By Susan Kreimer, MS, contributor Just before the new millennium, health care began building a foundation to advance patient safety. The catalyst: a 1999 landmark Institute of Medicine report that highlighted safety problems and paved the way for reducing medical errors.
- Since then, many evidence-based practices have evolved to offer effective solutions to common adverse events.
- Many are simple, common-sense practices that need to remain at the forefront of nurses’ work habits, including these 10 important safety measures.10 Best Practices for Patient Safety: 1.
- Curb infection spread – Wash and sanitize hands before coming into direct contact with each patient.
Data indicate that health care-associated infections are the most common serious hospital complication. Each year, they affect nearly two million patients, lead to an estimated 99,000 deaths, and cost the health care system as much as $20 billion, according to the Centers for Disease Control and Prevention.
The most frequent infection of this type is methicillin-resistant Staphylococcus aureus, or MRSA,2. Identify patients correctly – Rely on at least two pieces of information, such as name and date of birth. This helps ensure that patients receive the medicine or other treatment intended for them. Also, check for the appropriate blood type before a transfusion, according to The Joint Commission’s 2010 Hospital National Patient Safety Goals.3.
Use medicines safely – Label all drugs, including those in syringes, cups and basins. Take extra precautions with patients on blood thinners. With the enormous number of prescription drugs on the market, there is significant potential for error due to confusing brand or generic names and packaging.
- The Joint Commission’s safety goals require finding out which medicines each patient is taking.
- Make sure that any additional medication doesn’t conflict with current ones.4.
- Avoid surgical errors – Follow The Joint Commission’s “Universal Protocol” to prevent wrong-site or wrong-person surgery and performing the wrong procedure.
One effective strategy is called “time-out.” This a specific period for all team members to independently verify an impending clinical action, according to the World Health Organization’s Collaborating Centre for Patient Safety Solutions, which consists of The Joint Commission and The Joint Commission International.5.
Prevent venous thromboembolism (VTE) – Eliminate hospital-acquired VTE, the most common cause of preventable hospital deaths. A free guide from the Agency for Healthcare Research and Quality spells out the essential first steps, presents evidence and identifies best practices, analyzes care delivery, and tracks performance with metrics and interventions.
“Included in the guide are examples of standard order sets that can help ensure patients receive evidence-based care shown to prevent these clots,” said Jeff Brady, MD, MPH, the agency’s lead for the patient safety portfolio. It also would help to classify patients based on risk, ranging from low to mid and high.6.
Customize hospital discharges – Create an easy-to-follow plan for each patient. It should include a medication routine, a record of all upcoming medical visits, and names and numbers of whom to call if problems arise. These steps can help decrease potentially preventable readmissions by 30 percent, according to the agency.
Medications and follow-up care may have changed due to hospitalization, Brady said. “It’s not only telling the patient about any changes in medication regimens and what needs to happen after discharge, but also actually scheduling appointments for follow-up evaluation and care,” he added.
Equally important is documenting vital information clearly so that a patient understands.7. Use good hospital design principles – Prevent patient falls with evidence-based design of patient rooms and bathrooms as well as decentralized nurses’ stations. This allows for easier observation and access to patients.
Falls can result in serious injuries, extend a patient’s stay and dramatically drive up health care costs. For more information, nurses and administrators can download a free 50-minute DVD from the AHRQ, ” Transforming Hospitals: Designing for Safety and Quality,” 8.
- Assemble better teams and rapid response systems – Encourage everyone on the team, including junior members, to speak up.
- One thing that can be a barrier to effective communication is the hierarchy that exists on healthcare teams,” Brady said.
- A free toolkit called TeamSTEPPS ™, which stands for Team Strategies and Tools to Enhance Performance and Patient Safety, can be tailored to any health care setting, from emergency departments to ambulatory clinics.9.
Share data for quality improvement – Participate in The National Database of Nursing Quality Indicators (NDNQI)®. This proprietary database of the American Nurses Association (ANA) collects and evaluates unit-specific, nurse-sensitive data from more than 1,500 participating U.S.
hospitals. The facilities receive unit-level data reports that they can compare to similar units regionally, statewide and nationwide. This gives nurses and their managers the opportunity to evaluate performance and staffing levels relative to patient outcomes and set organizational goals for improvement.
“The future of health care is evidence-based practice. To have the evidence, you need to collect the data and make apples-to-apples comparisons – your nursing unit’s performance versus similar hospitals’ performance for the same type of unit,” said Isis Montalvo, MBA, MS, RN, director of ANA’s National Center for Nursing Quality®, which oversees the NDNQI program.
“The days are gone when nurses did what seemed right, or did things because that’s the way they had always been done. Our decisions today should be made based on a scientific foundation. Through NDNQI, we have data that allows us to make the best practice decisions possible. We know what practices lead to reduced fall rates, reduced hospital-acquired pressure ulcers and other adverse patient outcomes.” 10.
Foster an open-communication culture – Minimize mistakes due to lack of communication between doctors, nurses and other health professionals. A similar strategy worked for the airline industry. About 30 years ago, it became obvious that better communication between a pilot and crew members reduced human-error-related accidents and fatalities.
The Institute of Medicine in 2004 suggested emulating high-reliability industries such as the airlines to transform nursing. Since then, various “Crew Resource Management (CRM)” programs have been adopted in many U.S. hospitals. Through interactive sessions, nurses learn to maintain awareness in changing clinical situations, said Gary Sculli, RN, MSN, a former airline transport pilot who is now program manager at the VA National Center for Patient Safety in Ann Arbor, Mich.
This approach “challenges nurses to think differently about their work and empowers them to transform their practice.” © 2010. AMN Healthcare, Inc. All Rights Reserved. * Indicates required field Email: * First Name: * Last Name: * Discipline: * Specialty: * Mobile Phone: * Graduation: *
- 1 What is 5S in medical terms?
- 2 What factors influence patient safety?
- 3 What are the 7 P’s of patient care?
- 4 What are the 4 P’s of patient care?
- 5 What are the 6 P’s of patient care?
- 6 How many steps are in patient safety?
- 7 What did you identify as risks to the patient’s safety?
- 8 How can patient falls be prevented?
- 9 What are patient safety and human factors?
What is considered patient safety?
The occurrence of adverse events due to unsafe care is likely one of the 10 leading causes of death and disability in the world (1). In high-income countries, it is estimated that one in every 10 patients is harmed while receiving hospital care (2). The harm can be caused by a range of adverse events, with nearly 50% of them being preventable (3). Each year, 134 million adverse events occur in hospitals in low- and middle-income countries (LMICs), due to unsafe care, resulting in 2.6 million deaths (4). Another study has estimated that around two-thirds of all adverse events resulting from unsafe care, and the years lost to disability and death (known as disability adjusted life years, or DALYs) occur in LMICs (5). Globally, as many as 4 in 10 patients are harmed in primary and outpatient health care. Up to 80% of harm is preventable. The most detrimental errors are related to diagnosis, prescription and the use of medicines (6). In OECD countries, 15% of total hospital activity and expenditure is a direct result of adverse events (2). Investments in reducing patient harm can lead to significant financial savings, and more importantly better patient outcomes (2). An example of prevention is engaging patients, if done well, it can reduce the burden of harm by up to 15% (6).
Patient Safety is a health care discipline that emerged with the evolving complexity in health care systems and the resulting rise of patient harm in health care facilities. It aims to prevent and reduce risks, errors and harm that occur to patients during provision of health care.
A cornerstone of the discipline is continuous improvement based on learning from errors and adverse events. Patient safety is fundamental to delivering quality essential health services. Indeed, there is a clear consensus that quality health services across the world should be effective, safe and people-centred.
In addition, to realize the benefits of quality health care, health services must be timely, equitable, integrated and efficient. To ensure successful implementation of patient safety strategies; clear policies, leadership capacity, data to drive safety improvements, skilled health care professionals and effective involvement of patients in their care, are all needed.
What is five s in medical terms?
There are 5 steps: > Sort. >Shine * >Set In Order. >Standardise. >Sustain.
What is 5S in medical terms?
The 5S ( Sort, Set, Shine, Standardize and Sustain ) is aimed at bringing satisfaction of staff as well as the patients through improvement of working environment.
What factors influence patient safety?
Discussions – This study synthesized and integrated the status and factors influencing patient safety in healthcare institutions in Africa. Patient safety issues are essential for improving health outcomes, reducing risk, and minimizing the dangers associated with patient care.
Patient safety culture, since its inception, has received some concept analysis. It can be described as preventing medical errors, avoidable adverse events, protecting patients from harm or injury, and ensuring a collaborative effort for individual health care providers and integrated solid health care teams,
These factors related to patient safety in lower-middle-income countries may be individual or professional gaps or negligence, systemic factors or the lack of appropriate knowledge, obsolete equipment, technological failure or misapplication, or the total lack of the requisite resources.
- Patient safety as a product of health can be attained by ensuring having a positive reporting culture, minimizing error, creating awareness, providing education, ensuring the use of appropriate health care professionals and equipment, adopting a non-penalizing culture, and promoting teamwork,
- Essentially, the concept of patient safety is to ensure a safe environment for the care of patients and health care professionals and ensure that the risk of injury is minimum,
Patient safety practices should be regarded as a culture and become part of healthcare institutions’ everyday service delivery practices, The world health organization insists that the discipline of patient safety ensures coordinated efforts to prevent harm, reduce risk, secure health care processes, and produce a minimal threat to the patients,
This study demonstrated the variety of factors that can be attributed to patient safety in health care institutions in Africa. The study further identified the diversity of factors associated with practicing patient safety in health care institutions. These factors are related to communication, error identification, information dissemination, education, teamwork, professionalism, systems, patients, management culture, and leadership.
In a systematic review showing interventions studies focused on improving patient safety, five themes were associated with patient safety culture, i.e., error; communication; teamwork and leadership; systems, and situational awareness, The variety of the associated factors demonstrates the comprehensive nature of patient safety, and health care institutions ought to identify these factors as awareness creation and education remain a continuous activity.
This indicates that in-service staff training on patient safety attitudes must be a constant process that tackles, evaluates, and promotes each facet of the safety dimension. The categorization of patient safety dimensions must be clearly delineated to promote education and training while allowing for appropriate assessment of the concept using objective tools in health care institutions,
Also, recruiting the proper number of skilled staff is essential as staff burnout was identified as an important factor influencing patient safety practices, It was identified that several other factors influence the patient safety culture in health care institutions.
- These factors range from the individual, system, professional, hospital or institutional, and external factors.
- The contributions of these factors are varied and multiple.
- These findings are like those that were reported that some primary factors that seem to affect this culture are well-being, burnout, depression, anxiety, poor quality of life, and stress,
These factors were noted to be associated with self-reporting error, service process, error communication, human factors related to healthcare providers, and human factors related to patients (lack of attention, stress, anger, and fatigue), the healthcare environment, technical factors, and poor objective measures of errors,
- It has been noted that there is variation in the perception and utilization of patient safety culture within health care facilities in Africa.
- Increasing knowledge and encouraging patient safety culture remain cardinal to positive patient outcomes.
- The wide variation in the practices and knowledge on patients’ safety culture can be attributable to the variation pertaining to systems, socioeconomic, cultural, professional, and perception of health and health care within various African jurisdictions.
These contrasting views of perception of patient safety culture within health care facilities were also reported in another systematic review, Synchrony in ideas by all clinical service providers will aid the eventual outcome of patient safety cultural measures.
Standardization of procedures and methods across African countries is essential as those all remain a benchmark for promoting positive patient outcomes and minimizing the risk associated with poor care. The primary studies did not identify the influence of hospital type, workforce, type of services, and patient safety culture in health care institutions.
Patient safety practices must be segregated within these parameters to clearly delineate interventions that will be tailored to improve patient safety and promote patient safety within health care institutions. Therefore, future studies should also focus on the influence of hospital type, workforce, type of services and patient safety culture in health care institutions This study highlighted the factors associated with patient safety in African health care institutions.
It identified the antecedent, influencing factors, and how to promote positive patient safety cultures in those facilities. The study is not without some challenges, as only articles that were published only in the English language were included. Also, conference papers and other studies in grey literature were not included.
This might have limited the scope of perspectives related to patient safety in health service delivery. The study did not discriminate against a particular set of health professionals but included all, which might demonstrate the higher heterogeneity of synthesized perspectives.
Who is responsible for the patient safety?
The Role of the Patient Safety Officer in Promoting Hospital Patient Safety Patient safety as a basic principle of quality is dominant in the global health agenda and mentioned as an essential requirement to organize a qualified health care system.1 In hospitals, the Director or chief executive officer (CEO) has the main responsibility for patient safety in the whole hospital, although all clinical leaders are responsible for patient safety within their ward.
To clarify responsibilities and support clinical leaders in their work with patient safety, a formal structure is necessary. This formal structure may include a director of patient safety and patient safety officers in each large clinical unit. Moreover, a patient safety committee must be established to reviews all serious events and takes initiatives to improve clinical practice.
Unfortunately, the main cause of medical errors in most cases are due to system weakness and therefore the Director and other clinical leaders have responsibility as other clinical staffs when medical errors happen.2 Based on WHO document, Patient safety officer (PSO) is a qualified senior staff member with responsibility and accountability for patient safety.
- PSO has to develop a schedule of audits, risk management program in order to identify, assess and reduce any adverse events, medication errors and other patient safety subjects.
- Also, PSO develop reports on different safety and risk activities and disseminate them internally and externally.
- Furthermore, PSO measures outcome of care to assess performance, with a special focus on patient safety and finally acts on results of audits, measures and feedback by implementing patient safety improvement projects.1 Two major outcomes of world patient safety movement due to Institute of Medicine’s 1999 report on patient safety, To Err Is Human, were 1) new guidelines that focus on requirements for documenting compliance with patient safety data and 2) a new responsibility for health care organizations to establish a “safety culture” based on the “science” of safety.3,4 Thus, PSO is an emerging role to fulfill these responsibilities.
PSOs as managers of hospital’s patient safety programs, have a broad portfolio of tasks and responsibilities. These tasks range from reviewing patient charts in order to gather and present data that show compliance with formal regulations to the socially engaged task of planning and implementing programs so as to show improvement on safety targets.
- Thus, PSOs tasks lead to quality improvement due to data surveillance and reporting.
- Also, PSO role was defined as establishing connections within and between departments in the hospital.
- Usually, Most PSOs are nurses and this background help them to connect frontline staff to the hospital’s patient safety goals due to greater credibility with frontline staff and their supportive role between staff.4 Although PSO’s activities could lead to patient safety improvement and the quality consequently health care delivery; however, to achieve this success, there are serious challenges in this field such as high degree of mistrust and fear of reprisal on the frontline.4 To manage and overcome such challenging issues, the Director (CEO), PSOs and other staffs must create and establish a safety culture together to improve medical error reporting system and implement patient safety improvement projects.
: The Role of the Patient Safety Officer in Promoting Hospital Patient Safety
What are the 7 P’s of patient care?
Seven P’s of Service Marketing – Service marketing is an emerging trend that’s grown from the increasing shift from B2B to B2C. This can especially be seen in the healthcare industry, as providers and other healthcare players are having more direct conversations with their customers.
In turn, customers are having an increasing stake in their care. The Seven P’s include the original four, plus three additional considerations: price, product, promotion, place, physical evidence, people, and process. Let’s take a (very) brief look at the basics of these three additional P’s: 1. Physical evidence: “Proof” that the service was performed.
For a delivery service, this can be delivery packaging. For a surgeon, this can be a scar after the operation. Positive or negative, the physical evidence reassures customers that the service took place.
What are the 4 P’s of patient care?
Abstract – So-called “P4 Medicine” (predictive, preventive, personalized, participative) represents the cornerstones of a model of clinical medicine, which offers concrete opportunities to modify the healthcare paradigm: the individual‘s participation becomes the key to put into practice the other three aspects of P4 with each patient.
What are the 6 P’s of patient care?
Preventing Harm with the “6 Ps” – When Katherine Herrmann, the clinical quality facilitator at Henry Ford Health System, Detroit, was tasked with reducing preventable pressure ulcers and patient falls throughout the system, she didn’t simply tackle each problem in isolation.
Instead, Herrmann and her team created an improved nurse rounding program known as the “6 Ps” of patient care, or Pain, Personal Needs, Pulmonary Hygiene, Positions, Possessions and Place. Nurses perform duties designed to address the root causes of harm in each area every hour, marking a sundial-shaped board in each room to keep patients aware of their activities.
The system reduced its pressure ulcer rate from 8 cases per 1,000 discharges in January 2008 to approximately three cases per 1,000 discharges by November 2009. Last year, three of the system’s seven hospitals reduced patient falls 25 percent or more from 2008.
How many steps are in patient safety?
Seven steps to patient safety describes the steps that NHS organisations need to take to improve safety. They provide a checklist to help you plan your activities and measure your performance in patient safety.
What did you identify as risks to the patient’s safety?
4 Top Patient Safety Risks in Ambulatory Care A watchdog group has identified the top four risks for patient safety at ambulatory care settings, according to a, Ambulatory care facilities such as physician offices and outpatient clinics are the most widely used settings in U.S.
healthcare, according to the published last week. Ambulatory care settings provide a wide range of services to patients such as consultation, diagnosis, and interventions. “As healthcare delivery shifts from hospitals to ambulatory care settings, it can be challenging to coordinate care among various clinicians, systems, and facilities, raising the potential for errors that put patients at risk.
Reducing and eliminating adverse events in an outpatient environment will require an unprecedented commitment to collaboration and coordination,” Marcus Schabacker, MD, PhD, president and CEO of the, said in a prepared statement.
- The watchdog group is based in Plymouth Meeting, Pennsylvania.
- According to the ECRI Institute PSO (patient safety organization) report, the top four risks for patient safety at ambulatory care settings are diagnostic testing errors, medication events, falls, and security incidents.
ECRI Institute PSO examined more than 4,300 ambulatory care patient safety events from December 2017 to November 2018. Diagnostic testing errors accounted for the most events (47%), followed by medication safety events (27%). Highlights of the findings and recommendations are below.
How can patient falls be prevented?
3.2.1. What are universal fall precautions? – Universal fall precautions are called “universal” because they apply to all patients regardless of fall risk. Universal fall precautions revolve around keeping the patient’s environment safe and comfortable.
Familiarize the patient with the environment. Have the patient demonstrate call light use. Maintain call light within reach. Keep the patient’s personal possessions within patient safe reach. Have sturdy handrails in patient bathrooms, room, and hallway. Place the hospital bed in low position when a patient is resting in bed; raise bed to a comfortable height when the patient is transferring out of bed. Keep hospital bed brakes locked. Keep wheelchair wheel locks in “locked” position when stationary. Keep nonslip, comfortable, well-fitting footwear on the patient. Use night lights or supplemental lighting. Keep floor surfaces clean and dry. Clean up all spills promptly. Keep patient care areas uncluttered. Follow safe patient handling practices.
What is patient safety depends upon?
The Why, What, Where, How, and Who of Patient Safety – Going farther with the definition, each of its components is expanded here to offer a deeper description of patient safety: Why does the field of patient safety exist? Patient safety as a discipline began in response to evidence that adverse medical events are widespread and preventable, and as noted above, that there is “too much harm.” The goal of the field of patient safety is to minimize adverse events and eliminate preventable harm in health care.
- Depending on one’s use of the term “harm,” it is possible to aspire to eliminate all harm in health care.
- What is the nature of patient safety? Patient safety is a relatively new discipline within the health care professions.
- Graduate degree programs are currently being introduced in recognition of patient safety as a discipline.
It is a subject within heath care quality. However, its methods come largely from disciplines outside medicine, particularly from cognitive psychology, human factors engineering, and organizational management science. That, however, is also true of the biomedical sciences that propelled medicine forward to its current extraordinary capacity to cure illnesses.
Their methods came from biology, chemistry, physics, and mathematics, among others. Applying safety sciences to health care requires inclusion of experts with new source disciplines, such as engineering, but without any divergence from the goals or inherent nature of the medical profession. Patient safety is a property that emerges from systems design.
Patient safety must be an attribute of the health care system. Patient safety seeks high reliability under conditions of risk. Illness presents the first condition of risk in health care. Patient safety applies to the second condition: the therapeutic intervention.
- Sometimes the therapeutic risk is audacious, such as when a patient’s heart is lifted, chilled, cut, and sewn during cardiac transplantation surgery.
- Risk and safety are flip sides of the therapeutic coin.
- Patient safety demands design of systems to make risky interventions reliable.
- Two tenets of complexity theory apply: First, the greater the complexity of the system, the greater is the propensity for chaos.
Second, in open, interacting systems, unpredictable events will happen. The better the therapeutic design, the more resilient it is in the face of both predictable and unpredictable possible or impending failures, so they can be prevented or rescue can be achieved.17 Safety systems include design of materials, procedures, environment, training, and the nature of the culture among people operating in the system.
- Berwick and others have collaborated with Amalberti to apply Shewhart’s notion of statistical quality or error levels to health care.18 Systems are categorized by their level of adverse events.
- Barriers to progression from one level to another are identified.
- Interestingly, leaders of high-reliability organizations in other industries view the level of adverse events in medicine as so high that many of them would consider the health industry as existing in a state of chaos.
The patient safety discipline seeks systems that can move health care to higher and higher levels of safe care. Patient safety is a property that is designed for the nature of illness. High-reliability design is a concept that was not originally developed for health care.
However, health care has some essential features in common with how high-reliability design has evolved. While often complex and unpredictable, it can have the ultimate high-stakes outcome: preservation of life. A unique feature of patient care is its highly personal nature. Provision of care almost always requires health care workers to cross significant personal boundaries, both psychological and physical.
To protect patient integrity, the health professions have developed codes of professional ethics that guide how best to provide health care without doing dishonor to the ill person. Patient safety designs must allow for these important restrictions, which include confidentiality, physical privacy, and others.
At times, these needs conflict directly with the transparency and vigilance needed for optimal patient care, including safety. Another unique feature is the natural progression of illness. By definition, when illness care begins, something has already gone wrong. Thus, in many medical situations, failure to provide the correct intervention causes harm to the patient.
A missed diagnosis of meningococcal meningitis, for example, usually results in patient death. The patient safety discipline acknowledges the need to include harm due to omission of action, as well as the obvious harm due to actions taken. The vast diversity of possible etiologies and manifestations of illness makes systems design in health care a unique challenge.
Nonetheless, the reality is that most conditions are common and of common etiology, which allows for optimal design, if not infallible outcomes. If most patients with a condition such as breast cancer are best treated according to protocol but some require off-protocol, tailored treatment, systems can be designed to meet that need for the majority of protocols with tailoring options.
Patient safety is a property dependent on open learning. Patient safety has another inherent feature that derives directly from its dependence on errors and adverse events as a main source of understanding. It depends on a culture of openness to all relevant perspectives in which those involved in adverse events are treated as partners in learning.
- In this sense, patient safety espouses continuous cycles of learning, reporting of adverse events or near misses, dissemination of lessons learned, and the establishment of cultures that are trusted to not cast unfair blame.
- The patient safety field marries principles of adult education and effective behavioral learning with the traditional approaches of the medical profession.
Known from its early days as the field that seeks to move “beyond blame” to a culture trusted by all to be just patient safety, patient safety pioneers have pushed for a much deeper understanding of the mechanisms of errors that often lie beyond the actions or control of the individual.
Patient safety advocates turn away from the traditions of the guild in which social standing and privileged knowledge shielded practitioners from accountability. They also reject the defensive posture of old risk management approaches in which physicians and leaders of health care organizations were advised to admit no responsibility and to defend all malpractice claims, whether or not they were justified.
Patient safety embraces organizational and personal accountability, but it also recognizes the importance of moving beyond blame in both its organizational and its personal dimensions, while maintaining accountability and integrity in interactions with patients and families who have suffered avoidable adverse events.
Trustworthiness is essential to the concept of patient safety. The health care system designed for patient safety is trustworthy. This is not because errors will not be made and adverse events will never happen, but because the health care system holds itself accountable to applying safety sciences optimally.
Patient safety (as an attribute) prevents avoidable adverse events by paying attention (as a discipline) to systems and interactions, including human interactions, and allowing learning by all parties from near misses and actual adverse events. Through a concerted, conscientious effort, all those involved act to minimize the extent and impact of unavoidable adverse events by creating well-designed systems and well-motivated, informed, conscientious, and vigilant personnel, and by seeking to repair damage honestly and respectfully when it occurs.
Where does patient safety happen? The ultimate locus of patient safety is the microsystem. That is, the immediate environment in which care occurs—the operating room, the emergency department, and so on. It is in the microsystem where the “sharp end” resides, where patient-caregiver interactions occur, where failures of safety emerge, and where patients are harmed.
Breaches in safety may have occurred in many blunt-end components, and as described above, events constitute properties of interacting components of the overall system. Therefore, patient safety is irreducibly a matter of systems. Nonetheless, as the setting where the patient receives health care, the microsystem is the locus where the successes or failures of all systems to ensure safety converge.
- At the same time, patient safety must be concerned with the entire system.
- Importantly, patient safety recognizes that the microsystem is inherently unpredictable.
- Although it takes a mechanistic view of causation, patient safety acknowledges that each microsystem is open in that it can be influenced by another microsystem.
This may result in something unpredictable. Thus, for instance, the microsystem of concern in surgical safety might be the operating suite, but if a local emergency demands that two members of the surgical team leave the operating room, the microsystem has been unpredictably affected.
- How is patient safety achieved? A number of mechanisms are involved in achieving patient safety, including: High-reliability design.
- The fundamental mechanism by which patient safety can be achieved is high-reliability design, which includes many components.
- Thus, the irreducible unit of patient safety delivery is multifaceted; all components of health care delivery must be integrated into a system that is as reliable as possible under complex conditions.
A unique feature of high-reliability design comes from complexity theory, which notes that open, interacting systems will produce some level of chaos or inherently unpredictable events. High-reliability designs are resilient even when unpredictable events occur.
- Additional design features that guide health systems engineers include “lean process” and a notion of breaking through reliability boundaries in leaps from one safety level to another.
- These levels of reliability are often known as sigma levels—through the use of simplified and better processes.
- The concept of a multilayered system, in which the failures within each of the layers must be aligned for an error to occur, is known as the “Swiss cheese” model of accident causation.19 The components that make up the system include the institution and its organization, the professional team and the individuals it includes, and the technology in use.
Error traps (i.e., unpredictable situations in which error is highly likely) are another vivid concept on which safety sciences focus. The notion is that health care delivery is not only complex; it is also an open interacting system, in which illness is also a given, so the opportunities for making errors are many and endemic.
- Health care workers and health systems designers must therefore take this into account.
- Safety systems design in health care is early in its development.
- Practical approaches to design for safety have been pioneered by the Institute for Healthcare Improvement (IHI), the Agency for Healthcare Research and Quality (AHRQ), and the World Health Organization’s (WHO) World Alliance for Patient Safety (see also “Applying the Patient Safety Model,” below), among others.
For instance, patient safety designs can be thought of as falling into two types: those that are for types of routine care that vary little and can best be managed with protocols allowing for little deviation, and those that are for unique situations where on-the-spot innovation and significant deviation from protocol are required.
- Safety sciences.
- The term “safety science” refers to the methods by which knowledge of safety is acquired and applied to create high-reliability designs.
- The objective is to design systems that approach “fail-safe” conditions—i.e., those that ensure proper execution.
- The ideal design is one in which the operator cannot perform the function improperly.
Short of that ideal, much of the effort in the past has been directed toward developing defenses, which are barriers that prevent an unsafe act from resulting in harm. Over the years, health care has developed many of these barriers, and usually several must be breached for patient harm to occur.
- Acquisition of objective knowledge is a matter of science.
- Patient safety uses methods that are appropriate to the purpose, and these can be drawn from a range of disciplines.
- Some, such as understanding human error, come from human physiology and psychology.
- Some, such as systems analysis and quality improvement, come from engineering and management.
Others, such as organizational behavior, come from the social sciences. Still other methods come from health services research. The disciplines that contribute to safety use the methods that are appropriate to each field. These include controlled experiments, repeat tests, and other traditional scientific methods.
- Human factors engineering is built on, as appropriate, randomized controlled trials of human performance, anthropometry, anatomy, physiology, physics, and mathematics.
- A strong claim can be made that although safety sciences are scientifically grounded, the fundamental drive toward and the cutting edge of inquiry in patient safety uses the narrative; i.e., the stories of adverse events yield insights and drive adjustments.
Stories provide pattern recognition for patient safety practitioners. Stories of patient safety, like other stories, are specific and yet have insights that can be applied to other settings. This feature is well suited to the need for dealing with events that might be either familiar or entirely unpredictable.20 Importantly, however, one of the founding contributors to the safety sciences had a critical reason and unique standing to claim the term “science” for the safety sciences.
Philosopher Karl Popper—famous for his work in defining the scientific method—working with MacIntyre, identified error (and by extension, one can include systems failures more generally) as analogous to data that refute a hypothesis in the scientific method.21 Sciences, such as chemistry or biology, use as their core method a cycle that comprises observation, hypothesis generation, testing, and hypothesis verification or alteration, depending on the results of testing.
Deviation from this method causes the knowledge to be unreliable and the deviant methods to be discarded as unsound. The patient safety discipline uses an analogous cycle—observation, design, testing, then use—as its method, and system adjustment is based on analyzing how adverse events came about.
- This, in turn, is based on Deming’s assertion that making a change is a key source of knowledge for systems.22 The rather close analogue of method warrants the use of the term “science” in the safety sciences.
- To understand how human performance slips up, psychology, physiology, or social science must be used.
To understand how a machine fails, engineering methods must be used. Each method must be used with its full insistence on rigor so that the new knowledge is as reliable and objective as possible. However, in contrast to the application of the scientific method in the physical sciences, for ethical and practical reasons, in patient care there rarely can be a control or a repeat of the same event to check for reproducibility, except in a simulated environment.
- Nonetheless, when the analytic method has yielded to the best of its capacity a new insight, then this—like the new data in the process of science—generates a new cycle of adjusted design, testing, and use.
- In short, the analytic method must be unique to the adverse event, but then the safety sciences use the insight generated to create a new cycle of improved understanding and system design.
In short, patient safety applies many methods and techniques. However, two analytic methods have become widely associated with the field. One is retrospective. The analysis of what went wrong when an adverse event has occurred is known as “root cause analysis” (RCA).
Perhaps the close identification (probably excessively so) of patient safety with RCA is a result of heightened attention that occurs after a bad event. RCA is an approach to finding out what underlying features of a situation contributed to an adverse event. Adopting the idea that the immediate cause of an event is almost always the end result of multiple systems failures, RCA seeks, by review of data and interviews, to identify and understand all contributing causes in order to redesign the systems to make them safer in the future.
The other characteristic method of patient safety is prospective. Attempting to anticipate and prevent adverse events through safety design is known as “failure modes and effects analysis” (FMEA). FMEA is an engineering approach, usually taken early in the development of a product, that seeks to imaginatively identify potential failures and their effects.
- Nowledge from past failures might contribute to a designer’s ability to foresee potential failures in their design.
- Designs are then adjusted to make failure less likely.
- FMEA is used in analyzing every aspect of a system’s design, including the system’s global functioning, its components and their interactions, the functioning of equipment, the programming of equipment, and the procedures for activities.
Nevertheless, no one method is enough to produce the range of knowledge and types of understanding required for patient safety. In contrast to the clinical sciences in which the randomized controlled trial is the research method of choice, patient safety eschews the notion that the field can have confidence in a single “gold standard.” In patient safety, contributions are sought from engineering, social sciences, psychology, psychometrics, health services research, epidemiology, statistics, philosophy (theories of justice, accountability), ethics, education, computer sciences, and more.
Each discipline uses its own particular methods; patient safety takes each on its own merits and selects the method most suited to the topic or question at hand. Measurement remains an important area for development in patient safety. Many needed measures have not yet been developed. The IHI talks of three types of measurement: process, outcome, and balance.23 Process measures may need to be developed and validated for a complete bundle of carefully selected procedures for a given clinical setting.
Outcome measures might need to be developed for the particular outcome in question, but they might also need to be used in a fashion that has been developed to allow for balance—i.e., to look at the impact of intervention in one place in the system on other places in the system.
Methods for causing change. With its emphasis on making changes in health care workers’ actions, patient safety seeks to engage methods to bring about improvements that go beyond transmission of knowledge and acquisition of skills to the effective implementation of appropriate skills. In this regard, patient safety builds on the insights and techniques of quality improvement.
By its nature, separation between acquisition of new knowledge and service delivery is minimal. Rapid cycles of feedback and response methods for institutional improvement were pioneered in health care by Berwick and others.24 These processes are derived from continuous quality improvement methods originally designed by Deming 22 and others.
The methods focus on the systems of health care delivery more than on the medical issues and the knowledge that the rapid cycles produced are of the specific local system. The methods are designed to improve services in areas where a gap between acknowledged standards and actual practices exists. Usually, a guideline or protocol that has already been endorsed by an expert medical body or bundle of established practices is to be applied.
The rapid cycles tend to keep the guideline or protocol or bundle the same, altering its application only to optimize its full use in the local system. Once the implementation is done, quality indicators are monitored to maintain the new standards. Patient and family voice is important throughout.
Adverse events are subjected to analysis, which feeds into redesign or adjusted design of the systems of care. More traditional health services research and other methods of acquiring understanding are also fed into the recomposition of the systems. Dissemination of change is not a characteristic of the approach that uses rapid cycles or of quality improvement more generally.
This is in great part because the methods are designed to be tailored to the local system; therefore, they do not readily generalize, and measures of success might vary for the same reason. However, approaches that standardize measures and quality improvement methods are being used, which will allow for better dissemination.25 Alternatively, more traditional campaigns to get individual health care sites to each do their own improvement work can be used, as has been done by the IHI.
- Who is a patient safety practitioner? Most health-related disciplines are characterized by specialists who devote themselves to the full-time practice of the discipline.
- Similarly, patient safety is emerging as a specialty in which education at the masters’ level is offered and to which patient safety offices and patient safety officers devote their full-time effort.
However, patient safety requires that all members of the health care service delivery team be “patient-safety minded.” It also depends on both hands-on patient safety practices and leadership within every discipline in health care. As a quintessentially collaborative activity, patient safety needs leaders in each area of clinical administration and in each clinical discipline—including doctors, nurses, pharmacists, and others—in addition to information management, equipment and plant management, and other areas.
Patient safety practitioners truly include everyone in health care. For those who have an advanced degree in patient safety or a role determined by patient safety, it could be a primary professional identity. For most, it will be a personal and professional commitment—a part of their identify, but not their primary identity, which will remain cardiology or plant management, etc.
Nonetheless, since all in health care should acquire the characteristics needed for practicing safety, it is important to know what characteristics a patient safety practitioner (whether by primary or secondary identity) should have. What skills or unique characteristics should a patient safety practitioner possess? A professional who provides direct care needs to have a kind of wariness or patient safety vigilance.
- This quality is most often informed by a rich knowledge about adverse events and how to help avert them or minimize their damage.
- This kind of practical wisdom or “safety savvy” grows continuously from experience and an ability to recognize when something is not right.
- Often an adverse event that is about to unfold can be averted or its impact minimized if it is caught in action.
Patient safety practitioners are well storied. The role of narrative in patient safety has been emphasized, both as a vehicle for acquiring safety-relevant knowledge and as a vehicle for becoming, what Weick has called, mindful or safety wary.26 They understand that health care systems are full of “error traps,” and they are vigilant in foreseeing and preempting, mitigating, and rescuing patients from them.
Reason envisions a future for patient safety in which its practitioners share many true stories of adverse events in their training and educational venues.20 He sees this as the normative method for making members of the health care community “safety wise.” For example, studies of pediatric cardiac surgeons found that those surgeons—who were inclined to detect their errors and fix them, even at the price of having a longer and less elegant operation—had the best outcomes and reputations.
Patient safety practitioners must also become excellent team members, whether they are natural leaders or better in other roles. They must be able to substitute for one another and appreciate the other’s perspective. Importantly, since vigilance is essential for patient safety and is also tiring, working in teams during shift work is essential.27
What are patient safety and human factors?
Human factors are those things that affect an individual’s performance. A human factors approach is key to safer healthcare. It will become part of the core curricula of all health professionals. Training needs to be co-ordinated along interprofessional lines.
What is the definition of medication safety?
Medication safety is defined as the freedom. from accidental injury due to medical care or. medical errors during the medication-use. process, deserves the same prioritization, given the scope of medication use in patient care and the frequency and severity of potential harm.
What is patient safety and nursing role?
Background – Nurses play a critically important role in ensuring patient safety while providing care directly to patients. While physicians make diagnostic and treatment decisions, they may only spend 30 to 45 minutes a day with even a critically ill hospitalized patient, which limits their ability to see changes in a patient’s condition over time.