2.  Everyday a large number of patients are
treated and cared for without incident by
health care practitioners worldwide.
 Like other high risk industries safety incidents
occur during the course of medical
care, placing patients at risk for injury or
harm.
 Over the past ten years, patient safety has
been increasingly recognized as an issue of
global importance, but much work remains to
be done.

3.  What is 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, caused
by the process of health care itself, from
occurring to patients.

4.  Leading cause of harm in hospitals in
developed countries
 About one patient in 10 is harmed
 About a third are preventable
 One medication error per patient per day
 Most don’t result in harm

5.  Individuals made
Errors that are done due the human factor in the process
( mix up , wrong calculations , not following the 5 rights in
medication administration )
 system made
holes in the system that allows errors to slip through
( no clear and detailed policy and procedures, no double
checking system, no warning signs)
 Environmental made
the dangers that come from the seating of the hospital and
the material and equipments used inside it ( no exit doors ,
warn out cables and cords )

6. 1. Avoid reliance on memory
2. Simplify
3. Standardize
4. Use constraints and forcing functions
5. Use protocols & checklists wisely
6. Improve information access
7. Reduce handoffs
8. Increase feedback

7.  Protecting the patient from case prognoses.
This is done by making the right diagnoses and
formulating the correct treatment plan and making the
needed intervention as quick as possible
 Protecting the patient from medical errors.
This is done by setting a clear and unified departmental
manual of policies and procedures that comply with
international standards and patient safety guidelines for
medical practices and make sure that every one fallow's
it.
2/11/2009 Hatim Banjar

8.  Protecting the patient from the physical
surrounding:
That is done by making sure that the patient is placed in a
save place and free from any harmful mater that might
cause harm to the patient.
The patients consciousness level must be monitored to
prevent any possible danger of falling down for patients
during sleep precautions like sidereal, decreasing bed
height must be taken.
2/11/2009 Hatim Banjar

9.  GOAL (1) Identify Patients Correctly
 GOAL (2) Improve Effective Communication
 GOAL (3) Improve the Safety of High-alert
medications
 GOAL (4) Ensure Correct –Site, Correct
Procedure, Correct Patient Surgery
 GOAL (5) Reduce the Risk of Health Care associated
Infections
 GOAL (6) Reduce the Risk of Patient Harm Resulting
from fall
 GOAL (7) Improve the Safety of Using Infusion
Pump

13.  Blood sample tubes:
 - RED tube for serology (6cc)-
 -GREEN tube for chemistry (5cc)
 - VIOLET tube for hematology (2cc)
 If doctor order- ( hormone or depakin )
investigation use RED tube.
 (pt,ptt) investigation use BLUE tube.


14.  Give an example of human performance
limitation ?
 Give an example of a human factors
problem?
 Communication problem?
 Latent error in your setting?

15.  Although many of the patient safety risk factors
that exist in medical settings also apply to
mental health settings
 there are unique patient safety issues in mental
health that are
 different to those in medical care.
 Seclusion and restraint use, self-harming
behavior and suicide , absconding, and reduced
capacity for self-advocacy are particularly
prominent to mental health patients.
 Both the patient population and the
environment make patient safety in mental
health unique.

16.  Protecting the patient from harming himself :
That is done by monitoring patients with tendency to
comet suicide or to cause harm to themselves and placing
them under clues observation, exploring their thought
content and try to distract them away from such ideas and
try to occupy their time with different activities and give
them a since of hope in life and place them in a safe
environment in the wards away from any external
stimulators for such ideas and away from any harmful
object that he might use to cause harm to him self .
2/11/2009 Hatim Banjar

17. Protecting the patient from being harmed by
others:
 That is done by
 monitoring aggressive and provoking behaviors so
physical contact ( fights) don't happen among
patients, delusions and wrong beliefs are also monitored
to prevent patients from causing harm to each other due
to the delusions or beliefs and in case of any physical
contact among patients nurses must interfere as quickly
as possible using the right manner of intervention
 patients of deferent age groups and genders must be
separated to prevent sexual assault ( male – female )
( adult – teenagers - children ) .
2/11/2009 Hatim Banjar

18. Patient safety during restrain episodes
That is done by following the correct and safe steps to administer
restrains :
never use restrains with out a medical order.
never use retrains as a punishment method or for personal revenge.
always tell the patient the reason from restraining him.
make sure that restrains do not block the blood circulation .
chick on patient and take vital signs every 15min.
make sure room temperature is appropriate .
always restrain the patient in a supine position.
make sure that the patient's physical needs are met.
do not apply restrains to cases of resent ophthalmic surgery, spinal
surgery, harts conditions, chest and respiratory problems.
the restrain room physical surrounding must be appropriate and equipped
with a monitoring camera.
patient should be on monitors through all the restraining time .
2/11/2009 Hatim Banjar

19. Patient safety during seclusion episodes
That is done by following the correct safety measures:
never use seclusion with out a medical order.
never use seclusion as punishment or for personal revenge.
always tell the patient the reason of putting him in seclusion.
chick on patient every 15 min.
make sure that the room is harm free.
make sure that the room physical surrounding is appropriate
and equipped with a monitoring camera.
make sure that the patient physical needs are met.
seclusion should not be done to cases in risk of self
harm, autism, cardiac and respiratory disorders and phobic
patients.
2/11/2009 Hatim Banj

20.  Never face an aggressive P.T on your own.
 Always be calm and use an appropriate voice tone.
 Never turn your back to the patient.
 Always keep eye contact.
 Always keep an arm space between the nurse and
the patient during confrontation.
 When trying to physically control the patient
approach him from the back and sides.
2/11/2009 Hatim Banjar

21.  A patient that had been admitted to an
addiction treatment facility was recognized
by one of the employees and that employee
told his sister about the patient identity.
 Is there a safety risk?
 What kind of risk ?
 How dose it affect the patient?

22.  In easy words clinical risk management is
identifying the risk factors and sources of
harm that might cause a threat to patient
safety in a health service seating and working
on reducing and eliminating them

24.  Observation
 Self-reports
 Physical evidence (document review)

25. :
:
:
:
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26. 
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27. Patient safety rounds reports
Department:
Risk source sat sun mon tue wen
Patient safety officer: signature:

28. OVR flowchart
Incompatibility accurse
Discovering incompatibility
Yes Yes
Patient Needs
Take quick
safety immediate
corrective action
related action
No No
Fell out OVR form Fell out patient safety OVR form
Inform department head Inform department head
Comment of incompatible Comment of department
department head patient safety officer
Send OVR to TQM Comment of department head
No
Sentinel or recreant
Yes
Send recommendations of
TQM do RCA
corrective actions needed to
Recommendation responsible department
implementation Follow

29.  Error
 The failure of a planned action to be completed as
intended or use of a wrong inappropriate, or
incorrect plan to achieve an aim.
 Adverse event
 An injury that was caused by medical
management or complication instead of the
underlying disease and that resulted in prolonged
hospitalization or disability at the time of
discharge from medical care, or both

30.  Near miss
 An event that almost happened or an event that
did happen but no one knows about. If the person
involved in the near miss does not come forward,
no one may ever know it occurred.

31.  Safety culture
A culture that exhibits the following five high-level
attributes that health care professionals strive to
operationalize through the implementation of strong
safety management systems.
(1) A culture where all workers (including front-line staff, physicians, and
administrators) accept responsibility or the safety of themselves, their
coworkers, patients, and visitors.
(2) [A culture that] prioritizes safety above financial and operational goals.
(3) [A culture that] encourages and rewards the identification, communication, and
resolution of safety issues.
(4) [A culture that] provides for organizational learning from accidents.
(5) [A culture that] provides appropriate resources, structure, and accountability to
maintain effective safety systems.