Empathy
Summarize what points to
Strategy &
Step 5 emphasize especially in terms
Summary
of helping family to choose

Minimizing Infection Through Improved Infection Control

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