Lecture case 4 Patient Safety IQM
1.Patient safety: what is patient safety?
Patient safety (Definition by Emanuel, 2008):
a discipline (=theories etc) in the health care sector that applies safety science methods
toward the goal of achieving a trustworthy system of health care delivery.
An attribute (=way of doing things) of health care systems; it minimizes the incidence and
impact of, and maximizes recovery from, adverse events
In the last decades the attention for patient safety has increased due to:
1. Rising healthcare costs
2. Increased evidence of poor quality of care
3. Increased demands from the public accountability (if problems occur, public thinks
healthcare organizations should be held responsible)
4. Increased media exposure of preventable medical errors
A need for new solutions and new approaches to patient safety management
Patient safety has input from many disciplines (often from outside medicine) and therefore patient
safety methods originate mainly from disciplines outside medicine, for example:
Cognitive psychology
Human factors engineering
Organizational management sciences
2.Which terms are used for incidence in healthcare and how are they
defined?
Adverse event: unintended physical injury resulting from medical care
Preventable adverse event: harm is often related to errors, such as wrong treatment and
right treatment performed incorrectly
Nonpreventable adverse event: harm not related to errors such as complications from
treatment and medication side effects. (This are adverse events you can expect)
Ratio 50/50 in daily practice
Medical error:
o Doing something wrong (commission)
o Failing to do the right thing (omission)
Leading to undesirable outcome or significant potential for undesirable outcome
Difference adverse event vs medical error: adverse event is always a result of an undesirable
outcome and is not always caused by a medical error (60% often) and medical error can lead to no
consequence at all.
Negligent adverse events: Care professional conducted treatment in such a way below normal
protocol (not in line with standardized care) that you even can get compensation due to big mistakes
that could easily be prevented
1
, Near misses: almost errors that could result in adverse events
Automatic behavior: things we do almost unconsciously (routine
Conscious behavior: paying attention to a task, especially important when we are doing something
new
Types of errors:
-Slips: inadvertent (not meant), unconscious errors in the performance of some automatic task
-Mistakes: errors resulting from incorrect choices (in conscious behavior) caused by
Insufficient knowledge
Lack of experience or training
Inadequate information (or incorrect interpretation)
Applying the wrong set of rules or algorithms to a decision
There is a high risk of errors in healthcare because medical jobs typically combine three very
different types of tasks:
o Lots of conscious behavior
o Many customer interactions
o Innumerable automatic behaviors
The complexity of healthcare results in high risks of errors
Nurses who administer medication, can be disturbed by other patients or visitors -> can
contribute to mistakes (solution could be non-disturb sign or extra checklist).
3.How can incidence and safety be measured in healthcare?
Different methods to measure patient safety:
1. Incident reports
2. Patient safety indicators
3. Trigger tools
4. Hospital standardized mortality ratios (HSMR)
5. Asking the patient
1.Incident reports: self-reports of errors by providers which are reported by the frontline personnel
(e.g. nurse or physician) to improve quality and safety. There are three categories:
o Anonymous reporting: reporter is anonymous which encourages reporting (advantage),
however follow-up questions are not possible (disadvantage)
o Confidential reporting: reporter is known but shielded from authorities. Follow-up questions
can be asked (advantage), however when confidentiality is not trusted, staff will probably not
report (disadvantage)
o Open reporting: all people and places are (publicly) identified. This has a poor track record in
healthcare because individuals may want to cover up errors, risk of unwanted blame and
publicity (disadvantage). However it is transparent (advantage)
Therefore a few key components of effective reporting systems have been established:
Supportive environment that protects the privacy of reporters
Reports are received from a broad range of personnel
Summaries of reported events must be disseminated (shared) in a timely fashion
A structured mechanism for reviewing reports and developing action plans
2
1.Patient safety: what is patient safety?
Patient safety (Definition by Emanuel, 2008):
a discipline (=theories etc) in the health care sector that applies safety science methods
toward the goal of achieving a trustworthy system of health care delivery.
An attribute (=way of doing things) of health care systems; it minimizes the incidence and
impact of, and maximizes recovery from, adverse events
In the last decades the attention for patient safety has increased due to:
1. Rising healthcare costs
2. Increased evidence of poor quality of care
3. Increased demands from the public accountability (if problems occur, public thinks
healthcare organizations should be held responsible)
4. Increased media exposure of preventable medical errors
A need for new solutions and new approaches to patient safety management
Patient safety has input from many disciplines (often from outside medicine) and therefore patient
safety methods originate mainly from disciplines outside medicine, for example:
Cognitive psychology
Human factors engineering
Organizational management sciences
2.Which terms are used for incidence in healthcare and how are they
defined?
Adverse event: unintended physical injury resulting from medical care
Preventable adverse event: harm is often related to errors, such as wrong treatment and
right treatment performed incorrectly
Nonpreventable adverse event: harm not related to errors such as complications from
treatment and medication side effects. (This are adverse events you can expect)
Ratio 50/50 in daily practice
Medical error:
o Doing something wrong (commission)
o Failing to do the right thing (omission)
Leading to undesirable outcome or significant potential for undesirable outcome
Difference adverse event vs medical error: adverse event is always a result of an undesirable
outcome and is not always caused by a medical error (60% often) and medical error can lead to no
consequence at all.
Negligent adverse events: Care professional conducted treatment in such a way below normal
protocol (not in line with standardized care) that you even can get compensation due to big mistakes
that could easily be prevented
1
, Near misses: almost errors that could result in adverse events
Automatic behavior: things we do almost unconsciously (routine
Conscious behavior: paying attention to a task, especially important when we are doing something
new
Types of errors:
-Slips: inadvertent (not meant), unconscious errors in the performance of some automatic task
-Mistakes: errors resulting from incorrect choices (in conscious behavior) caused by
Insufficient knowledge
Lack of experience or training
Inadequate information (or incorrect interpretation)
Applying the wrong set of rules or algorithms to a decision
There is a high risk of errors in healthcare because medical jobs typically combine three very
different types of tasks:
o Lots of conscious behavior
o Many customer interactions
o Innumerable automatic behaviors
The complexity of healthcare results in high risks of errors
Nurses who administer medication, can be disturbed by other patients or visitors -> can
contribute to mistakes (solution could be non-disturb sign or extra checklist).
3.How can incidence and safety be measured in healthcare?
Different methods to measure patient safety:
1. Incident reports
2. Patient safety indicators
3. Trigger tools
4. Hospital standardized mortality ratios (HSMR)
5. Asking the patient
1.Incident reports: self-reports of errors by providers which are reported by the frontline personnel
(e.g. nurse or physician) to improve quality and safety. There are three categories:
o Anonymous reporting: reporter is anonymous which encourages reporting (advantage),
however follow-up questions are not possible (disadvantage)
o Confidential reporting: reporter is known but shielded from authorities. Follow-up questions
can be asked (advantage), however when confidentiality is not trusted, staff will probably not
report (disadvantage)
o Open reporting: all people and places are (publicly) identified. This has a poor track record in
healthcare because individuals may want to cover up errors, risk of unwanted blame and
publicity (disadvantage). However it is transparent (advantage)
Therefore a few key components of effective reporting systems have been established:
Supportive environment that protects the privacy of reporters
Reports are received from a broad range of personnel
Summaries of reported events must be disseminated (shared) in a timely fashion
A structured mechanism for reviewing reports and developing action plans
2
