In the presentation, a summary of initiatives to be taken by hospitals in different areas for patient safety have been described for the knowledge, practices and implementation of patient safety initiative by hospital managers/Administrators.

1. PATIENT SAFETY
DR. N. C. DAS

2. WHAT IS SAFETY
S – Sense the error
A – Act to prevent it
F – Follow Safety Guidelines
E – Enquire into accidents/Deaths
T – Take appropriate remedial measure
Y – Your responsibility

3. WHY SAFETY IN THE HOSPITAL
• Hospital is a people intensive place
• Provide services to sick people round the clock
24 hours daily 365 days a year.
• People have a free access to enter any part of
the hospital any time for advice and treatment
• The hospital atmosphere is filled with emotions,
excitement, life & happiness, death & sorrow
• Since hospital operates under continuous
strain, it gives rise to irritation, confrontation,
conflicts & aggression, threatening the life of
hospital staff & hospital properties

4. WHO’S SAFETY

5. SAFETY OF PLACE

6. SAFETY OF PROPERTY

7. SAFETY OF PEOPLE

8. PATIENT SAFETY
Patient safety is the absence of preventable
harm to a patient during the process of health
care.
The discipline of patient safety is the
coordinated efforts to prevent harm to patients,
caused by the process of health care itself.
 It is generally agreed upon that the meaning
of patient safety is…“Please do no harm”

9. ORIGIN OF PATIENT SAFETY
CONCEPT
 HIPPOCRATIC OATH
I will prescribe regimens for the good of my
patients according to my ability and my
judgment and ”never do harm” to anyone.
 Improving Patient Safety means reducing
patient harm.
 Hospitals were founded to give care to those
who need it and to keep patients safe is their
moral duty

10. CURRENT ENVIRONMENT
• Errors and system failures repeated
• Action on known risks is very slow
• Detection systems in their infancy
• Many events not reported
• Understanding of causes limited
• Few examples of successful scale up
• Limited measurement of impact
• Blame culture 'alive and well'
• Defensiveness and secrecy

11. M E D IC A L E R R O R S
•1 in 10 patients admitted to hospital suffers
an adverse event
•The Institute of Medicine in their study found
out that in USA.
•Medical Error injures 1 in 25 hospital
patients.
•Kills about 44000 to 98,000 patients every
year.
•Medical errors cost the United States billions
of dollars each year.

12. HOW DANGEROUS IS HEALTH CARE
• Less than one death per 100 000 encounters
– Nuclear power
– European railroads
– Scheduled airlines
• One death in less than 100 000 but more than 1000
encounters
– Driving
– Chemical manufacturing
• More than one death per 1000 encounters
– Bungee jumping ( Tying rope on leg)
– Mountain climbing
– Health care SOURCE: Internate

13. WHO’S ERROR
B
A 16%
66%
C
D 14%
4%
66% - Accidents caused entirely by patient.
16% - Accidents due to error by hospital staff.
14% - Accidents staff and patient both equally
responsible.
4% - Accidents due to physical, mechanical or
electrical errors.
SOURCE: Internate

14. WHY ERROR
-In most cases fault is not willful negligence,
but systemic flaws, inadequate
communication and wide-spread process
variation and patient ignorance.
-People responsible are the doctors, nurses,
pharmacists , technicians and Patient.

15. TYPES OF ERRORS
i. Adverse Health Care Event – event or omission arising during clinical care
and causing physical or psychological injury to a patient
ii. Error – failure to complete a planned action as intended, or the use of an
incorrect plan of action to achieve a given plan
iii. Health Care Near Miss – situation in which an event or omission (or
sequence) arising during clinical care fails to develop further, whether or not
as the result of compensating action, thus preventing injury.
iv. Adverse Drug Reaction – any response to a drug which is noxious,
unintended and occurs at doses used for prophylaxis, diagnosis or therapy1
Predictable
Unpredictable
v. Medication Error – any preventable event that may cause or lead to
inappropriate medication use or patient harm while the medication is in the
control of health professional, patient or consumer
vi. Sentinel error-
Surgery on the w r o n g b o d y p a r t
Surgery on the w r o n g p a t i e n t
Patients receiving the w r o n g m e d i c a t i o n

16. FOCUS ON NEAR MISSES
• No patient harm, therefore no blame
• No guilt
• No fear of litigation
• Focus on future prevention

17. HUMANE ERROR
“ To Err Is HUMANE”
“Human beings make mistakes because the systems, tasks and
processes they work in are poorly designed.”
(Professor Lucian Leape, testifying to the US President’s Commission on Consumer
Protection and Quality in Health)
Every Error has a root cause and every cause has
a solution.
One Un willful Error is a miss
Repeated Error is a Crime.
Errors can be prevented with Every one’s
Initiative in the system.
“HERE COMES THE ROLE OF PATIENT SAFETY”

18. “WHA” INITIATIVE
• Jan 2002 – Executive Board discuss patient
safety
• May 2002 – resolution adopted by 55th World
Health Assembly
• May 2004 – WHA support establishing World
Alliance for Patient Safety
• October 2004 – launch of the World Alliance
and Forward Programme by DG of WHO
• December 2005 – first progress report of the
Alliance

19. WHO/WORLD ALLIANCE FOR PATIENT
SAFETY
Co-ordinate, spread and accelerate improvements in patient
safety worldwide
WHO Patient Safety was created to facilitate the development of
patient safety policy and practice across all WHO Member States
and to act as a major force for patient safety improvement across
the world.
Our mission
The mission of WHO Patient Safety is to coordinate,
facilitate and accelerate patient safety improvements around
the world by:
•being a leader and advocating for change;
•generating and sharing knowledge and expertise;
•supporting Member States in their implementation of patient
safety actions.
Our vision
•Every patient receives safe health care, every time, everywhere.

20. WORLD ALLIANCE FOR PATIENT
SAFETY: TEN ACTION AREAS
Global Patient Safety Challenges : Solutions to improve
1. Clean Care is Safer Care patient safety
2. Safe Surgery Saves Lives
High 5s WHO Project
Patients for
Patient Safety
Catalyse Technology for
Patient Safety
Research for
Patient Safety countries’ action
to achieve Knowledge Management
International safety of care Special projects:
Classification for - Education
Patient Safety (ICPS) - Radiotherapy
- Rewarding excellence
- When things go wrong
Reporting & - Vincristine sulphate
Learning

21. HIGH 5s WHO PROJECT
A High 5s Steering Group was established in 2006 to determine the overall
architecture of the initiative. The project is being implemented in three phases.
The first phase (2006-2008), initiated in late 2006, has involved the
identification of five evidence-based solutions for patient safety and the
development of a Standard Operating Protocol (SOP) for each solution.
The solutions are:
Managing Concentrated Injectable Medicines;
Assuring Medication Accuracy at Transitions in Care;
Communication During Patient Care Handovers;
Improved Hand Hygiene to Prevent Health Care-Associated Infections; and
Performance of Correct Procedure at Correct Body Sites
The second phase (2008 -2010) identify a lead technical agency in each
participating country to coordinate the High 5s initiative at the country level.
Impact will be measured using the following tools:
Root cause analyses of indicator events and other adverse events
Patient safety indicators
Cultural assessments
Economic impact indices.
The third phase (2010-2011) Over time, the project will encourage participating
countries to use their established relationships with other countries

22. PATIENT SAFETY INITITIVE
•Patients know that their ailments may not always be cured, but they
don’t expect to be inadvertently harmed during their medical care.
• The “blame and train” approach to medical errors and close calls
doesn’t work well.
• human factors engineering techniques tease out root causes of
medical errors and close calls.
• Playing the Blame Game: An Ineffective strategy for improving
patient safety
• Preventing inadvertent harm to patients requires use of human
factors engineering principles.
• In other high hazard jobs such as airplane flying and running nuclear
reactors, systems have been developed to minimize risks based on the
science of human factors engineering.
There fore concept of Patient safety has been derived from
Aviation industry.

23. Summary
SHARED SAFETY BEHAVIORS
AVIATION & MEDICINE
• Broaden dimensions
• human factors engineering
• fatigue & stress management
• effective communication
• shared awareness
• teamwork
• Countermeasures
• briefings, debriefings
• workload distribution
• cross-monitoring
• graded assertiveness
• checklists

24. LESSONS FOR HEALTH FROM THE AIRLINE INDUSTRY
• Statutory reporting of procedures
• A voluntary (without jeopardy) reporting
culture
• Recurring statutory examinations
• Systems development
• Safety analysis of data
• Acceptance that staff make mistakes
• Role of teamwork

25. PATIENT SAFETY GOAL
Improve the accuracy of patient identification.
Improve the effectiveness of communication among
caregivers.
Improve the safety of using medications.
Reduce the risk of healthcare associated infections.
Accurately and completely reconcile medications across
the continuum of care.
Reduce the risk of patient harm resulting from falls.
Special emphasis on ,Dangerous abbreviations, infection
control, “Look alike and sound-alike” medications, time outs.

26. PRINCIPLE OF PATIENT SAFETY
PROPER IDENTIFICATION OF PATIENT
AND MATCHING TO THEIR CARE ELEMENTS
PREVENTION OFPATIENT HAND OVER
ERROR AND SAFETY DURING TRANITION
ASSESING MEDICAL ACCURACY WHILE
GIVING CARE TO A PATIENT
PERFORMANCE OF CORRECT PROCEDURE
AT CORRECT BODYSITE
TAKE APPROPRIATE PRECAITIONARY
MEASURES TO AVOID INFECTION

27. PRINCIPLE OF PATIENT SAFETY

28. TYPES OF SAFETY
ENVIRONMENTAL MEDICAL SURGICAL
SAFETY SAFETY SAFETY
EQUIPMENT PATIENT SAFETY ELECTRICAL SAFETY
INSTALLATION SAFETY
SANITATION
BLOOD SAFETY INFECTION CONTROL LABORATORY SAFETY
BMW DISPOSAL

29. WORK ENVIRONMENT SAFETY
 There is a direct link between work environment and
patient safety
 Therefore, if not addressing work environment, we are
not addressing patient safety
 Healthy work environments do not just happen
 Therefore, if we do not have a formal program in place
addressing work environment issues, little will change
 Creating healthy work environments requires changing
long-standing cultures, traditions and hierarchies
 Therefore, though everyone must be involved in the
creation of healthy work environments, the onus is on
organizational, departmental and unit leaders to
ensure that it happens

30. ENVIRONMENTAL SAFETY
• Adequate light
• Adequate ventilation, exhaust fan
• Stairs with hand rails
• Window-door-closer
• Slip preventing floors
• Fire extinguishers and fire alarms
• Prevent noise pollution
• Heavy and fixed beds
• Safe wheel chairs and trolleys
• No water logging in bathrooms
• Call bell system for patients
• Adequate no. of bed screens to maintain privacy of the patient.

31. MEDICAL SAFETY
1. Illegible Writing prescription by doctors.
2. Wrong medicines or wrong does or wrong patient.
3. Wrong injection, wrong does or wrong patient, wrong route
of administration.
4. Drip sets, air bubbles, over hydration, drip speed.
5. Oxygen flow check empty gas cylinders.
6. Clear, written medication guidelines.
7. Identification of each patient with Similar patient names
8. Proper handing taking over during change of shift.
9. Look alike and Sound Alike “LASA”

32. A- Medication orders should be written legibly in ink and should include:
• Patient’s name and location (ward, room No, and bed No) .
• Medication Generic Name.
• Dosage, frequency and route of administration.
• Signature of the physician.
• Date and hour the order was written.
B- Any abbreviations used in medication orders should be agreed to and
jointly adopted by the medical, nursing, pharmacy, and medical records staff
of the institution. Lately, in the interest of patient safety, “Do Not Abbreviate”
is the new practice nowadays.
C- Before dispensing the drug The pharmacist must receive the physician’s
original order or a direct copy of the order (except in emergency situations).
This permits the pharmacist to:
•Resolve questions or problems with drug orders before the drug is dispensed
and administered.
• Eliminate errors which may arise when drug orders are transcribed into
another form for use by the pharmacy.
D- to check at least two patient identifiers before providing care, treatments
or services.
• Patient name and medical record number
E- Discourage Telephonic orders , Do not accept verbal order
F- Examine safety Code

33. Methods of sending the Physician’s orders to the pharmacy are:
1. Self-copying order forms: This method provides the pharmacist
with a duplicate copy of the order and does not require special
equipment. There are two basic formats:
a. Orders for medications included among treatment orders.
b. Medication orders separated from other treatment orders on the
order form.
`
2. Electromechanical: Copying machines or similar devices may be
used to produce an exact copy of the physician’s order. Provision
should be made to transmit physicians’ orders to the pharmacy in the
event of mechanical failure.
3. Computerized: Computer systems, in which the physician enters
orders into a computer which then stores and prints out the orders in
the pharmacy or elsewhere.

34. SURGICAL SAFETY
1. Consent of the patient/ relative in writing
2. Proper identification of patient, name wrist band
3. Proper identification mark of parts to be operated
4. Pre- anesthetic check-up
5. Anesthetic Safety
6. Ensure no foreign body left inside
7. Safety measures from ward to OT & coming back (Safety check
list)
8. Prevention of surgical wound infections
9. Use of Surgical safety proforma in all operations
10. Check Safety code if available
DNR Purple
Falls Risk Yellow
Allergies Red
(Red for Allergy Alert, yellow for Fall Risk, and Purple for Do Not Resuscitate).

35. Summary
WHO SURGICAL SAFETY CHECKLIST
• The primary benefit of the checklist may
be to engage the medical team.
• By using the checklist, we may be
gaining the ability to open
communication by the medical team, to
encourage teamwork behaviors, & to
develop discipline in the team.
• Reducing sentinel error
35

36. INSTALLATION HAZZARDS
1. Regular checking of equipments
2. Proper earthling to avoid shock
3. Regular maintenance & repair
4. Training of nurses & technical staff
5. How do you control hazards?
• Preventing inadvertent harm to patients requires
use of human factors engineering principles.
6. The “hierarchy of hazard control:”
• Eliminate hazard
• Guard against hazard
• Train to avoid hazards
• Warn against hazards

38. NEW DEVICES
• Acceptance, safety inspection,
compatibility, education, procedures, and
appropriate purchasing documents
(including loan agreements).
• When in doubt, have CE (Certified
Equipment)check, supply chain
management .(SCM),

39. WHY REPORTING MEDICAL DEVICE
PROBLEMS
• Prevent future problems and protect patients, staff,
families, and visitors
• Achieve performance improvement goals
• Assist Risk Management with claims or litigation
• Provide information to manufacturers and/or Food and
Drug Administration
• Publicize report for the general good of patients and
health care providers
• Effect changes in policies and procedures of procurement

40. WHEN TO REPORT
• When you think a device has or may
have caused or contributed to any of
the following outcomes (for a patient,
staff member or visitor):
– Death
– Serious injury
– Minor injury
– Close calls or other potential for harm

41. INDIVIDUAL’s ROLE
• Identify actual and potential problems,
adverse events, close calls with
medical devices
• Report the problem or adverse event to
your supervisor, according to policy
and procedure
• Make sure your report includes details
• Remove the device, keep all affected
items, save the packaging

42. ELECTRICAL SAFETY
1. Safety fuses with each equipment
2. No loose wires or connection
3. Properly plugged and fixed
4. If short circuit call electrician
5. Electricity back up battery/ generator
6. Use of CVT/UPS

43. FIRE SAFETY
Use Fire proof material for construction.
Have Fire Exit in all Buildings.
Smoke detectors and water sprinklers
on the roof of all Floors.
 Fire Extinguishers in all areas.
 Fire Hydrants in all buildings.
Training in Fire management

44. BLOOD SAFETY
1. Proper grouping & cross matching
2. Tests of HIV, Inf. hepatitis & VDRL
3. Proper leveling of group, name of the patient
4. Control of mismatch reaction
5. Standard operating procedure
6. Screening against HIV, Hepatitis. VD,
Malaria.
7. Inform adverse reaction to BB

45. SANITATION- INFECTION CONTROL-
BMW DISPOSAL
Sanitation
BMW
HAI Disposal
• Proper segregation & transportation of biomedical wastes
• Sanitation & hygiene of different parts of hospital to avoid
infection
• Use of sterile procedures
• Safety in use of incinerator, autoclave, shredder, needle
destroyers and proper disposal of biomedical waste.
• Formation of hospital infection control committee
• Investigation of all hospital infections
• Use of proper antibiotics in right doses in right time
• Reorientation of Resident doctors & Nursing staff

46. LABORATORY SAFETY
•Avoid needle prick & spilling of blood
• Safety measures in Radiology & Radiotherapy
departments
• Safety norm guide lines for different areas of
hospitals.
• Regular pest control measures
• Care in handling acids, reagents, inflammable
substances.
• BMW segregation and disposal

47. WHO IS RESPONSIBLE
NURSE
DOCTOR PATIENT
NURSE
PATIENT
DOCTOR

48. PATIENT INVOLVEMENT
• Individual Advocacy – In doctor & hospital visits
– Share information
• Create lists of health problems, previous
operations, etc.
• List or bring all medications, supplements, and
vitamins
– Get information
• Ask questions about treatments, medications, etc.
• Research illnesses and treatments
– Bring an Advocate
– Know what to do before leaving
• Ask about medications and future appointments

49. PREVENT MEDICAL ERRORS BY
PATIENT
A. MEDICINES
1. Make sure that all of your doctors know about
every medicine you are taking. This includes
prescription and over-the-counter medicines and
dietary supplements, such as vitamins and herbs.
2. Bring all of your medicines and supplements to
your doctor visits. Your medicines can help you and
your doctor talk about them and find out if there are
any problems.
3. Make sure your doctor knows about any
allergies and adverse reactions you have had to
medicines.

50. ERRORS BY PATIENT
4. When your doctor writes a prescription for you,
make sure you can read it.
5. Ask for information about your medicines in
terms you can understand—both when your
medicines are prescribed and when you get them:
•What is the medicine for?
•How am I supposed to take it and for how long?
•What side effects are likely? What do I do if they
occur?
•Is this medicine safe to take with other medicines or
dietary supplements I am taking?
•What food, drink, or activities should I avoid while
taking this medicine?

51. 6. When you pick up your medicine from the
pharmacy, ask: Is this the medicine that my doctor
prescribed?
7. If you have any questions about the directions on
your medicine labels, ask if "four times daily" means
taking a dose every 6 hours around the clock or just
during regular waking hours.
8. Ask your pharmacist for the best device to
measure your liquid medicine. Special devices, like
marked syringes, help people measure the right dose.
9. Ask for written information about the side effects
your medicine could cause. If you know what might
happen, you will be better prepared if it does or if
something unexpected happens.

52. B. HOSPITAL STAYS
10. If you are in a hospital, consider asking all health
care workers who will touch you whether they have
washed their hands. Hand washing can prevent the
spread of infections in hospitals.
11. When you are being discharged from the hospital,
ask your doctor to explain the treatment plan you will
follow at home.
•About your new medicines,
•When you can get back to your regular activities.
•Continuing old medicines before your hospital stay.
•When to come back to the hospital for check up

53. C. SURGERY
12. If you are having surgery, make sure that you,
your doctor, and your surgeon all agree on
exactly what will be done.
Surgeons are expected to sign their initials directly
on the site to be operated on before the surgery.
13. 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.

54. D. OTHER STEPS
14. Speak up if you have questions or
concerns.
15. Make sure that someone, such as your
primary care doctor, coordinates your
care.
16. Make sure that all your doctors have
your important health information.
20. Learn about your condition and
treatments by asking your doctor and nurse
and by using other reliable sources.

55. PATIENT INVOLVEMENT
• Patient Representative – In health care
organizations
– Work to improve safety at the organization
and individual unit level
– Serve on committees and boards
– Assist on rounds and here patient
greivences
– Support staff and families

56. PATIENT INVOLVEMENT
• Patient Participant/Activist
– Participate on state and regional coalitions
and organizations and/or
– Serve nationally
– Advocate for public reporting and
accountability of hospital and health system
performance
– Volunteer, make donations, work with fund-
raising
– Be aware of state and national legislation,
contact legislators

57. PATIENT INVOLVEMENT
• Patient Advocate – For friends and family
– Willingness to go with the patient to
appointments, be with them in the hospital
and clinics
– Listening and taking notes
– Speak up when necessary to clarify an
issue and to ask a question
– Question when something does not seem
right in the hospital, nursing homes, clinics,
etc.

58. PREVENT MEDICAL ERRORS BY
MEDICAL STAFF
Communication & coordination deficits drive
errors
Application of Aviation Safety concepts & skills are
being introduced in healthcare
Strong Correlation between Teamwork results in:
•Improved Patient Outcomes
•Patient Satisfaction
•Staff Satisfaction
•Reduced Errors
•Reduce malpractice
claims
•Reduce ‘Blame culture’

59. TWO-CHALLENGE RULE :
It is your responsibility to assertively voice your
concern at least two times to ensure that it has
been heard
The member being challenged must
acknowledge
Provide supporting information with second
challenge
If the outcome is still not acceptable use ‘CUS’
Concern, Un comfortable , Stop
Take a stronger course of action “Empower
any member of the team to “stop the line” if he
or she senses or discovers an essential safety
breach.”

60. EFFECTIVE COMMUNICATION
Communication Breakdowns Contributing Factor in
43% of adverse surgical events
Pivotal Factor in 65% of Sentinel Events (3,000
events 1995-2005)
(Joint Commission on Accreditation of Healthcare
Organizations. (2006)
Primary contributing factor in adverse events 70-80%
of root cause analysis
(National Center for Patient Safety(2006). Root
Cause Analysis Database)
 Common in:
•Medical errors
•Medical malpractice cases
•Adverse surgical events
•Adverse medical events
•Sentinel events

61. ADVERSE INCIDENT REPORTING
• Complete and submit
• Notify Risk Management
• Drug controller notification if Medical
Device or Medication
• Begin Root Cause/Intensive analysis to
examine process changes that may
prevent future events
• Take preventing measures for future
near miss.

62. PEER REVIEW
Monitor and improve physician care of
patients
Accomplish by:
•Open, non-punitive discussion
•Review and discuss alternatives
•Disseminate to ALL physicians
•Monthly review schedule
Move towards: review previous 48 hour record (Code Blue)
•Could this event have been prevented?
•Were signs of deterioration missed?
Elevated BP, dropping BP
Elevated HR, dropping HR
Elevated RR

63. HEALTH EXECUTIVE’S ROLE
 Set Culture
Accountability
Measures
High Reliability/Redesign
Communication and Teamwork
Professional Development
 Reliability principles:
 simplification
 standardization
 relation of humans to the work
 environment

64. BARRIERS TO IMPLEMENTATION
SOURCE: INTERNATE

65. PRATICE OF PATIENT SAFETY
( WHO )
1. Be aware of Look-Alike, Sound-Alike Medication
Names.
2. Proper Patient Identification.
3. Explain in Detail During Patient Hand/Take- Overs.
4. Performance of Correct Procedure at Correct Body
Site.
5. Careful About Electrolyte Imbalance.
6. Assuring Proper Treatment During Shifting.
7. Avoid Catheter and Tubing, Wrong Connections .
8. Single Use of Injection Syringes.
9. Improved Hand Hygiene to Prevent Health Care-
Associated Infections .
10. Proper Disposal of BMW and Good House Keeping.
11 Practice Surgical Safety Guide Lines.

66. TIPS FOR IMPROVING PATIENT SAFETY
1. Constitution of Patient Safety Committee.
2. Develop clear policies and protocols for patient safety.
3. Discuss regularly patient safety initiative within hospital
staff.
4. Orientation, Re-orientation hospital staff on patient safety
5. Encourage transparency in the regular death review.
6. Non- punitive incident reporting by staff.
7. Each department to devise their own patient safety
protocols.
8. Investigate each accident/ incident reported and take
remedial measures.
9. Review, monitor & evaluate. safety procedures regularly.

67. hospiad
Hospital Administration Made Easy
http//hospiad.blogspot.com
An effort solely to help students and aspirants
in their attempt to become a successful
Hospital Administrator.
DR. N. C. DAS