Case 4: What can we learn from incidents?
Learning goals
1. What is patient safety?
2. What are different strategies that can be applied to improve patient safety?
2a. How can incidents and safety be assessed in healthcare?
3. What is an adverse event?
3a. What is the difference between incidents, medical errors, mistakes etc.?
4. What are the different approaches and theories underlying patient safety?
1. What is patient safety?
Definition of Emanuel (2008):
- Patient safety is a discipline in the health care sector that applies safety science
methods towards the goal of achieving a trustworthy system of healthcare delivery.
- Patient safety is also an attribute of health care systems; it minimizes the incidence
and impact of, and maximizes recovery from, adverse events.
There are many disciplines involved within patient safety. The methods originate mainly
from disciplines outside medicine, such as cogitative psychology, human factors engineering
and organizational management science.
Key concepts of patient safety
- There is a need for standardization and simplification;
- More forcing functions; engineering solutions that lower the probability of human
error
- There is a growing recognition of the importance of improving communication and
teamwork;
- It is important to learn from one’s mistake;
- Appreciation of the importance of well-trained, well-staffed and a well-rested
workforce.
Increased attention to patient safety due to:
, Patient safety as a discipline began in response to evidence that adverse medical events are
widespread and preventable, there is “too much harm.” Attention also increased due to:
- Rising health care costs
- Increased evidence of poor quality
- Increased demands from the public for accountability
- Increased media exposure of preventable medical errors
These trends result in a need for new solutions and new approaches to patient safety
management.
2. What are different strategies that can be applied to improve patient safety?
Safety programs
Many organizations have begun safety programs, hired safety officers and formed patient
safety committees. This has to do with the increased focus on patient safety, regulatory
requirements and accreditation requirements.
Important to understand is that:
- Safety programs will always come from multiple sources.
- Safety officers need to collaborate with a variety of other personnel (boards and
physicians) and programs.
- Elements of top-down management and bottom-up engagement and innovation
should be combined.
- Board and physicians must be fully engaged for programs to be successful.
- Rigorous studies are essential for understanding which intervention are effective, and
the role of context in determining local effectiveness.
Other general strategies to create safer systems; general principles of patient safety
(Wachter)
- Building in redundancies and cross checks
- Standardization and simplification
- Using forcing functions such as engineering solutions that lower the probability of
human error
- Improving communication and teamwork
Learning goals
1. What is patient safety?
2. What are different strategies that can be applied to improve patient safety?
2a. How can incidents and safety be assessed in healthcare?
3. What is an adverse event?
3a. What is the difference between incidents, medical errors, mistakes etc.?
4. What are the different approaches and theories underlying patient safety?
1. What is patient safety?
Definition of Emanuel (2008):
- Patient safety is a discipline in the health care sector that applies safety science
methods towards the goal of achieving a trustworthy system of healthcare delivery.
- Patient safety is also an attribute of health care systems; it minimizes the incidence
and impact of, and maximizes recovery from, adverse events.
There are many disciplines involved within patient safety. The methods originate mainly
from disciplines outside medicine, such as cogitative psychology, human factors engineering
and organizational management science.
Key concepts of patient safety
- There is a need for standardization and simplification;
- More forcing functions; engineering solutions that lower the probability of human
error
- There is a growing recognition of the importance of improving communication and
teamwork;
- It is important to learn from one’s mistake;
- Appreciation of the importance of well-trained, well-staffed and a well-rested
workforce.
Increased attention to patient safety due to:
, Patient safety as a discipline began in response to evidence that adverse medical events are
widespread and preventable, there is “too much harm.” Attention also increased due to:
- Rising health care costs
- Increased evidence of poor quality
- Increased demands from the public for accountability
- Increased media exposure of preventable medical errors
These trends result in a need for new solutions and new approaches to patient safety
management.
2. What are different strategies that can be applied to improve patient safety?
Safety programs
Many organizations have begun safety programs, hired safety officers and formed patient
safety committees. This has to do with the increased focus on patient safety, regulatory
requirements and accreditation requirements.
Important to understand is that:
- Safety programs will always come from multiple sources.
- Safety officers need to collaborate with a variety of other personnel (boards and
physicians) and programs.
- Elements of top-down management and bottom-up engagement and innovation
should be combined.
- Board and physicians must be fully engaged for programs to be successful.
- Rigorous studies are essential for understanding which intervention are effective, and
the role of context in determining local effectiveness.
Other general strategies to create safer systems; general principles of patient safety
(Wachter)
- Building in redundancies and cross checks
- Standardization and simplification
- Using forcing functions such as engineering solutions that lower the probability of
human error
- Improving communication and teamwork
