1. PATIENT SAFETY
GROUP 14

2. Patient Safety
 Patient safety is a fundamental principle of health care. Every point in the
process of care-giving contains a certain degree of inherent unsafety.
 Adverse events may result from problems in practice, products, procedures or
systems. Patient
effort, involving
safety improvements demand a complex system-wide
a wide range of actions in performance
improvement, environmental safety and risk management, including infection
control, safe use of medicines, equipment safety, safe clinical practice and safe
environmentof care.

3. 10FACTS ON PATIENT SAFETY
FACT 1
Patient safety is a serious global public health issue. In recent years, countries have
increasingly recognized the importance of improving patient safety. In 2002, WHO
Member States agreed on a World Health Assembly resolution on patient safety.
FACT 2
Estimates show that in developed countries as many as one in 10 patients is harmed while
receiving hospital care. The harm can be caused by a range of errors or adverse
events.
FACT 3
In developing countries, the probability of patients being harmed in hospitals is higher than
in industrialized nations. The risk of health care-associated infection in some
developing countries is as much as 20 times higher than in developed countries.
FACT 4
At any given time, 1.4 million people worldwide suffer from infections acquired in hospitals.
Hand hygiene is the most essential measure for reducing health care-associated
infection and the development of antimicrobial resistance.
FACT 5
At least 50% of medical equipment in developing countries is unusable or only partly
usable. Often the equipment is not used due to lack of skills or commodities. As a
result, diagnostic procedures or treatments cannot be performed. This leads to
substandard or hazardous diagnosis or treatment that can pose a threat to the safety
of patients and may result in serious injury or death.

4. 10FACTS ON PATIENT SAFETY
FACT 6
In some countries, the proportion of injections given with syringes or needles reused without
sterilization is as high as 70%. This exposes millions of people to infections. Each
year, unsafe injections cause 1.3 million deaths, primarily due to transmission of blood-
borne pathogens such as hepatitis B virus, hepatitis C virus and HIV.
FACT 7
Surgery is one of the most complex health interventions to deliver. More than 100 million
people require surgical treatment every year for different medical reasons. Problems
associated with surgical safety in developed countries account for half of the avoidable
adverse events that result in death or disability.
FACT 8
The economic benefits of improving patient safety are compelling. Studies show that
additional hospitalization, litigation costs, infections acquired in hospitals, lost
income, disability and medical expenses have cost some countries between US$ 6
billion and US$ 29 billion a year.
FACT 9
Industries with a perceived higher risk such as aviation and nuclear plants have a much
better safety record than health care. There is a one in 1 000 000 chance of a traveller
being harmed while in an aircraft. In comparison, there is a one in 300 chance of a
patient being harmed during health care.
FACT 10
Patients' experience and their health are at the heart of the patient safety movement. The
World Alliance for Patient Safety is working with 40 champions – who have in the past
suffered due to lack of patient safety measures – to help make health care safer
worldwide.

5. 5

6. FIRST GLOBAL PATIENT
SAFETY CHALLENGE
CLEANCARE IS SAFER CARE
The goal of Clean Care is Safer Care is to ensure
that infection control is acknowledged universally as a
solid and essential basis towards patient safety and
supports the reduction of health care-associated
infections and their consequences.
SA
VE LIVES: Clean Your Hands is a major
component of Clean Care is Safer Care.

7. SAFE SURGERY SAVES LIVES
THE SECOND GLOBAL PATIENT SAFETY CHALLENGE
The goal of the Safe Surgery Saves Lives Challenge is to
improve the safety of surgical care around the world by
ensuring adherence to proven standards of care in all
countries.
The WHO Surgical Safety Checklist has improved
compliance with standards and decreased complications from
surgery in eight pilot hospitals where it was evaluated.

9. Equ i t y and e x cellence: The
role o f patient s a f e t y
• The Department of Health puts increased safety
at the heart of its proposals, emphasizing that
the NHS should refuse to tolerate unsafe and
substandard care. The supporting consultation
document on the development of an outcomes
framework also has patient safety as a key
focus.

10. Improving Patient Safety

11. • McFadden et al. (2006), found that the most widespread
error reducing method being used in health care
organizations to date is the development of blame free
error reporting systems.
• Blame free reporting systems allow hospital
employees to report errors for the purpose of
correcting hospital policy and procedures.

12. • National Patient Safety Center should be formed to ensure patient
safety within health care settings. This organization would be
committed to research,tracking, andgoal setting.
• This organization would also work with health care organizations
to implement corrections in protocols that have already been
identified as problem areas through the use of blame free error
reporting systems.
• This organization would also work with health care organizations
to implement corrections in protocols that have already been
identified as problem areas through the use of blame free error
reporting systems.
• Amain goal of the Center for Patient Safety would be reducing
medical errorsby50%within5 years

13. THE PATIENT SAFETY SYSTEM
SHALL ADDRESS THE FOLLOWING:
1. detection of safety issues
2. preventive and corrective action
3. processes to reduce risks
4. implementation of corrective action plans
5.on-going measurement to ensure action
effectiveness

14. Patient Safety Guidelines
• Better lighting and less clutter in work areas where
medications are prepared, keeping distractions to a
minimum, and keeping noise levels down.
• Drug companies and health care facilities are also
standardizing medication labels and packaging.
• Medications that can have a particularly dangerous
effect are being marked as ―high alert‖.
• Many hospitals are investing in technology to
minimize errors, such as machines that dispense
medications for just one patient at a time.
• Patients are given identification bracelets showing
their names and allergies.
• All medical personnel are required to wear name
tags showing their level of training.

15. • Unacceptable abbreviations are not used in
documentation and the medical record.
• Two identifiers are checked prior to procedures
and medication administration.
• Physician's verbal or telephone orders are read
back to the physician.
• Medication is labelled appropriately.
• Hand washing guidelines are utilized.
• Medications are reconciled by the physician on
discharge.
• Fall prevention.
• Encourage patient involvement in their own care.
• Pressure ulcer prevention.
• Time out procedure prior to procedures
requiring anesthesia or conscious sedation.
• Blood components checked by two registered
nurses at the bedside of the patient.

16. Hygiene and Cleanliness
• "Hand washing" - nurses should
wash their hands or use a hand
sanitizer before and after each
patient interaction.

18. PROMOTING SAFETY
• Measures to ensure the safety of people of all ages
focus on:
 observation or prediction of potentially harmful
situations so that harm can be avoided.
 client education that empowers clients to protect
themselves and their families from injury. Safety
measures covering the life from infancy to elders
are listed in the accompanying Client Teaching.

19. POSTOPERATIVE CLIENTS
• Nursing during the postoperative phase
is especially important for the client’s
recovery because anesthesia impairs the
environmental stimuli and to
ability o f clients to respond to
help
themselves, although the degree of
consciousness of clients will vary/
Moreover, surgery itself traumatizes the
body by disrupting protective
mechanisms and homeostasis.

20. Potential Postoperative Problems Preventive measures
RESPIRATORY
Pneumonia exercises and
in bed, early
Deep-breathing
coughing, moving
ambulation
Atelectasis exercises and
in bed, early
Deep-breathing
coughing, moving
ambulation
Pulmonary embolism ambulation,
sequential
antiemboli
compression
Turning,
stockings,
devices.

21. Hypovolemia Early detection of signs; fluid and/or
blood replacement
Hemorrhage Early detection of signs
Hypovolemic shock Maintain blood volume
adequate fluid replacement,
through
prevent
hemorrhage; early detection of signs
Thrombophlebitis Early ambulation,
antiemboli
stockings
, fluid intake
leg
SCDs,
exercises,
adequate
CIRCULATORY
Thrombus Venous:same as thrombophlebitis
Arterial: maintain prescribed position;
early detection of signs
Embolus Turning, ambulation, leg exercises,
sequential compression devices; careful
maintenance of IV catheters

22. URINARY
Urinary retention Monitoring fluid intake and output,
interventions to facilitate voiding, urinary
catheterization as needed
Urinary Tract infection Adequate fluid intake, early ambulation,
aseptic straight catheterization only as
necessary, good perineal hygiene.
GASTROINTESTINAL
Nausea and vomiting IV fluids until peristalsis returns; then clear
fluids, full fluids, and regular diet;
antiemetic drugs if ordered; analgesics for
pain
Constipation Adequate fluid intake, high-fiber diet, early
ambulation
Tympanites early ambulation; avoid using a straw,
provide ice chips or water at room
temperature

23. WOUND
Wound infection Keep wound clean and dry, use
surgical aseptic technique when
changing dressings
Wound dehiscence/
evisceration
nutrition, appropriate
support and avoidance
Wound Adequate
incisional
of strain
PSYCHOLOGIC
Postoperative depression Adequate rest, physical activity,
opportunity to express anger and
other negative feelings

24. DRUG SAFETY

25. INTRODUCTION
Over-the-counter (OTC) drugs are those
available without a prescription.
OTC drugs enable people to relieve many
annoying symptoms and to cure some diseases
simply and without the cost of seeing a doctor.
However, safe use of these drugs requires
knowledge, common sense, and responsibility.

26. SAFETY CONSIDERATIONS
• Safety is a major concern when the FDA considers
reclassifying a prescription drug as OTC.
fo ods, dietary
supplements
• Most OTC drugs—unlike
(including herbs) and
complementary t herapies
health
medicinal
have been stu died
scientifically and extensively.
• However, all drugs have benefits and risks, and some
degree of risk has to be tolerated if people are to
receive a drug's benefits.
• Defining an acceptable degree of risk is a judgment call.
• Safety depends on using a drug properly.
• For OTC drugs, proper use often relies on consumer
self-diagnosis, which leaves room for error.

27. CONSIDERATIONSINRECLASSIFYINGA
DRUGASOVER-THE-COUNTER
SAFETY
• Has the drug been used for a long
enough time so that any harmful
effects are fully understood?
• What harmful effects (including those
from misuse) may the drug produce?
• Is the drug habit forming?
• Do the benefits of OTC status
outweigh the risks?

28. EASEOFDIAGNOSISANDTREATMENT
Can the average person self-diagnose the
condition that calls for the drug?
Can the average person treat the condition without
the help of a doctor or other health care
practitioner?
LABELING
Can adequate directions for use be written?
Can warnings against unsafe use be written?
Can the average person understand the
information on the label?

29. READINGADRUGLABEL
• Nonprescription drugs are
required to have labels that
explain what a drug's benefits
and risks are and how to use the
drug correctly. The label is
entitled ―Drug Facts.‖

30. Active ingredient: The drug itself is the active ingredient. Combination
products have more than one active ingredient.
Uses: Symptoms or disorders.
Warnings: When the drug should not be used, when a doctor or
pharmacist should be consulted (and after how long), and which
factors can alter the expected response to the drug are listed, usually
in four sections.
• ―Ask a doctor before use if you have‖
• ―Ask a doctor or a pharmacist before use if you are taking‖
• ―When using this product‖
• The last section lists special warnings for women who are
pregnant or breastfeeding and for children, with instructions
about what to do in case of an overdose.
• Directions: How much of the drug and how often to take the drug are
given for different age groups
• Other information: Special instructions
• Inactive ingredients: In addition to the drug, drug products—the
tablets, capsules, or other formulations that consumers buy—contain
substances added to facilitate the administration of the drug
• Inactive ingredients are usually harmless, but some of them cause an
allergic reaction in a few people, who should look for products made
without those ingredients.

31. INJECTIONSAFETY
WHO estimates that in developing
and transitional Member States, 16 billion
health care injections are administered
each year – an average of 3.4 injections per
person per year. This figure, along with
reports indicating inappropriate use of
injections, suggests that injections are
overused as a means of administering
medications. In addition to being
overused, injections may also be
administered through unsafe procedures
and cause infections.

32. CAUSES OF HARM FROM INJECTIONS
• Injections may harm the patient when injection devices are reused in the
absence of sterilization.
Reuse of injection devices in the absence of sterilization is of
greatest concern, since it leads to the heaviest burden of disease. A
mathematical model developed by WHO suggests that in 2000, in
developing and transitional Member States, reuse of injection
devices accounted for an estimated 22 million new infections with
Hepatitis B virus (one-third of all such infections), 2 million new
infections with hepatitis C virus (40% of all such infections) and 260
000 new HIV infections (5% of all such infections). The infections
acquired in 2000 alone are expected to lead to an estimated 9 million
years of life lost (adjusted for disability) between 2000 and 2030.
• Injections may harm health-care workers when dirty needles are not
collected in safety boxes.
• Injections may also harm the community at large when health-care
facilities are surrounded by sharp health-care waste – mostly dirty
syringes and needles.

33. EVIDENCE SHOWS THAT DEATH AND
DISABILITY ASSOCIATED WITH UNSAFE
INJECTIONS ARE HIGHLY PREVENTABLE.
First, interventions that aim at improving
communication between patients and doctors
and at improving prescriptions through
monitoring of providers have effectively
decreased injection overuse.
Second, interventions to make single-use
syringes regularly available in each health care
facility effectively prevent reuse of injection
devices.

34. FOUR KEY STRATEGIES:
• increasing population awareness regarding the risk
of HIV and other infections associated with
unsafe injections;
• making sure there are sufficient quantities of
single-use injection devices and safety boxes in
every health-care facility where injections are
administered;
• ensuring that donors and lenders supporting the
supply of injectable substances in developing and
transitional Member States also support the
provision of injection devices with reuse-
prevention features and safety boxes;
• managing the waste associated with dirty syringes
and needles in a safe and appropriate way.

36. MISSION OF BT SAFETY
Promotetheformationofnational blood
programmesensuringthesafety,qualityand
adequacy of blood and blood products to meet the
needsofall patients,ontheunderstandingthat
patientswillreceivebloodtransfusionsonlywhen
they need them.
Blood and blood products are provided as part of a
sustainablebloodprogrammewithin the health
care system.

37. INTEGRATED STRATEGY FOR
BLOOD SAFETY
• establishmentofa nationallycoordinatedbloodtransfusionservicethat
can ensure adequate and timely availability of safe blood for all patients
in need;
• collection of blood from voluntary, non-remuneratedblood donors from
low-risk populations;
• testing of all donated blood for transfusion-transmissible infections, blood
grouping and compatibilitytesting;
• appropriate clinical use of blood and blood products.
The strategy addressesall the steps in
collecting, testing, processing, storage and use of blood and blood products
thatcoulddirectlyorindirectlyinfluencethesafetyofpatients. Itcanbe
effectiveonlyif qualitysystemscoverall aspectsoftransfusion,from
recruitmentandselectionofblooddonorstotransfusionofbloodandblood
products.

38. MEDICAL DEVICES AND
EQUIPMENT SAFETY

39. The devices group in WHOcarries out
activities to ensure the safety of
patients, health-care workers and
thecommunitywithregardto
medical devices and equipment.

40. FOUR STRATEGIC AREAS
• Development of national policy: tools to assess and strengthen national
regulatory authorities, including the recent medical device regulations:
global overview and guiding principles, in order to promote national
coordination and management of equipment.
• Quality and safety: elements such as the elaboration of new ISO
standards and WHO performance specifications, the pre-qualification
of suppliers, the development of standardized procedures for alerts
and recalls, and tools to assess safety and performance of products, in
order to reduce risks linked to substandard products and procedures.
• Access: quality management systems covering identification of
equipment needs, and the selection, procurement and distribution
process. Tools include the development of a model list of essential
equipment, the WHO Essential Healthcare Technology
Package, guidelines for good donation practices and increased
collaboration with industry.
• Appropriate use of equipment in order to reduce risks: elaboration
and diffusion of materials on information, education and
communication and of training manuals for managers and users of
equipment, particularly as regards preventive maintenance.

41. ―Don't play for safety - it's
the most dangerous thing in
the world.‖
-Hugh Walpole