Case 4 Patient Safety 04-10-2022
What are the aspects of patient safety?
Definition of Emanuel (2008): a combination of a discipline and a way of doing things
- Patient safety is a discipline in the health care sector that applies safety science
methods toward the goal of achieving a trustworthy system of health care delivery.
- Patient safety is also an attribute of health care systems; it minimizes the incidence
and impact of, and maximize 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 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’s important to learn from one’s mistake
- Appreciation of the importance of well-trained, well-staffed and a well-rested
workforce
Key terms in patient safety
Adverse events
- They are unintended physical injury resulting from medical care. Can be distinguished
between:
o preventable AE: harm related to errors, such as a wrong performed treatment
and usually resolve in errors
o nonpreventable AE: harm not related to errors, such as complications of a
treatment
Behavior
- Conscious behavior: paying attention to a task (especially important when doing
something new)
- Automatic behavior: things we do almost unconsciously, habits
Medical errors
- Doing something wrong (commission) or failing to do the right thing (omission).
- A medical error leads to an undesirable outcome or a significant potential for
undesirable outcome. NOT all medical errors leads to adverse events!
- Errors can be divided in slips and mistakes:
o Slips: inadvertent, unconscious errors in the performance of some automatic
task
o Mistakes: errors resulting from incorrect choices, caused by insufficient
knowledge, lack of experience/training, inadequate information or applying
the wrong set of rules.
, - The complexity of the health care works leads to slips and mistakes. Within
healthcare, medical jobs combine three different types of tasks. Healthcare providers
sometimes work based on their automatic behavior and sometimes on their
conscious behavior. Besides this, there are many customer interactions. This
complexity of healthcare results in a high risk of errors.
Most preventable events are errors. But there are a small group of preventable adverse
events that are not errors; you can follow the rules and guidelines but an adverse event can
still happen since we’re all human.
Negligent adverse events: errors that involve care that falls below a professional standard
of care
Near misses; medical errors that almost result in an adverse event
Incident
- any unplanned or unintended event or circumstance which could have resulted or
did result in harm to a patient. This includes harm from an outcome of an illness or its
treatment that did not meet the patient's or the clinician's expectation for
improvement or cure.
How is patient safety measured?
Incidents reports
- Incidents reports are self-reports of errors by providers and are reported by frontline
personnel such as the nurse or physician caring for a patient. The goal is to improve
the safety and quality.
- There are three categories:
o Anonymous reporting; reporter is anonymous. This category encourages
reporting but asking follow-up questions is not possible.
o Confidential reporting; reporter is known but shielded from authorities. If
confidentiality is not trusted, staff will probably not report. Follow-up
questions can be asked.
o Open reporting; all people and places are publicly identified. There is a poor
track record in healthcare since individuals may cover up errors, risk of
unwanted blame and publicity. For example, your mistake comes big in the
picture which has large impact in your reputation.
- There are several key components of effective reporting systems.
What are the aspects of patient safety?
Definition of Emanuel (2008): a combination of a discipline and a way of doing things
- Patient safety is a discipline in the health care sector that applies safety science
methods toward the goal of achieving a trustworthy system of health care delivery.
- Patient safety is also an attribute of health care systems; it minimizes the incidence
and impact of, and maximize 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 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’s important to learn from one’s mistake
- Appreciation of the importance of well-trained, well-staffed and a well-rested
workforce
Key terms in patient safety
Adverse events
- They are unintended physical injury resulting from medical care. Can be distinguished
between:
o preventable AE: harm related to errors, such as a wrong performed treatment
and usually resolve in errors
o nonpreventable AE: harm not related to errors, such as complications of a
treatment
Behavior
- Conscious behavior: paying attention to a task (especially important when doing
something new)
- Automatic behavior: things we do almost unconsciously, habits
Medical errors
- Doing something wrong (commission) or failing to do the right thing (omission).
- A medical error leads to an undesirable outcome or a significant potential for
undesirable outcome. NOT all medical errors leads to adverse events!
- Errors can be divided in slips and mistakes:
o Slips: inadvertent, unconscious errors in the performance of some automatic
task
o Mistakes: errors resulting from incorrect choices, caused by insufficient
knowledge, lack of experience/training, inadequate information or applying
the wrong set of rules.
, - The complexity of the health care works leads to slips and mistakes. Within
healthcare, medical jobs combine three different types of tasks. Healthcare providers
sometimes work based on their automatic behavior and sometimes on their
conscious behavior. Besides this, there are many customer interactions. This
complexity of healthcare results in a high risk of errors.
Most preventable events are errors. But there are a small group of preventable adverse
events that are not errors; you can follow the rules and guidelines but an adverse event can
still happen since we’re all human.
Negligent adverse events: errors that involve care that falls below a professional standard
of care
Near misses; medical errors that almost result in an adverse event
Incident
- any unplanned or unintended event or circumstance which could have resulted or
did result in harm to a patient. This includes harm from an outcome of an illness or its
treatment that did not meet the patient's or the clinician's expectation for
improvement or cure.
How is patient safety measured?
Incidents reports
- Incidents reports are self-reports of errors by providers and are reported by frontline
personnel such as the nurse or physician caring for a patient. The goal is to improve
the safety and quality.
- There are three categories:
o Anonymous reporting; reporter is anonymous. This category encourages
reporting but asking follow-up questions is not possible.
o Confidential reporting; reporter is known but shielded from authorities. If
confidentiality is not trusted, staff will probably not report. Follow-up
questions can be asked.
o Open reporting; all people and places are publicly identified. There is a poor
track record in healthcare since individuals may cover up errors, risk of
unwanted blame and publicity. For example, your mistake comes big in the
picture which has large impact in your reputation.
- There are several key components of effective reporting systems.
