Category Archives: patient safety

Patient safety

You go to the hospital to get well, right? Of course, but did you know that you can get infections in the hospital while you are being treated for something else? Time in the hospital can put you at risk for a healthcare-associated infection HAIsuch as a blood, surgical site, or urinary tract infection. These infections can have devastating emotional, financial, and medical effects. Worst of all, they can be deadly.

Healthcare procedures can leave you vulnerable to germs that cause HAIs. These germs can be spread in healthcare settings from patient to patient on unclean hands of healthcare personnel or through the improper use or reuse of equipment. These infections are not limited to hospitals. For example, in the past 10 years alone, there have been more than 30 outbreaks of hepatitis B and hepatitis C in non-hospital healthcare settings such as.

It is a life-threatening medical emergency. Without timely treatment, sepsis can rapidly lead to tissue damage, organ failure, and death. Learn more about sepsis.

patient safety

Skip directly to site content Skip directly to page options Skip directly to A-Z link. Healthcare-associated Infections.

Section Navigation. Minus Related Pages. For example, in the past 10 years alone, there have been more than 30 outbreaks of hepatitis B and hepatitis C in non-hospital healthcare settings such as outpatient clinicsdialysis centersand long-term care facilities.

Protect yourself and your family from harmful germs that can cause infections Keep your hands clean. Regular hand cleaning is one of the best ways to remove germs, avoid getting sick, and prevent spreading germs.

Take antibiotics only when your provider thinks you need them. Ask if your antibiotic is necessary. Watch for signs of infection and its complications, like sepsis. Tell your doctor if you think you have an infection, or if your infection is not getting better or is getting worse.

Watch out for life-threatening diarrhea caused by C. If you have been taking an antibiotic, tell your doctor if you have 3 or more diarrhea episodes in 24 hours. Get vaccinated against flu and other infections to avoid complications. Be a safe patient in the hospital Tell your doctors if you have been hospitalized in another facility, have recently received health care outside of the United States, or have recently had an infection.

Ask your healthcare provider what they and the facility will do to protect you and your family from an antibiotic-resistant infection. If you have a catheter, ask daily when it can be removed. If you are having surgery, ask your doctor how they prevent infections. Also, ask how you can prepare for surgery to reduce your infection risk. Keep your hands clean.

Make sure everyone cleans their hands before touching you.Patient Safety is a health care discipline that emerged with the evolving complexity in health care systems and the resulting rise of patient harm in health care facilities. It aims to prevent and reduce risks, errors and harm that occur to patients during provision of health care. A cornerstone of the discipline is continuous improvement based on learning from errors and adverse events. Patient safety is fundamental to delivering quality essential health services.

Indeed, there is a clear consensus that quality health services across the world should be effective, safe and people-centred. In addition, to realize the benefits of quality health care, health services must be timely, equitable, integrated and efficient. To ensure successful implementation of patient safety strategies; clear policies, leadership capacity, data to drive safety improvements, skilled health care professionals and effective involvement of patients in their care, are all needed.

A mature health system takes into account the increasing complexity in health care settings that make humans more prone to mistakes. For example, a patient in hospital might receive a wrong medication because of a mix-up that occurs due to similar packaging.

In this case, the prescription passes through different levels of care starting with the doctor in the ward, then to the pharmacy for dispensing and finally to the nurse who administers the wrong medication to the patient. Had there been safe guarding processes in place at the different levels, this error could have been quickly identified and corrected.

In this situation, a lack of standard procedures for storage of medications that look alike, poor communication between the different providers, lack of verification before medication administration and lack of involvement of patients in their own care might all be underlying factors that led to the occurrence of errors. Traditionally, the individual provider who actively made the mistake active error would take the blame for such an incident occurring and might also be punished as a result.

Unfortunately, this does not consider the factors in the system previously described that led to the occurrence of error latent errors. It is when multiple latent errors align that an active error reaches the patient. To err is human, and expecting flawless performance from human beings working in complex, high-stress environments is unrealistic.

Assuming that individual perfection is possible will not improve safety 7. Humans are guarded from making mistakes when placed in an error-proof environment where the systems, tasks and processes they work in are well designed 8. Therefore, focusing on the system that allows harm to occur is the beginning of improvement, and this can only occur in an open and transparent environment where a safety culture prevails.

This is a culture where a high level of importance is placed on safety beliefs, values and attitudes and shared by most people within the workplace 9. Every year, millions of patients suffer injuries or die because of unsafe and poor-quality health care. Many medical practices and risks associated with health care are emerging as major challenges for patient safety and contribute significantly to the burden of harm due to unsafe care.

Below are some of the patient safety situations causing most concern. Health care-associated infections occur in 7 and 10 out of every hospitalized patients in high-income countries and low- and middle-income countries respectively Almost 7 million surgical patients suffer significant complications annually, 1 million of whom die during or immediately following surgery Unsafe injections practices in health care settings can transmit infections, including HIV and hepatitis B and C, and pose direct danger to patients and health care workers; they account for a burden of harm estimated at 9.

Most people will suffer a diagnostic error in their lifetime Unsafe transfusion practices expose patients to the risk of adverse transfusion reactions and the transmission of infections Data on adverse transfusion reactions from a group of 21 countries show an average incidence of 8. Radiation errors involve overexposure to radiation and cases of wrong-patient and wrong-site identification A review of 30 years of published data on safety in radiotherapy estimates that the overall incidence of errors is around 15 per 10 treatment courses Because these infections are often resistant to antibiotics, they can rapidly lead to deteriorating clinical conditions, affecting an estimated 31 million people worldwide and causing over 5 million deaths per year Annually, there are an estimated 3.

Safety of patients during the provision of health services that are safe and of high quality is a prerequisite for strengthening health care systems and making progress towards effective universal health coverage UHC under Sustainable Development Goal 3 Ensure healthy lives and promote health and well-being for all at all ages 7.

Target 3. It is also important to recognize the impact of patient safety in reducing costs related to patient harm and improving efficiency in health care systems.

The purpose of World Patient Safety Day is to promote patient safety by increasing public awareness and engagement, enhancing global understanding and working towards global solidarity and action. World Patient Safety Day. The Patient Safety and Risk Management unit at WHO has been instrumental in advancing and shaping the patient safety agenda globally by focusing on driving improvements in some key strategic areas through:.Patient Safety Primer.

The concept that patients could be harmed while receiving medical care has been known for thousands of years, since Hippocrates coined the phrase "first, do no harm. Although the idea of medical mistakes has been long known, the modern literature began with a famous New England Journal of Medicine paper discussing diseases of medical progress.

Yet, despite research that continued to document frequent episodes of preventable harm in hospitalized patients, the safety field remained small and relatively ignored until the s. The publication of the seminal commentary, " Error in Medicine ," by Dr. Lucian Leape highlighted the issue and presented a framework for error analysis and prevention that is still used today.

Inthe Institute of Medicine's To Err Is Human famously estimated that 44,—98, Americans die each year due to preventable harm.

Most consider its publication to represent the beginning of the modern patient safety movement. Since To Err Is Human, considerable attention has been paid to improving patient safety in hospitals, and increasingly in other settings of care as well. While much remains to be done, recent years have brought a much deeper understanding of the causes of safety issues and some progress in reducing preventable harm. This Primer is intended to provide an overview of patient safety through defining key concepts and linking to other Primers that explore specific safety concepts in more detail.

The patient safety field uses the term adverse events to describe patient harm that arises as a result of medical care rather than from the underlying disease. Important subcategories of adverse events include:. The Adverse Events, Near Misses, and Errors Primer discusses these terms in more detail and explores controversies regarding these definitions. The Detection of Safety Hazards Primer describes how errors and adverse events are identified and analyzed, with the goal of preventing future harm.

While there is general consensus about the frequency of preventable harm in hospitals, the number of deaths that directly results from these preventable adverse events is controversial, with different studies producing widely varying estimates.

This controversy arises in part because measurement of specific adverse events remains a complex and evolving area, and there is no gold standard for measuring overall safety at an institutional level.

Even when an adverse event is detected, it can be difficult to determine whether the event was preventable. These concepts are discussed in more detail in the Measurement of Patient Safety Primer.

Regardless, it is clear that each hospital likely has several preventable deaths per year, and a Annual Perspective explores methods by which hospitals can detect and analyze preventable deaths to try to improve overall safety. The prevalence of preventable adverse events has not been as extensively studied in other health care settings, but a growing body of research documents that preventable harm is common in all sites of care.Browse Topics.

Topics A-Z.

Patient Safety and Quality Improvement

Quality and Disparities Report Latest available findings on quality of and access to health care. Funding Opportunity Announcements. Home Patient Safety. Patient Safety and Quality Improvement. Improving Diagnostic Safety and Quality. Question Builder App. Watch Patient Safety in Action. Patients and providers share how asking questions can reduce risks and improve care.

Areas of Interest. AHRQ is the lead Federal agency for patient safety research.

patient safety

Our work helps providers make care safer for patients. Preventing Infections. Learn About Patient Safety. Research-based tools to get your team on board and help them understand and use core concepts of patient safety. Building Capacity for Change. AHRQ has developed tools that can help organizations build the capacity for change to make health care safer.

By understanding patient safety concepts and how team and individual behaviors and attitudes influence safety culture, teams build the foundations for a future of safer care. Patient Safety Resources by Setting. AHRQ has developed a wealth of materials focused on a wide range of patient safety risks in specific healthcare settings: acute, long-term, ambulatory, and more. Quality Measures.

patient safety

Reports and Resources.NCBI Bookshelf. We articulate an intellectual history and a definition, description, and model of patient safety. We define patient safety as a discipline in the health care professions that applies safety science methods toward the goal of achieving a trustworthy system of health care delivery.

We also define patient safety as an attribute of health care systems that minimizes the incidence and impact of adverse events and maximizes recovery from such events. Our description includes: why the field of patient safety exists the high prevalence of avoidable adverse events ; its nature; its essential focus of action the microsystem ; how patient safety works e.

Our simple and overarching model identifies four domains of patient safety recipients of care, providers, therapeutics, and methods and the elements that fall within the domains. Eleven of these elements are described in this paper. A defining realization of the s was that, despite all the known power of modern medicine to cure and ameliorate illness, hospitals were not safe places for healing.

Instead, they were places fraught with risk of patient harm. One important response to this realization has been the growth of interest in patient safety. It is increasingly clear that patient safety has become a discipline, complete with an integrated body of knowledge and expertise, and that it has the potential to revolutionize health care, perhaps as radically as molecular biology once dramatically increased the therapeutic power in medicine.

patient safety

And yet there continue to be significant challenges to implementing patient safety policies and practices. One fundamental requirement for adopting any new approach is a clear articulation of its premises and manifestations. Components of patient safety have been expressed by thought leaders, and models have been presented. However, a single rendition that can help a thorough adoption of patient safety throughout health care has not been available.

This paper aims to offer that. After introducing salient points in the intellectual history of patient safety, we offer a definition, a description, and finally, a model of patient safety.

We call on organizations to adopt a definition and model for patient safety. Critical assumptions in health care were rewritten by patient safety thinking. How to understand why people make errors that lead to adverse events shifted from a single cause, legalistic framework to a systems engineering design framework, and in so doing, it changed forever the way people think about health care delivery. The realization that adverse events often occur because of system breakdowns, not simply because of individual ineptitude prompted the change.

The traditional approach assumed that well-trained, conscientious practitioners do not make errors. Traditional thinking equated error with incompetence and regarded punishment as both appropriate and effective in motivating individuals to be more careful.

The use of this kind of blame had a toxic effect.

6 Dimensions of Healthcare Quality

Practitioners rarely revealed mistakes, and patients and supervisors were frequently kept in the dark. Low reporting made learning from errors nearly impossible, and legal counsel often supported and encouraged this approach in order to minimize the risk of malpractice litigation.

Thinking began to change in the s in response to several kinds of new information. First, medical injury was acknowledged as occurring far more often than heretofore realized, with most of these injuries deemed preventable.

To punish individuals for such mistakes seemed to make little sense, since errors are bound to continue until underlying causes are remedied. Thought leaders in health care offered persuasive arguments that errors could be reduced by redesigning systems and processes using human factors principles. These could reduce mistakes through design features, including standardization, simplification, and the use of constraints.

Another corollary quantum leap to view health care as a system took place as people applied engineering design concepts to health care. Some of these systems changes were related to tools and technology, such as using better intravenous pumps or computerizing physician medication prescribing. Others were related to organizations and people, such as training doctors and nurses to work better in teams or including a pharmacist in the team during rounds.

Some were more successful than others, but the important change was that people were thinking of health care delivery in terms of systems. Interestingly, in earlier phases of medical history, different forms of systems thinking were dominant.

However, these forms focused on the biologic systems within the individual patient, rather than on care and interactions between individuals in the environment of care.The Joint Commission has been in the business of health care quality for more than 60 years.

The journey to zero harm moves at a similar pace. Together with providers like you, we constantly study emerging patient safety issues — and roll out evidence-based methods to solve them. We encourage you to explore our collection of best practices, reference materials and other resources. Take advantage of our award-winning Speak Up program, which has carried our patient safety message to more than 40 countries.

Organizations contemplating introduction or upgrade of such systems should strive to eliminate the use of dangerous abbreviations, acronyms, symbols and dose designations from the software. Advancing Effective Communication, Cultural Competence, and Patient-and Family-Centered Care Effective patient-provider communication is critical to the successful delivery of health care services. The Joint Commission supports a number of efforts to improve communication between health care providers and patients, including standards, monographs, videos, and other resources.

Health care professionals whose focus is on patient safety are very familiar with these alarming and frequently cited statistics from the Institute of Medicine: medical errors result in the death of between 44, and 98, patients every year. Health care professionals whose focus is on occupational health and safety, however, are likely aware of additional statistics that are less well known: health care workers experience some of the highest rates of nonfatal occupational illness and injury—exceeding even construction and manufacturing industries.

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I Agree Learn More. Background Image:. Patient Safety Surpass your safety targets. Do Not Use List of Abbreviations. This list is part of the Information Management standards Does not apply to pre-programmed health information technology systems i.

Look-alike sound-alike drug list. Advancing Effective Communication. Improving Patient and Worker Safety. Patient Safety Related Products and Events.The objective of World Patient Safety Day is to raise global awareness about patient safety and encourage global solidarity and action.

Member States and non-state actors in official relations with WHO presented their statements at the WHA72 emphasizing the centrality of patient safety in health services delivery for a strengthened health care system, and the importance of government and policy makers to prioritize patient safety as the top agenda of health care policies and programmes.

The commitment to patient safety is crucial for countries to progress towards universal health coverage as extending health coverage should mean extending safe care. To decrease medication-related harm and to improve medication safety practices, WHO is launching three technical reports on high-risk situationspolypharmacy and transitions of care. WHO has asked countries and key stakeholders to prioritize these three areas for strong commitment, early action and effective management to protect patients from harm while maximizing the benefit from medication.

The 5 Moments for Medication Safety are the key moments where action by the patient or caregiver can greatly reduce the risk of harm associated with the use of their medications.

This tool aims to engage and empower patients to be involved in their own care. As countries advance towards universal health coverage UHCthey must also improve the safety of their health systems.

The GPSC will enable countries to collaborate at global, regional and national levels to focus on patient safety as one of the most important components of health care delivery, essential to achieving UHC and moving towards UN SDGs.

It represented a call for urgent action by all key national and international stakeholders — policy-makers, health care leaders, professionals and patients — to improve patient safety globally while working towards achieving effective UHC. Medication Without Harm campaign was launched in Brisbane on 10 October Campaign materials are available to download in all WHO official languages.

Patient safety is the absence of preventable harm to a patient during the process of health care and reduction of risk of unnecessary harm associated with health care to an acceptable minimum. An acceptable minimum refers to the collective notions of given current knowledge, resources available and the context in which care was delivered weighed against the risk of non-treatment or other treatment.

Every point in the process of care-giving contains a certain degree of inherent unsafety. Clear policies, organizational leadership capacity, data to drive safety improvements, skilled health care professionals and effective involvement of patients in their care, are all needed to ensure sustainable and significant improvements in the safety of health care.

The GPSC will enable countries to collaborate at global, regional and national levels to focus on patient safety as one of the most important components of health care delivery. This brochure outlines the vision and strategic direction of this global initiative. It provides an overview of the key components of the Challenge including the local, national and global action to be taken. On 29 March, experts gathered to deliberate key topics in six workshops to gain consensus and synthesize key information for reporting back to the Ministers of Health from participating countries.

The WHO Technical Series on Safer Primary Care is a series of monographs that describes issues and potential solutions for improving patient safety in primary care.

Patient Safety 101

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