1. PATIENT SAFETY - “To Err Is Human:
Building a Safer Health System”
Dr. Lallu Joseph
Quality Manager,
CMC Hospital, Vellore

2. HOSPITALS
“Healthcare Organizations are the most complex
organizations to manage”
Peter Drucker
“Running a Hospital isn’t Brain Surgery….
…..Its Harder

3. How we want the hospitals to be……

4. How hospitals are……

5. Source: 2002. IHI. Leape

6. Medical Error
Source – The Philadelphia Inquirer

7. PATIENT INTERFACE IN HEALTHCARE
Complex interactions
Many stakeholders involved
Every patient is different
Every situation is different
Highly sensitive and emotional
Errors cannot happen

8. IC
U
Ward

9. Swiss cheese model

10. TEAM WORK IN HOSPITALS
When caregivers work together- benefits for the
employees, the patients and the health-care facility
Patients receive thorough care when providers
collaborate
Providers can concentrate on their areas of
expertise, knowing they are part of a team looking
after the whole patient- shared responsibility
Quality of care improves
Hospitals save money with effective team care

12. TEAMWORK IS ENHANCED BY
QUALITY MANAGEMENT AND
ACCREDITATION

13. Patient safety?????

14. PREVENTING ERRORS- IPSG
 International Patient Safety Goals (IPSG) help hospitals address
specific areas of concern in some of the most problematic areas of
patient safety.
 The goals describe evidence and expert based consensus
solutions to these problems

15. IPSG Goals-Info graphic 2017

16. Goal 1: Identify patients correctly
 ECRI Institute- PSO reviewed 7,600 wrong-patient events
occurring over 32-months- voluntarily submitted by 181 hospitals.
 Deep dive report on patient identification errors (News release -
26/Sep/2016 - Preventable, Potentially Fatal Patient Identification
Errors Analysed )
 About 9% of the patient identification events led to temporary or
permanent harm or even death.

17. IDENTIFY PATIENTS
Primary responsibility of healthcare workers- check identity
and match the correct patients with correct care.
Using two identifiers
• UHID No. and Patient full name.
• Additional identifiers- Age of patient and sex
• DO NOT use Room No./Location for identification
Standardize patient identification (ID band colour, Marker)
Incorporate training on identifying patients
Educate and involve the patients on correct identification.
http://www.who.int/patientsafety/solutions/patientsafety/PS-Solution2.pdf

18. When to identify patients
Before any surgery, minor procedure and treatment
Before administering medications, blood or blood
products
Before taking blood and other specimens for clinical
testing
Before investigations and imaging

19. Goal 2: Improve effective Communication
 Communication failures- major factor in 30 % malpractice cases
examined by CRICO Strategies- research and analysis offshoot of
the company that insures Harvard-affiliated hospitals.
 Communication failures linked to 1,744 deaths in five years- US
malpractice study- 1.7 billion dollars as malpractice costs- Feb 2016
 A large scale European Commission project has found that handover
communication is responsible for 25% to 40% of adverse events
(2015)

20. Effective communication situations
 Can be verbal, electronic or written
 Effective communication is timely, accurate, unambiguous,
complete and understood by the recipient
 Patient care orders given verbally are most error prone.
 Critical test result reporting is found to be another error prone

21. Effective Communication in critical
situations
 Verbal and telephone order or test result is written down and
read back by the receiver.
 Critical value/reports intimation immediately to the treating
team member and documented. Read back to be followed.
 Standardized approach to hand-over communication between
staff, change of shift and between different patient care units in
the course of a patient transfer. Suggested elements of this
approach include:
Use of the SBAR (Situation, Background, Assessment, and
Recommendation) technique.

22. SBAR Tool for Communication
 A structured communication technique designed to convey a
great deal of information in a succinct and brief manner.
 This is important as we all have different styles of
communicating, varying by profession, culture and gender.

23. SBAR
S Situation
Concise statement of the
problem
What is going
on now
B Background
Pertinent and brief
information
related to the situation
What has
happened
A Assessment
Analysis and
considerations of
options
What you
found/think is
going on
R Recommendation
Request/recommend
action
What you want
done

24. Goal 3: Improve the safety of high-alert
medications
 From January 1997 to December 2007, 446 medication-error
sentinel events were reported to TJC’s (the Joint Commission)
sentinel event database.
 High-Alert Medications (HAMs) are
 Medications involved in a high percentage of errors and/or
sentinel events
 Medications that carry a higher risk for adverse outcomes
 Look-Alike/Sound-Alike medications (LASA)

25. HAMs
 Performing an independent double-check (IDC) helps ensure safe
administration of HAMs (High Alert Medications).
 According to ISMP, IDCs can prevent up to 95% of errors before
they reach the patient.

26. PREVENTING MEDICATION ERRORS
 Look alike & sound alike – separate storage and re-check drug name
 High risk – check and verification by a second staff before dispensing
and double check before administration
 Concentrated electrolytes – strict control and check for dilution
 Avoid storing concentrated electrolytes in patient care areas, unless
clinically necessary
 Concentrated electrolytes that are stored in patient care units are
clearly labelled and stored in manner that restricted access.
 Loaded syringes to be labelled before loading the next drug – meet the
labelling requirements including dilution
 Medicine reconciliation at all transition points - up-to-date list of
medicines patient currently on

27. 15 hospitalised after wrong drug
injected before sterilization
12 Jan 2017, Kamalapur, Ballari district
15 women admitted for tubectomy, for
tubectomy
Hospitalised after being injected wrong
medicine before the surgery.
Adrenaline administered instead of
Atropine sulfate injection
Women felt giddy, began to vomit and felt
their hearts race and rushed to Taluk
Hospital
Root Cause: LOOK ALIKE MEDICINES

28. Goal 4: Ensure safe surgery
 From 1995 to 2005, the Joint Commission (TJC) sentinel event
statistics database ranked wrong site surgery as the second most
frequently reported event with 455 of 3548 sentinel events (12.8%)

29. Steps………
 ENSURE CORRECT-SITE, CORRECT-PROCEDURE, CORRECT
PATIENT SURGERY
 Surgical site marking with active patient involvement throughout
the hospital
 Time out for all invasive procedures throughout the hospital
 Inside OR- follow sign in, time out and sign out using surgical
safety checklist
 Pause before the surgery to make sure that a mistake is not being
made

30. Doctors operate on wrong leg of 24-
year-old
• June 22, Fortis
Hospital, Delhi
• Fractured right foot due
to fall in the stair case
• Operated on the
healthy left ankle of a
24 year old
• Multiple screws placed
on the left ankle
• Temporary cast placed
on the fractured foot

31. Goal 5: Reduce the risk of health care-associated
infections
FACT SHEET WHO - Health care-associated infections
At any given time, the prevalence of health care-associated
infection in developed countries varies between 3.5% and
12%.
Of every 100 hospitalized patients at any given time, 7 in
developed and 10 in developing countries will acquire at least
one health care-associated infection.
 At any given time, the prevalence of health care-associated
infection varies between 5.7% and 19.1% in low and middle-income
countries.

32. Reduce the risk of HAI
 SSIs -31% of all HAIs among hospitalized patients (CDC
prevalence study)
 15% of patients who get it may die from VAP and 10% critically
ill on ventilator develop VAP(Agency for Healthcare Research
and Quality, CDC)
 Approximately 12 – 16 % hospitalized adults will have an
indwelling urinary catheter and each day, patient has a 3%-7%
increased risk of acquiring CAUTI
 CLABSIs - prolongation of hospital stay and increased cost and
risk of mortality ( 7 – 21 days)

33. Recommendations
 5 moments of hand hygiene (WHO)
 Use hand rub (20 – 30 sec) or hand wash (40 – 60 sec)
 Appropriate PPE to be used
 Care bundles to prevent HAI (VAP, CAUTI, CLABSI, SSI)
 Use proven guidelines to prevent infections that are difficult to
treat
 Surveillance and monitoring

34. continued…….
 The organization has adopted or adapted currently published
and generally accepted hand-hygiene guidelines.
 The organization implements an effective hand-hygiene
program.
 Policies and/or procedures are developed that support
continued reduction of health care-associated infections.

35. Goal 6: Reduce the risk of patient harm
resulting from falls
 Falls and recurrent falls are the leading cause of injury –related
death
 1 of 3 people above 65 years fall every year
 1 of 5 falls causes a serious injury.
 10% of fatal falls for older adult occur in the hospital setting
 Fall related hospitalizations in older adults increased 50%
 Inpatient fall rates range from 1.7 to 25 falls per 1,000 patient
day

36. Fall risk management
 Daily fall risk assessment and re-assessment as and when required
 Side rails should always be up – always!
 Safety belt/side rails while transport
 Identify slip and trip areas and take necessary action

37. Roles and responsibilities
 Implements a process for the initial assessment of patients for
fall risk and reassessment of patients when indicated by a
change in condition or medications, among others.
 Measures are implemented to reduce fall risk for those assessed
to be at risk.
 Measures are monitored for results, both successful fall injury
reduction and any unintended related consequences.

38. BUILDING A SAFETY CULTURE
 Top management commitment- Conduct Patient Safety Leadership Rounds
 Encourage reporting- Create a Reporting System
 Create openness- do not blame or shame
 Designate a Patient Safety Officer
 Active patient safety committee
 Appoint safety champions/ advisors in units
 Involve Patients in Safety Initiatives
 Re-enact Real Adverse Events from Your Hospital
 Simulate Possible Adverse Events
 Safety training and awareness
 Priority to safety and take safety issues seriously

39. The patient……
THE SOLE BREAD WINNER OF THE FAMILY,
HE IS THE FATHER OF A SMALL KID,
SON OF AN OLD FATHER,
HUSBAND OF A YOUNG LADY,
AND IS NOW YOUR RESPONSIBILITY
TO TREAT HIM AND SEND HIM SAFE TO HIS
LOVED ONES
IMAGINE YOUR OWN THERE
TAKE CARE OF HIM LIKE YOUR BROTHER
By…..Dr. Lallu Joseph

40. Thank you.......