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Patient Safety


Each of us has been, is, or will be a patient one day. In 1999, a groundbreaking report, To Err is Human: Building a Safer Health System was published. It became the beginning of a new Healthcare era focused on Patient Safety culture. The same institute, The Institute of Medicine, soon thereafter published, Crossing the Quality Chasm, a report which laid the foundation for a Patient Safety culture.


One of the many reasons why these papers were even published is contributed to the number of hospital deaths related to preventable medical errors. This became headline news. It also led to a series of congressional hearings with government agencies, professional groups, accreditation organizations, insurers, and others. Thus, the modern Patient Safety movement was born.


What is Patient Safety?


According to the Agency for Healthcare Research and Quality (AHRQ), patient safety is defined as a discipline in the healthcare sector that applies safety science methods toward the goal of achieving a trustworthy system of healthcare delivery. Patient safety is also an attribute of healthcare systems; it minimizes the incidence and impact of, and maximizes the recovery from, adverse events.


Patient Safety can be also defined as a patient's right not to suffer unnecessary harm associated with healthcare. It is a central component of healthcare provided to patients. It is the prevention of errors and harm to the patients, as well as the reduction of adverse events and mitigation of their consequences resulting from healthcare. And it’s also important to realize that it does not rely solely on individual persons or departments but results from the interaction of the individual components of the system. Finally, it's for every clinician a priori from the beginning. ”Primum non nocere!”


Patient Safety Terminology (some)


Patient Safety Goals


The National Patient Safety Goals is a quality and patient safety improvement program established by the Joint Commission in 2003.


Patient Safety Program


Crossing the Quality Chasm report laid the foundation for a Patient Safety culture.

Critical Factors for an effective Patient Safety program:

  • Make patient safety a strategic priority

  • Involve key stakeholders

  • Communicate and build awareness

  • Set a supervisory level objective

  • Measure medical errors and injuries over time

  • Support staff and patients / families affected by health errors and harm

  • Align system strategy, measures and projects for improvement

  • Redesign the patient care process and increase reliability

The specific Patient Safety program shall include at least:

  • Infrastructure: The role of managers, management team, person responsible

  • Clear link to quality strategy, integration of individual functions and safety programs

  • Handbooks, standards and educational materials focused on patient safety

  • Occurrence event reporting process

  • Mechanisms to participate in national patient safety initiatives

  • Proactive identification of high-risk processes

  • Implementation of action plans to eliminate medical errors and injuries

  • The process of providing response to a medical error and an adverse event

  • Performance measurement, tracking and their subsequent analysis

  • Improvement activities

  • Documentation and reporting


Patient Safety Plan


For the successful Patient Safety program, a plan is needed.


Patient Safety Tools (some)


An example of possible complimentary tools taken from goleansixsigma.


In this blog rather theoretical, I focused on Patient Safety. Some of the above information was taken from The Janet A. Brown Healthcare Quality Handbook.


In closing, I'd like to express my heartfelt thanksgiving to everyone working in healthcare and my dearest mom for showing me the way of love, care, and compassion.


Marek


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