Case 4: What can we learn from incidents?
An orthopedist enters the room of the manager of the quality department of a general hospital. He
looks very concerned, and directly starts to talk: “This morning a terrible incident happened at the
orthopedic ward. One of the patients has received a dose of ten times the amount of the prescribed
medication. This patient had to be transferred to the intensive care unit and is still in a critical
condition. What must we do to never let this happen again?”
The quality manager also looks concerned and asks: “Which actions have already been taken after
this incident?”
The orthopedist replies: “We have directly informed the family and talked with the nurses of the
ward to find out what went wrong. The nurses indicated that a mistake was made by one of the
nurses, who misread the prescription, due to a bad handwriting of one of the orthopedists. However,
she should have known that this dose is life threatening for such a frail patient! We immediately have
reported the error in the incidence reporting system.”
The quality manager responds: “I prefer to refer to it as an adverse event.”
The orthopedist answers slightly irritated: “Okay, whatever... Well, I have already discussed it with
the nurse who made the mistake. I told her that she should be much more careful in the future!”
Quality manager: “To err is human, so you shouldn’t blame this nurse. The current approach in
patient safety is that we don’t blame the person but try to search for causes of errors in the system.
We should assess how we can improve the prescription system, in order to prevent this type of
adverse events in the future.”
Orthopedist: “Okay, okay, I understand. But what should we do next? How can we improve the
safety of our patients!”
Quality manager: “Several different strategies can be applied to improve safety. Let’s plan a meeting
with your team to discuss these strategies this afternoon!”
Practical application (to be discussed during the post-discussion of case 4)
How can technology be used to manage patient safety in hospitals? Provide at least 5 examples.
- Ventilation equipment
- Blood pressure monitor
- Monitor
- Infusion pumps
- Barcode on drugs
What is patient safety?
Patient safety
What is patient safety? (Emanual, 2008)
Definition
- Patient safety is a discipline in the healthcare sector that applies safety science methods
towards the goal of achieving a trustworthy system of healthcare delivery
- Patient safety is also an attribute of healthcare systems; it minimizes the incidence and
impact of, and maximizes recovery from, adverse events
This definition acknowledges that patient safety is both a way of doing things and an emergent
discipline. It seeks to identify essential features of patient safety
The rise of patient safety (Emanuel, 2008)
, Attention increased due to
- Rising healthcare costs
- Increased evidence of poor quality of care
- Increased demands from the public for accountability
- Increased media exposure of preventable medical errors
A need for new solutions and new approaches to patient safety management
Input from many disciplines (Emanuel, 2008)
Patient safety methods originate mainly from disciplines outside medicine
- Cognitive psychology
- Human factors engineering
- Organizational management science
- Etc.
What different types of incidents can occur?
Some relevant terms
- Adverse event (harm): unintended physical injury resulting from medical care (including the
absence of indicated medical treatment) that requires additional monitoring, treatment, or
hospitalization, or that results in death
o Preventable adverse event (50%) (e.g. wrong dose of drugs, cutting the wrong leg,
not enough monitoring)
Harm related to errors, such as
Wrong treatment
Right treatment performed incorrectly
o Nonpreventable adverse event (50%) (e.g. side-effects of drugs, bleeding after
surgery)
Harm not related to errors, such as
Complications from treatment
Medication side-effects
- Medical error: an act of commission (doing something wrong) or omission (failing to do the
right thing) leading to an undesirable outcome or significant potential for such an outcome
Medical errors vs adverse events (Wachter, 2018)
- Negligent adverse events: a healthcare professional who really performs under the
standards of the profession (e.g. trying to get compensation from the hospital)
- Near misses: errors that almost result in an adverse event (corrected just in time)
- Preventable adverse events which are no errors: more optimal care could have been
provided than in the guidelines is set (e.g. monitoring patients more intensively than in the
guidelines is set so an adverse event could be prevented)
Different types of incidents
An orthopedist enters the room of the manager of the quality department of a general hospital. He
looks very concerned, and directly starts to talk: “This morning a terrible incident happened at the
orthopedic ward. One of the patients has received a dose of ten times the amount of the prescribed
medication. This patient had to be transferred to the intensive care unit and is still in a critical
condition. What must we do to never let this happen again?”
The quality manager also looks concerned and asks: “Which actions have already been taken after
this incident?”
The orthopedist replies: “We have directly informed the family and talked with the nurses of the
ward to find out what went wrong. The nurses indicated that a mistake was made by one of the
nurses, who misread the prescription, due to a bad handwriting of one of the orthopedists. However,
she should have known that this dose is life threatening for such a frail patient! We immediately have
reported the error in the incidence reporting system.”
The quality manager responds: “I prefer to refer to it as an adverse event.”
The orthopedist answers slightly irritated: “Okay, whatever... Well, I have already discussed it with
the nurse who made the mistake. I told her that she should be much more careful in the future!”
Quality manager: “To err is human, so you shouldn’t blame this nurse. The current approach in
patient safety is that we don’t blame the person but try to search for causes of errors in the system.
We should assess how we can improve the prescription system, in order to prevent this type of
adverse events in the future.”
Orthopedist: “Okay, okay, I understand. But what should we do next? How can we improve the
safety of our patients!”
Quality manager: “Several different strategies can be applied to improve safety. Let’s plan a meeting
with your team to discuss these strategies this afternoon!”
Practical application (to be discussed during the post-discussion of case 4)
How can technology be used to manage patient safety in hospitals? Provide at least 5 examples.
- Ventilation equipment
- Blood pressure monitor
- Monitor
- Infusion pumps
- Barcode on drugs
What is patient safety?
Patient safety
What is patient safety? (Emanual, 2008)
Definition
- Patient safety is a discipline in the healthcare sector that applies safety science methods
towards the goal of achieving a trustworthy system of healthcare delivery
- Patient safety is also an attribute of healthcare systems; it minimizes the incidence and
impact of, and maximizes recovery from, adverse events
This definition acknowledges that patient safety is both a way of doing things and an emergent
discipline. It seeks to identify essential features of patient safety
The rise of patient safety (Emanuel, 2008)
, Attention increased due to
- Rising healthcare costs
- Increased evidence of poor quality of care
- Increased demands from the public for accountability
- Increased media exposure of preventable medical errors
A need for new solutions and new approaches to patient safety management
Input from many disciplines (Emanuel, 2008)
Patient safety methods originate mainly from disciplines outside medicine
- Cognitive psychology
- Human factors engineering
- Organizational management science
- Etc.
What different types of incidents can occur?
Some relevant terms
- Adverse event (harm): unintended physical injury resulting from medical care (including the
absence of indicated medical treatment) that requires additional monitoring, treatment, or
hospitalization, or that results in death
o Preventable adverse event (50%) (e.g. wrong dose of drugs, cutting the wrong leg,
not enough monitoring)
Harm related to errors, such as
Wrong treatment
Right treatment performed incorrectly
o Nonpreventable adverse event (50%) (e.g. side-effects of drugs, bleeding after
surgery)
Harm not related to errors, such as
Complications from treatment
Medication side-effects
- Medical error: an act of commission (doing something wrong) or omission (failing to do the
right thing) leading to an undesirable outcome or significant potential for such an outcome
Medical errors vs adverse events (Wachter, 2018)
- Negligent adverse events: a healthcare professional who really performs under the
standards of the profession (e.g. trying to get compensation from the hospital)
- Near misses: errors that almost result in an adverse event (corrected just in time)
- Preventable adverse events which are no errors: more optimal care could have been
provided than in the guidelines is set (e.g. monitoring patients more intensively than in the
guidelines is set so an adverse event could be prevented)
Different types of incidents
