Patient safety-Dr.Emad ALAZAZI

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Patient Safety Dr. Emad ALAZAZI Specialist Anesthesiologist & Intensivist

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A Story: When Things Go Wrong!! What is Patient Safety? Why Patient Safety? How Common is Medical Error? Why Does Error Happen? Do Fatigue/Production Pressure influence the Performance of our Job? How Can Safety Be Improved? What to Do After an Adverse Event? How Can We Build a Safe Healthcare System? What I want to talk about?

Real Story-Drug Error -1:

Real Story-Drug Error -1 A 5-year-old, 20 kg boy, admitted for outpatient herniotomy to correct his right inguinal hernia. He was assessed as being generally healthy, apart from a history of mild asthma without any previous hospitalization. He took occasionally inhaled Ventoline . Preoperative physical examination was normal. He had no clinical evidence of bronchospasm . Lungs were clear and heart sounds were normal. →Everything was normal !!!!

Real Story-Drug Error- 2:

Real Story-Drug Error- 2 Patient received Antihistamine H1 ( Hydroxyzine-Atarax ™) = 10mg syrup p.o ., Paracetamol = 500mg p.r . 2H before surgery and Hydrocortisone = 0.1mg/kg IV as premedication. →In the O.R. Precordial sthetoscope was applied. The patient was on ECG, SpO2, and automated blood pressure monitor prior to anesthetic induction. Vital signs were normal. Patient was submitted to IV and inhalational general anesthesia.

Real Story-Drug Error- 3:

Real Story-Drug Error- 3 Anesthetic management was consisted of: Atropine sulfate = 0.02mg/kg IV as pre-anesthetic medication. Anesthesia was induced with → Propofol = 3mg/kg → Halothane at 0.5% and was increased in 0.5% increments with FiO2=100% The Halothane vaporizer concentration had reached 5% and was decreased to 2%.

Real Story-Drug Error- 4:

Real Story-Drug Error- 4 Shortly after the beginning of surgery, while maintaining the anesthesia on assist ventilation with mask and ETCO2 monitoring: →Patient has developed an erratic arterial blood pressure and SpO2 with swings from high to low , arrhythmias and diffuse bilateral pulmonary crepitations : possible development of acute pulmonary edema (confirmed later by CXR). Resuscitation started by →calling for help, → starting continuous infusion of Dopamine and Dobutamine , →ventilating lungs manually with FiO2= 100%, →communicating with surgeon to finish surgery rapidly.

Real Story-Drug Error- 5:

Real Story-Drug Error- 5 Surgery was completed and patient emerged from anesthesia. He was admitted and monitored in the pediatric intensive care unit for 48 hours. Patient presented progressive pulmonary improvement and sinus rhythm while blood pressure, and HR remained within normal values. Weaned from vaso -active drugs. Patient was discharged from PICU with spontaneous breathing in room air, and normal O2 saturation, pulmonary auscultation and blood pressure. Echocardiography postoperatively was normal.

Real Story-Drug Error- 6:

Real Story-Drug Error- 6 2 days after discharging of the patient: Anesthesia Technician, who was giving anesthesia drugs to the patient, confessed that he gave by Error → Adrenaline = 0.4 mg IV in stead of Atropine. - When I asked him why he did not tell us about the mistake immediately , he said that he was afraid that the patient may die and we may blame and punish him!!!

What actions would I take in this case?:

What actions would I take in this case? Console the anesthesia technician? Training? Process changes? Procedure changes? Disciplinary action? Termination?

Should I Play the Blame Game?! :

Should I Play the Blame Game?! An Ineffective Strategy for Improving Patient Safety. Blaming People Doesn’t Improve the Healthcare System. “ Don’t forget next time!” “Be more careful!” “You should have been trained better!” AMA-RFS Public Health Committee 2006-07

What is Patient Safety?:

What is Patient Safety? The prevention of inadvertent harm to patients by understanding the causative factors. The absence of Clinical errors, either by Commission (Unintentionally doing the wrong thing) Or Omission (Unintentionally not doing the right thing) . AMA-RFS Public Health Committee 2006-07 To Err is Human: “Building a safer Health System” raised the public profile of patient Safety

Why Patient Safety?:

Why Patient Safety? Risk is part of life, The aims of a civilised society is to make life as safe as possible for its citizens, And that risks should be kept to a minimum Patient safety has become a major public concern. Patients know that their illnesses may not always be cured, but they don’t expect to be inadvertently harmed due to medical care. Consequently,relatives , and society expect that no patient should be harmed by medical care. AMA-RFS Public Health Committee 2006-07 Andrew SMITH RISK PERCEPTION AND COMMUNICATION IN ANAESTHESIA Euroanaesthesia 2003 - Glasgow

How Common is Medical Error ?:

How Common is Medical Error ? Recent studies suggest that: Medical errors occur in 2.9% to 3.7% of hospital admissions. 8.8% to 13.6% of errors lead to death. 2% of hospital admissions have a preventable adverse drug event resulting in: prolonged admission produced disability at the time of discharge National Patient Safety Foundation ( ) Sue Sanford-Ring Patient Safety Lecture Presented September 27, 2006 Coralville, IA Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence in hospitalized patients: Results of the Harvard Medical Practice Study I-II. NEJM 1991; 324: 370-84. Thomas EJ, Studdert DM, Burstin HR, et al. Incidence and types of adverse events and negligent care in Utah and Colorado. Med Care 2000; 38: 261-71

Why Does Error Happen ?:

Why Does Error Happen ? All humans make errors: indeed, “the ability to make mistakes” allows human beings to function Each individual is affected by multiple factors…. Individual Strengths and Vulnerabilities Individuals Experience, Errors, Performance Physiologic factors such as fatigue, emotional stress, illness Most of medicine is complex and uncertain Most errors result from “Healthcare system”: High workload , Lack of personnel, Long working hours, Noisy working conditions , Inadequate training, Ampoules that look the same, Lack of checks, Lack of communication . Tony Chang, Crisis management in anesthesia. Tuesday Conference September 6, 2005 GR Baker . Human factors, high reliability and patient safety: selecting strategies for improvement. University of Toronto 2004

Does Fatigue influence the performance of our job?:

Does Fatigue influence the performance of our job? Precursor to human error, Survey data = 50% reported fatigue error!!! Ignored by medical community, Factors promote fatigue: Sleep loss, Prolonged work hours, Circadian disruption. Stressful conditions ↓ Fatigue ↓ Impair Vigilance ↓ Reduce Safety ↓ Increase Risk of Adverse Events Tony Chang, Crisis management in anesthesia. Tuesday Conference September 6, 2005 Take a Break !… Don’t lose control at any time; take a deep breath !!

Production Pressure: Hurry Up Syndrome!!:

Production Pressure: Hurry Up Syndrome!! Common problem for healthcare providers, Decrease performance Survey data Sources of pressure: 49% witnessed an event where patient safety was comprised due to pressure (colleague, attending, fatigue). Pressure to put efficiency and output ahead of safety has caused catastrophic accidents. Patient safety must remain the highest priority. Tony Chang, Crisis management in anesthesia. Tuesday Conference September 6, 2005

What Are The Repercussions? :

What Are The Repercussions? Errors are attributed to nursing and usually involve medication errors or patient falls. Responsibility for patient safety is attributed to nursing. Nurses fear & experience blame & shame. Ann Cook, Helena Hoas . ALICE’S GUIDE TO PATIENT SAFETY Lecture presented at The University of Montana

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How Can Safety be Improved?... 1 Patient Identification Use at least two patient identifiers when providing care, treatment or services. Prior to the start of any invasive procedure, conduct a final verification process, to confirm the correct patient, procedure and site, using active—not passive—communication techniques. Have you checked the Patient ID -Prior to the Procedure- ? Are you sure !

How Can Safety be Improved?...2 Improve the effectiveness of communication among caregivers:

How Can Safety be Improved?... 2 Improve the effectiveness of communication among caregivers Enhances safety, A healthy team has mutual collegial respect; members share tasks, goals and information. For verbal or telephone orders or for telephonic reporting of critical test results, verify the complete order or test result by having the person receiving the information record and "read-back" the complete order or test result. Standardize a list of abbreviations, acronyms, symbols, and dose designations. Implement a standardized approach to “hand off” communications, including an opportunity to ask and respond to questions. Handoff communication is providing accurate information about patient care, treatment, condition and any recent or anticipated changes, when transferring responsibilities from one healthcare provider to another: Nurse to nurse Nurse to non-nurse Physician to physician ER to a procedural area ( labs,x-ray,etc )

How Can Safety be Improved?...3 Medication Safety:

How Can Safety be Improved?... 3 Medication Safety Improve the safety of using medications. Identify and, at a minimum, annually review a list of look-alike/sound-alike drugs used by the organization, and take action to prevent errors involving the interchange of these drugs. Label all medications, medication containers (for example, syringes, medicine cups, basins), or other solutions . National Center for Patient Safety (

How Can Safety be Improved?...4 Reduce the Risk of Health Care-Associated Infections:

How Can Safety be Improved?... 4 Reduce the Risk of Health Care-Associated Infections Comply with current World Health Organization (WHO) Hand Hygiene Guidelines Hand washing is the first and most important step to prevent spread of infection. WHO Hand hygiene guideline(

How Can Safety be Improved?...5 Reconcile Medications:

How Can Safety be Improved?... 5 Reconcile Medications Accurately and completely reconcile medications across the continuum of care. A complete list of the patient’s medications is communicated to the next provider of service when a patient is referred or transferred to another setting, service, practitioner or level of care within or outside the organization. The complete list of medications is also provided to the patient on discharge from the facility.

How Can Safety be Improved?...6 Reduce Falls:

How Can Safety be Improved?... 6 Reduce Falls Reduce the risk of patient harm resulting from falls . All staff are to be aware of their responsibility in preventing patient falls from occurring. 1. Identify the patient at high risk for falling. 2. Provide assistance for patients who are attempting an unsafe transfer or who are in distress. 3. If you are unable to assist, request assistance for the patient and stay with him until help arrives. 4. Report unsafe patient situations to the charge nurse.

How Can Safety be Improved?...7 Call for Help:

How Can Safety be Improved?... 7 C all for H elp Calling for help is an appropriate response when confronted with potentially overwhelming circumstances. Learn to call for help early because it may not be available immediately. Ask for needed relief when overtired or ill …. “Nurse, get on the internet, go to ANESTHESIA.COM, scroll down and click on the ‘Are you totally lost ?’ icon.” Tony Chang, Crisis management in anesthesia. Tuesday Conference September 6, 2005

What to Do After an Adverse Event?:

What to Do After an Adverse Event? Adverse event happened all of a sudden… Serious mishaps involve a lapse in vigilance in combination with errors in knowledge, judgment, or skill. Focus: what is right for the patient not who is right…!! Obtain help, Limit patient injury, Identify the cause, Provide for continuing care, Contact Nurse-in-charge, Head of department, Medical director Not discard supplies, Document event in the patient’s file, Not to alter the record, Stay involved with the follow-up care, Arrange immediate comfort and support for patient/family, Incident report → relevant facts, →avoid judgmental statements Tony Chang, Crisis management in anesthesia. Tuesday Conference September 6, 2005

How Can We Build a Safe Healthcare System ?--1 :

How Can We Build a Safe Healthcare System ?--1 Principles Safety is everybody’s business After a mishap management concentrates on fixing the system not blaming the individual Policies Meetings on safety are attended by staff from many levels and departments Procedures Keep updated, Adequate training, Clinical supervisors Brown- Spath & Associates The Basics of Patient Safety Sue Cornacchio . Anesthesia Risk Assessment & Joint Commission Issues

How Can We Build a Safe Healthcare System ?--2 :

How Can We Build a Safe Healthcare System ?--2 Practices Rapid, useful, and intelligible feedback on lessons learnt and actions needed. And when mishaps occur: Acknowledge responsibility, Apologise , Convince patients, victims and their families that lessons learned will reduce chance of recurrence. Sue Cornacchio . Anesthesia Risk Assessment & Joint Commission Issues Brown- Spath & Associates The Basics of Patient Safety

The Critical Issue:

The Critical Issue Avoiding errors is impossible Human beings will always make errors Fallibility is part of the human condition We can’t change the human condition We can change the conditions under which people work Naming, blaming and shaming have no remedial value Dr. Lucian Leape , Harvard School of Public Health

Key Challenge:

Key Challenge “Incompetent people are, at most, 1% of the problem. The other 99% are good people trying to do a good job who make very simple mistakes and it's the processes that set them up to make these mistakes”. Dr. Lucian Leape , Harvard School of Public Health “The Best People are not those who are Error-free but those who are Error-aware”. “The Biggest Challenge is to get People in Hospitals-Physicians, Surgeons, Pharmacists, Nurses, and Administrators- to recognize that Errors are Systems Problems and not People Problems.”

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Let's hope that patient safety is never compromised …….. !!! THANK YOU

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