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Safety concern IN HEALTH CARE

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SAFETY CONCERN WORLDWIDE

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SAFETY CONCERNS IN HEALTHCARE Prepared by Raveen Isamel Abdullah B.CS.in Nursing Hawler medical university College of nursing 2016-2017
Outlines • Introduction to safety concerns in health care • Definition of safety concern • Importance of addressing safety concerns . • Classification of medical errors • How to identify errors • Reporting errors • top 10 safety concerns in health care in 2015
Objectives 1. By end of seminar students will be able to identify the main safety concerns in healthcare worldwide in 2015. 2. Understand the process of reporting errors and classify the medical errors in general .
Introduction • Health care services are provided to patients in an environment with complex interactions among many factors, such as the disease process itself, clinicians, technology, policies, procedures, and resources. • When these complex factors interact, harmful and unexpected outcomes (e.g., errors) can occur.
Safety Concern • Any condition, practice, or violation that causes a big probability of physical harm, property loss, and/or environmental impact.
Health Care • Is the maintenance or improvement of health via the diagnosis, treatment, and prevention of disease, illness, injury, and other physical and mental impairments in human beings.
Importance of adressing safety concerns in healthcare 1. Identify potential threats to patient safety.ƒ 2. Improve patient safety by addressing concerns. 3. Improving healthcare system by improving patient safety . 4. Minimize death rate which caused by existence of safety hazards .
Classification of medical Errors
Error Identification 1. Morbidity and Mortality. 2. Retrospective chart review . 3. Reporting systems for serious accidents and important “near misses”
Purpose of Reporting 1. Improve the management of an individual patient 2. Identify and correct systems failures. 3. Prevent recurrent events. 4. It helps in providing a safe environment for patient care. 5. Provide a record of the event. 6. Obtain immediate medical advice and legal counsel
Reporting 1. Date when the report is made 2. Method of reporting (written or visual/oral ) 3. Date, time and place of the event 4. Personal details of those involved 5. A brief description of the nature of the event or disease.
What could happen if incident reporting is Not done? 1. Hazard may not be identified. 2. Incorrect assumptions may be made about exposure to hazard and associated risks. 3. Outcome for the next person may not be so favorable.
Example There is an adult patient been admitted to ICU in order to receive intensive care !routinely diagnostic tests were sent to lab according to his condition so the physician can clearly study the level of improvement during his stay at ICU!?
What are the expected errors which might occur regarding daily diagnostic tests !
Answer 1. Not performed when needed or indicated 2. Incomplete 3. Unavailable 4. Wrong patient 5. Wrong process 6. Wrong time
Why people don’t report ?! 1. There is slow action towards improving errors due to presence of a variety of barriers . 2. People stop reporting or do not report in first place because they think it is waste of time . 3. People are not aware of nature of errors ,then how will they know to report it ?! 4. Sometimes they don’t differentiate between what's right and what's wrong regarding safety hazards within health system !!!!!
Top 10 Patient Safety Concerns for Healthcare Organizations 2015 1. Alarm hazards: inadequate alarm configuration 2. Data integrity: incorrect or missing data in EHRs and other health IT systems 3. Managing patient violence 4. Mix-up of IV lines leading to misadministration of drugs and solutions 5. Care coordination events related to medication reconciliation 6. Failure to conduct independent double checks independently 7. Opioid-related events 8. Inadequate reprocessing of endoscopes and surgical instruments 9. Inadequate patient handoffs related to patient transport 10.Medication errors related to pounds and kilograms
Conclusion • Everything about health care is complex. • Recognizing the complexity of care and how several factors combine at a specific time and result in errors and adverse events. • organizations, leaders, and clinicians will dedicate themselves to using data and evidence and to continuously improve the quality and safety of care, even when there are complex challenges!!
References 1. Top 10 Patient Safety Concerns for Healthcare Organizations [Internet]. Health Data Management. [cited 2017 May 6]. Available from: https://www.healthdatamanagement.com/slideshow/top-10-patient-safety- concerns-for-healthcare-organizations 2. The 10 Patient Safety Concerns Every Health Care Worker Needs to Know About [Internet]. Monster Career Advice. [cited 2017 May 6]. Available from: https://www.monster.com/career-advice/article/patient-safety-concerns 3. 2017_PSTop10_ExecutiveBrief.pdf [Internet]. [cited 2017 May 6]. Available from: https://www.ecri.org/EmailResources/PSRQ/Top10/2017_PSTop10_ExecutiveBrief. pdf 4. Hughes RG. Nurses at the ‘sharp end’ of patient care [Internet]. Agency for Healthcare Research and Quality (US); 2008 [cited 2017 May 6]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK2672/ 5. Safety Concern Law and Legal Definition | USLegal, Inc. [Internet]. [cited 2017 May 6]. Available from: https://definitions.uslegal.com/s/safety-concern/
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Safety concern IN HEALTH CARE

  • 1. SAFETY CONCERNS IN HEALTHCARE Prepared by Raveen Isamel Abdullah B.CS.in Nursing Hawler medical university College of nursing 2016-2017
  • 2. Outlines • Introduction to safety concerns in health care • Definition of safety concern • Importance of addressing safety concerns . • Classification of medical errors • How to identify errors • Reporting errors • top 10 safety concerns in health care in 2015
  • 3. Objectives 1. By end of seminar students will be able to identify the main safety concerns in healthcare worldwide in 2015. 2. Understand the process of reporting errors and classify the medical errors in general .
  • 4. Introduction • Health care services are provided to patients in an environment with complex interactions among many factors, such as the disease process itself, clinicians, technology, policies, procedures, and resources. • When these complex factors interact, harmful and unexpected outcomes (e.g., errors) can occur.
  • 5. Safety Concern • Any condition, practice, or violation that causes a big probability of physical harm, property loss, and/or environmental impact.
  • 6. Health Care • Is the maintenance or improvement of health via the diagnosis, treatment, and prevention of disease, illness, injury, and other physical and mental impairments in human beings.
  • 7. Importance of adressing safety concerns in healthcare 1. Identify potential threats to patient safety.ƒ 2. Improve patient safety by addressing concerns. 3. Improving healthcare system by improving patient safety . 4. Minimize death rate which caused by existence of safety hazards .
  • 9. Error Identification 1. Morbidity and Mortality. 2. Retrospective chart review . 3. Reporting systems for serious accidents and important “near misses”
  • 10. Purpose of Reporting 1. Improve the management of an individual patient 2. Identify and correct systems failures. 3. Prevent recurrent events. 4. It helps in providing a safe environment for patient care. 5. Provide a record of the event. 6. Obtain immediate medical advice and legal counsel
  • 11. Reporting 1. Date when the report is made 2. Method of reporting (written or visual/oral ) 3. Date, time and place of the event 4. Personal details of those involved 5. A brief description of the nature of the event or disease.
  • 12. What could happen if incident reporting is Not done? 1. Hazard may not be identified. 2. Incorrect assumptions may be made about exposure to hazard and associated risks. 3. Outcome for the next person may not be so favorable.
  • 13. Example There is an adult patient been admitted to ICU in order to receive intensive care !routinely diagnostic tests were sent to lab according to his condition so the physician can clearly study the level of improvement during his stay at ICU!?
  • 14. What are the expected errors which might occur regarding daily diagnostic tests !
  • 15. Answer 1. Not performed when needed or indicated 2. Incomplete 3. Unavailable 4. Wrong patient 5. Wrong process 6. Wrong time
  • 16. Why people don’t report ?! 1. There is slow action towards improving errors due to presence of a variety of barriers . 2. People stop reporting or do not report in first place because they think it is waste of time . 3. People are not aware of nature of errors ,then how will they know to report it ?! 4. Sometimes they don’t differentiate between what's right and what's wrong regarding safety hazards within health system !!!!!
  • 17. Top 10 Patient Safety Concerns for Healthcare Organizations 2015 1. Alarm hazards: inadequate alarm configuration 2. Data integrity: incorrect or missing data in EHRs and other health IT systems 3. Managing patient violence 4. Mix-up of IV lines leading to misadministration of drugs and solutions 5. Care coordination events related to medication reconciliation 6. Failure to conduct independent double checks independently 7. Opioid-related events 8. Inadequate reprocessing of endoscopes and surgical instruments 9. Inadequate patient handoffs related to patient transport 10.Medication errors related to pounds and kilograms
  • 18. Conclusion • Everything about health care is complex. • Recognizing the complexity of care and how several factors combine at a specific time and result in errors and adverse events. • organizations, leaders, and clinicians will dedicate themselves to using data and evidence and to continuously improve the quality and safety of care, even when there are complex challenges!!
  • 19. References 1. Top 10 Patient Safety Concerns for Healthcare Organizations [Internet]. Health Data Management. [cited 2017 May 6]. Available from: https://www.healthdatamanagement.com/slideshow/top-10-patient-safety- concerns-for-healthcare-organizations 2. The 10 Patient Safety Concerns Every Health Care Worker Needs to Know About [Internet]. Monster Career Advice. [cited 2017 May 6]. Available from: https://www.monster.com/career-advice/article/patient-safety-concerns 3. 2017_PSTop10_ExecutiveBrief.pdf [Internet]. [cited 2017 May 6]. Available from: https://www.ecri.org/EmailResources/PSRQ/Top10/2017_PSTop10_ExecutiveBrief. pdf 4. Hughes RG. Nurses at the ‘sharp end’ of patient care [Internet]. Agency for Healthcare Research and Quality (US); 2008 [cited 2017 May 6]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK2672/ 5. Safety Concern Law and Legal Definition | USLegal, Inc. [Internet]. [cited 2017 May 6]. Available from: https://definitions.uslegal.com/s/safety-concern/
  • 20. THANKS FOR BEING PATIENT