"So long as it involves humans, health care will never

be free of errors.,. but it can be free of injury".

Donald Berwick
 Medical Errors
• Medical error: is an
unintentional preventable
mistake in the provision
of care that has an actual
or potential adverse
impact on the patient.
 Medical Errors
• Medical error is "an act of
omission (failure to do the
right thing) or commission
(doing the right thing
wrong) that contribute or
could contributes to an
unintended result.
Medical Errors
• A Medical error may or may
not result in adverse events.

- Such as when a patient

receives the wrong medication
but there is no harm to the
patient.
• Adverse event is an unintended

injury caused by medical

management rather than the

underlying condition of the patient

that results in measureable

disability, prolonged hospitalization,

or both" .
• Since not all adverse events are a
result of error, An adverse event
attributable to error is a
“preventable adverse event.”

• Adverse events have been classified

as either

- Preventable: due to error.

- Not preventable.
• For a near miss, it is best to
complete a Failure Mode
Effectiveness Analysis (FMEA) or
a Root Cause Analysis (RCA)
• Sentinel events signal the need for
immediate investigation and response; an
intensive in-depth analysis.

• Another name for a sentinel event is a

never event. A never event is an event
that should never happen.

• The National Quality Forum (NQF)

changed the 'never event' term to 'Serious
Reportable Events (SRE)'.
James Reason’s Swiss Cheese •
Model
 James Reason's Swiss Cheese Model
• Each slice of Swiss cheese has

holes in it, but the hole location

will not be consistent to allow a

straight line to be drawn from

the front to the back. There is a

barrier preventing further

passage through the cheese.

 James Reason's Swiss Cheese Model
• Catastrophic errors do not occur
in isolation. It is only when the
systems align in a certain way,
and the fail-safe mechanisms all
fail, that the catastrophic event
occurs.

• A number of smaller errors

leading up to a catastrophic error.
 The IOM, To Err is Human Report
• Was released to stimulate

the healthcare industry to

develop a patient safety

culture and thus to decrease

medical errors and

preventable adverse events.

 The IOM, To Err is Human Report
• The majority of medical errors
are not results of 'individual
recklessness'. More often, the
errors are results of faulty
systems, processes, and
conditions that lead individuals
to make mistakes, or at least
fail to prevent mistakes.
Four categories of errors were identified in
the IOM report
1. The communication

errors include an error or

delay in the diagnosis,

failure to order indicated

tests.
Four categories of errors were identified in the
IOM report
2. The treatment errors include an

error in the performance of a

procedure or test, an error in the

administration of the treatment, an

error in the dose or method of

using a drug, and/or inappropriate

care.
Four categories of errors were identified in the
IOM report
3. Preventative errors

include failure to provide

prophylactic treatment

and/or inadequate

monitoring or follow-up of

treatment.
Four categories of errors were identified in the
IOM report

4. And lastly, other

errors include

equipment failure, and

other system failures.

 The IOM (2000) laid out a four-tiered approach to
developing a strategy to improve patient safety

1. Establish a national focus

to create leadership tools,

research, and protocols to

increase the knowledge

base about patient safety.

 The IOM (2000) laid out a four-tiered approach to
developing a strategy to improve patient safety

2. Identify and learn from errors

by developing a nation-wide

public mandatory reporting

system as well as encouraging

healthcare staff, practitioners, and

the organization to participate in

voluntary reporting systems.

 The IOM (2000) laid out a four-tiered approach to
developing a strategy to improve patient safety
3. Raising performance
expectations and standards for
improvements in patient safety
through the professional
organizations, group
purchasers, and so forth within
healthcare.
 The IOM (2000) laid out a four-tiered approach to
developing a strategy to improve patient safety

4. Implementing patient

safety systems in healthcare

organizations and systems

to ensure safe practices at

the delivery area.

• The IOM felt that if these known improvements
were utilized, 50% of medical errors would have
been reduced by 2004, five years after the report
was released.

• Unfortunately, Agency for Healthcare Research and

Quality (AHRQ) annual reports continue to indicate
that deaths related to error remain similar to the
statistics cited in 1999, even over fifteen years later.
• The 2013 National Healthcare Quality Report states
the prevalence of harm associated with hospital
stays from 2000-2007 was 25.1 per 100 admissions,
and the number of preventable adverse events
among adults (excluding obstetrics) per year in U.S.
hospitals was 3,023,000 in 2009 (AHRQ, 2013).
Patient Safety Practices
• Patient Safety Practices were recommended
for Implementation by AHRQ (AHRQ, 2013).
Patient Safety Practices
• AHRQ defines a Patient Safety
Practice (PSP) as a process or
structure that reduces the
probability of adverse events
occurring in the healthcare
system across a range of
diseases and procedures.
Patient Safety Practices

• The PSPs were evaluated on the evidence

of the outcomes of the safe practices.
 Strongly encourage implementation
• Hand hygiene.

• Barrier precautions to
prevent healthcare-
associated infections.

• Do Not Use" list of

hazardous abbreviations.
 Strongly encourage implementation
• Preoperative checklists and
anesthesia checklists.

• Use of real-time ultrasound for

central line placement.

• Bundles that include checklists

for central line insertion and
care.
 Strongly encourage implementation
• Bundles that include head-

of-bed elevation, sedation

vacations, oral care with

chlorhexidine and

subglottic-suctioning

endotracheal tubes.
 Strongly encourage implementation
• Interventions to reduce urinary
catheter use, including catheter
reminders, stop orders, or nurse-
initiated removal protocols.

• Multicomponent interventions to
reduce pressure ulcers.

• Interventions to improve
prophylaxis for VTE.
 Encourage Implementation
• Multicomponent

interventions to reduce falls.

• Use of clinical pharmacists to

reduce adverse drug events.

• Computerized provider order

entry (CPOE).
 Encourage Implementation
• Medication reconciliation.

• Obtaining informed consent to

improve patients' understanding

of the potential risks of

procedures.

• Use of surgical outcome

measurements.
 Encourage Implementation
• Practices to reduce radiation

exposure from fluoroscopy and

computed tomography scans.

• Documentation of patient

preferences for life-sustaining

treatment.

• Rapid response systems.

 Encourage Implementation
• Utilization of complementary

methods for detecting adverse

events/medical errors to monitor

for patient safety problems.

• Team training.

• Use of simulation exercises in

patient safety efforts.

 Basic principles of patient safety
1. Patient safety emerges from systems design.

• The more complex a system is,

the more chance there is for
error, especially when there are
different systems working
together. Safety systems have
many components.
 Basic principles of patient safety
1. Patient safety emerges from systems design.

• The safety systems are comprised of

procedures, the environment, the
design of the material used, the
training that has been done, and the
culture of the team caring for the
patient. All of these can contribute to
errors.
A central principle of TQM is that mistakes may be
made by people, but most of them are caused, or at
least permitted, by faulty systems and processes.
 SYSTEMS THINKING IN HEALTHCARE
• Systems are multiple,
interconnected
(interrelated) components:
people, machines,
processes, and data which
operate toward a common
purpose.
 SYSTEMS THINKING IN HEALTHCARE
• "The goal of a system is
to maximize the output
of the whole
components (system),
not the output of each of
its components.“
 SYSTEMS THINKING IN HEALTHCARE
• Health systems are
considered
"macrosystems." Each
clinical unit and support
unit is a "microsystem."
 Complex System Theory: A "complex
adaptive system (CAS)
• A healthcare organization, is:

1. complex because it is diverse

and comprised of many
interconnected elements and

2. adaptive because it can learn

from experience and change.
 Basic principles of patient safety
2. Patient safety is designed for the nature of illness.

• Patients can be treated with standardized protocols

and/or guidelines to help minimize error.

• The standardization decreases the opportunities for

errors.
 Basic principles of patient safety
3. Patient safety is dependent on open learning.

• When errors occur, the team should learn from

those errors.
 Basic principles of patient safety
4. Trustworthiness is essential to the concept of
patient safety.

• The members of the healthcare team must trust

each other to speak up when an error or a potential
error is identified.
• Emphasis is placed on the system
of care delivery that:

1. prevents errors;

2. learns from the errors that do

occur;

3. is built on a culture of safety that

involves health care professionals,
organizations, and patients.
 High Reliability Organizations
• Are those that achieve
zero defects in quality
outcomes.

• Patient safety seeks high

reliability of a system that
is filled with risk.
 The five High Reliability Factors
1. Preoccupation ‫االنشغال‬ with
failure:

- All people within an organization

must seek, report, and correct all
potential or small risks before the
risk has the opportunity to turn
into a negative outcome.
 The five High Reliability Factors
• Organizations then frequently
use Lean-Six Sigma tools to
address those areas of risk that
have potential for problems.

• Communicate.
 The five High Reliability Factors
2. Reluctance ‫ عدم رغبة‬to
simplifications: These
organizations ask "why" more
often to better understand
the reasons for problems and
leverage new thinking to get
the right answer.
 The five High Reliability Factors
3. Sensitivity to operations
‫تشغيل‬: Pay attention to the
front line and help them to
develop situational
awareness and speak up
about safety issues. Leaders
must cultivate this.
 The five High Reliability Factors
4. Commitment to resilience.
A key human factors concept is “resilience,”
which investigates how individuals, teams
and organisations monitor, adapt to and act
on failures in high-risk situations.

it moves from simplistic reactions to error

making toward valuing a proactive focus on
error recovery.
 The five High Reliability Factors
5. Deference ‫ احترام‬to expertise.
Recognize that those closest to the
frontline are the experts and
understand the reasons behind
issues that arise. Frontline staff
members can more easily
determine how to make the
environment safer.
 High Reliability Organizations
What benefit does being a highly
reliable organization afford the
patient?

• Expectations are high from the

patient and family for a better
quality of life and safety during
care delivery and of the move
toward health and wellness.
 Safety Culture
• It is the product of values,
competencies, and
behavior of the
organization that
determines the
commitment to safety
management.
 Just Culture
• "Most serious medical errors are
committed by competent, caring
people doing what other
competent, caring people would
do"

• Everyone has a job to protect the

patient and others and to be part
of the solutions to reduce the risk
of errors.
 Just Culture
• In a 'Just Culture' all
employees, practitioners
and others understand
that the mission and the
vision of the organization
guides them to do the
best that they can in
completing their job.
 Just Culture
• The IHI estimated that 80%
of medical errors are system-
driven.

• A just culture recognizes

that professionals should not
be held accountable for
system failings over which
they have no control.
 Just Culture
• Just culture defines
three possible behavior
choices that an
individual makes and
needs to manage
Measurement tool:
• AHRQ free “Hospital survey on
patient safety culture”

• The safety culture assessment helps

identify and measure conditions in
healthcare organizations that lead to
adverse events and patient harm.

• Surveys occurring every two

years.
• In a hospital, high-risk
areas include the ICU, the
ER, Labor and Delivery,
Surgery, and so on.

• One year the survey could

be focused on one or more
of these high-risk areas.
• Then two years later when
the survey is repeated,
these areas should again
complete the survey, but
other areas should also be
selected to participate.
Six areas you have to review
(assess):
1. Leadership and culture:
analyze processes, implement
changes, non-punitive, error
reporting
2. People (staff): attitude,
education, training
3. Processes: need
improvement? redesign?

4. Equipment/technology.
5. Environment: light,
temperature, noise,
surfaces, storage.

6. Structure: supplies,
policies.
Benefit from assessing a patient safety culture of the
organization:

1. Raise staff awareness about

patient safety.

2. Diagnose and assess the

current status of patient safety

Culture.
3. Examine trends in patient
safety culture change over
time.

4. Identify strengths and

areas for patient safety
culture improvement.
5. Evaluate the cultural impact of
patient safety initiatives and
interventions.

6. Conduct internal and external

comparisons.

7. Prioritize quality strategies.