Patient Safety; Everything You Need to Know [An Indepth Review]

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Patient Safety; Everything You Need to Know [An Indepth Review]

According to WHO, Patient Safety refers to – 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.

Resolutions and declarations on Patient Safety

The global need for quality of care and patient safety was first discussed during the World Health Assembly in 2002, and resolution WHA55.18 on ‘Quality of care: patient safety’ at the Fifty-fifth World Health Assembly urged Member States to “pay the closest possible attention to the problem of patient safety”. Since then, there have been several international initiatives, which have brought the importance of the matter to the attention of policy-makers in many countries, including:

  • Development of global norms and standards;
  • Promotion of evidenced-based policies;
  • Promotion of mechanisms to recognize excellence in patient safety internationally;
  • Encouragement of research;
  • Provision of assistance to countries in several key areas.

These resolutions illustrate that the drive for safer health care is a worldwide endeavour, bringing significant benefits to patients in low-, middle- and high-income countries, in all corners of the globe.

See Global Patient Safety Action Plan – Document

Patient Safety Practice

Practices considered to have sufficient evidence to include in the category of patient safety practices are as follows:

  • Appropriate use of prophylaxis to prevent venous thromboembolism in patients at risk
  • Use of perioperative beta-blockers in appropriate patients to prevent perioperative morbidity and mortality
  • Use of maximum sterile barriers while placing central intravenous catheters to prevent infections
  • Appropriate use of antibiotic prophylaxis in surgical patients to prevent postoperative infections
  • Asking that patients recall and restate what they have been told during the informed-consent process to verify their understanding
  • Continuous aspiration of subglottic secretions to prevent ventilator-associated pneumonia
  • Use of pressure-relieving bedding materials to prevent pressure ulcers
  • Use of real-time ultrasound guidance during central line insertion to prevent complications
  • Patient self-management for warfarin (Coumadin®) to achieve appropriate outpatient anticoagulation and prevent complications
  • Appropriate provision of nutrition, with a particular emphasis on early enteral nutrition in critically ill and surgical patients, to prevent complications
  • Use of antibiotic-impregnated central venous catheters to prevent catheter-related infections

Many patient safety practices, such as use of simulators, bar coding, computerized physician order entry, and crew resource management, have been considered as possible strategies to avoid patient safety errors and improve health care processes; research has been exploring these areas, but their remains innumerable opportunities for further research.

Quality Care

Many view quality health care as the overarching umbrella under which patient safety resides. For example, the Institute of Medicine (IOM) considers patient safety “indistinguishable from the delivery of quality health care.” Ancient philosophers such as Aristotle and Plato contemplated quality and its attributes. In fact, quality was one of the great ideas of the Western world. Harteloh reviewed multiple conceptualizations of quality and concluded with a very abstract definition: “Quality [is] an optimal balance between possibilities realised and a framework of norms and values.” This conceptual definition reflects the fact that quality is an abstraction and does not exist as a discrete entity. Rather it is constructed based on an interaction among relevant actors who agree about standards (the norms and values) and components (the possibilities).

Work groups such as those in the IOM have attempted to define quality of health care in terms of standards. Initially, the IOM defined quality as the “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.” This led to a definition of quality that appeared to be listings of quality indicators, which are expressions of the standards. Theses standards are not necessarily in terms of the possibilities or conceptual clusters for these indicators. Further, most clusters of quality indicators were and often continue to be comprised of the 5Ds—death, disease, disability, discomfort, and dissatisfaction—rather than more positive components of quality.

The work of the American Academy of Nursing Expert Panel on Quality Health focused on the following positive indicators of high-quality care that are sensitive to nursing input: achievement of appropriate self-care, demonstration of health-promoting behaviors, health-related quality of life, perception of being well cared for, and symptom management to criterion. Mortality, morbidity, and adverse events were considered negative outcomes of interest that represented the integration of multiple provider inputs. The latter indicators were outlined more fully by the National Quality Forum. Safety is inferred, but not explicit in the American Academy of Nursing and National Quality Forum quality indicators.

The most recent IOM work to identify the components of quality care for the 21st century is centered on the conceptual components of quality rather than the measured indicators: quality care is safe, effective, patient centered, timely, efficient, and equitable. Thus safety is the foundation upon which all other aspects of quality care are built.

Read Also: 10 Occupational factors that affect health and safety in the workplace

Types of Patient Safety

This covers areas of concern about patient safety.

Here, in no particular order, are 10 important patient safety issues for providers to consider in the upcoming year.

Healthcare-associated infections: HAIs have long plagued healthcare facilities, both clinically and financially. Protocol including hand hygiene and antimicrobial stewardship play directly into the rate and prevalence of HAIs, and all three are continuously deemed patient safety concerns. According to the CDC, one in every 25 patients will contract an HAI during a hospital stay, and treating such infections costs the healthcare industry upwards of $9.8 billion, by some estimates.

Antibiotic resistance: Given current prescribing practices, the lack of new antibiotic development and the speed with which pathogens are developing resistance to certain drugs, a scenario in which antibiotics are rendered useless may be sooner than many realize. The Centers for Disease Control and Prevention estimate 2 million people contract an infection by bacteria that are resistant to antibiotics each year, and 23,000 people die as a direct result of this infection.

Since the 1940s, the beginning of the “Golden Age of Antibiotics,” society has leaned on antibiotics as a go-to fix, regardless of whether they could actually cure the ailment at hand. Clinicians also have adopted a preemptive, precautionary attitude, prescribing antibiotics to protect themselves in the event a patient does develop an infection. Antimicrobial stewardship programs can play a key role in transforming antibiotic prescribing practices to reduce both the use of antibiotics and pathogens’ ability to develop resistance to such organisms.

Personal protective equipment protocol: 2014 saw the largest Ebola virus outbreak to date. As of Nov. 16, the World Health Organization reported 5,420 deaths in eight countries attributed to the virus. Although the overwhelming majority of the outbreak was contained in West Africa, the United States cared for seven Ebola patients through November; five of whom were travelled back to the country from West Africa and two of whom contracted the virus in the U.S., marking the first Ebola transmissions in the country. The two patients who contracted Ebola in the U.S. were nurses caring for the U.S.’s first imported Ebola patient. It is suggested the virus was contracted through lack of or inadequate PPE protocol, sparking controversy and a reexamination of such guidelines. The WHO and the Centers for Disease Control and Prevention issued guidelines for donning and removing PPE, and hospitals are bolstering their infection control tactics. Additionally, nursing unions such as National Nurses United are going on strike, demanding better protective gear and safety precautions and increased education and training on treating patients with Ebola or other infectious diseases.

Hand hygiene: The first line of defense against infections remains one of the least-used tactics. Despite the relative easiness of washing hands, hand hygiene compliance rates simply remain too low. “Hand hygiene has well-documented ties to patient safety, yet median hand hygiene compliance is still only 40 percent, meaning healthcare workers clean their hands less than half the time they enter patient rooms,” says Jason Burnham, associate director of patient care solutions of Halyard Health, a global medical technology company spun-out of Kimberly Clark Health Care.

Mr. Burnham adds financial incentives are pushing healthcare providers to explore different avenues by which to increase hand hygiene. “With CMS penalties for infections adding to the cost of poor quality in 2015, hospitals across the country are exploring electronic monitoring as a way to create rapid improvement and individual accountability where manual audits and observations have not succeeded in improving behavior in this fundamental of patient care.”

Hospitals and health systems have implemented hand hygiene intervention and conducted studies to determine when clinicians achieve optimal hand hygiene compliance. But the fact remains that clinicians just aren’t washing their hands enough.

Health IT issues: The proliferation of health IT has been both a blessing and a curse in the patient safety sphere. At its core, health IT is meant to quicken processes, aggregate and analyze data and eventually improve outcomes. However, implementation of IT has been rocky, and the scope of technology’s reach is shorter than anticipated, creating an environment conducive to human error and patient safety mistakes.

“We believe there is a lot of promise for health IT to improve quality and safety, but new technology generally also brings new problems,” says Tejal Gandhi, MD, MPH, president and CEO of the National Patient Safety Foundation. “The job now is to enhance the technology, so we are using it in optimal ways to improve communication within and between teams, improve timeliness of care, and create meaningful data for monitoring and evaluation.”

Medication errors: The Institute of Medicine has estimated nearly 1.5 million Americans experience an adverse event due to a medication error each year, costing the health system nearly $3.5 billion in extra costs. The Mayo Clinic suggests medication errors are largely communication errors, be it between patient and provider, provider and pharmacist or pharmacist and patient. This is one arena in which health IT can offer a proven solution. A recent study at Boston Children’s Hospital found medication errors fell by 58 percent when an electronic reconciliation tool was implemented. Innovations and adaptations such as electronic tools may begin to help cut down the incidences of this adverse event.

Workforce safety: Clinicians can’t treat others if they themselves are not well. The NPSF believes ensuring safety of the workforce and in the workplace is a prerequisite for patient safety. This includes both the physical and psychological safety of healthcare employees. “The Occupational Safety and Health Administration reports that hospitals and health settings are among the most hazardous workplaces in the country, with high rates of injury such as musculoskeletal problems and needlestick injuries,” says Dr. Gandhi. “We also know that there are intense pressures in healthcare, and disruptive behaviors, disrespect and even violence against health workers is all too common. We believe these issues have a direct impact on patient safety because workers can only perform at their best when in an environment of physical and psychological safety.”

Transitions of care: The healthcare spectrum is a string of transitions, whether it is a physical transfer or just a change of physician. “Our communication around patient care is critical in that we must communicate exact information at each change of care to provide the next caregiver with the necessary information to start care without having to read the chart from the beginning or until the personnel can assess the patient themselves,” says Nan Finch, system director of compliance and quality at Arise Austin (Texas) Medical Center.

Health IT has also stepped up to the plate to deliver technologies and solutions to address care transitions, such as remote patient monitoring, wireless data aggregation and analysis and electronic data sharing. As Ms. Finch says, the clearer communication channels are, the better care patients will receive as they move through the healthcare spectrum.

Diagnostic errors: In addition to the severe issues they cause patients, diagnostic errors are both the most common and the most costly form of medical malpractice claims. A 2013 study from Johns Hopkins Medical Center in Baltimore found nearly 8 percent of medical malpractice payouts exceeding $1 million from 2004 to 2010, the majority of which were due to misdiagnoses.

Frank Seidelmann, DO, co-founder, chairman and CMO of Radisphere, a national radiology practice, says diagnostic errors are largely an issue in radiology due to substandard operating models. “To date, there is still no established set of standard best practices that radiologists, patients, health systems and payers can use to gauge the quality of radiology services,” Dr. Seidelmann says. “What is needed, at the very least, is a better clinical operating system that ensures routing of images to the right subspecialty and a consistent practice of blinded peer reviews. This will significantly increase quality of care, reduce costs and enable radiologists to practice at the top of their license.”

Diagnostic errors were a key issue at NPSF’s Patient Safety Awareness Week 2014, adds Dr. Gandhi, saying such errors may be more prevalent than people initially realize. These errors can result from a number of combined forces, including failure to order appropriate tests and a lack of patient engagement. She says it is a complex error, but even missed communications, such as not following up on a test or a patient not realizing how important a test is, could lead to a diagnostic misstep.

Patient engagement: Patients are becoming consumers of healthcare, and the industry has to shift to meet this new demand. By involving patients in their treatment plans and processes, they become allies in their care and can serve as another layer of defense against many safety issues. The more minds tuned into an issue, the better the outcome.

“NPSF has been a strong advocate for increased patient engagement in healthcare at all levels,” says Dr. Gandhi. “This is an extremely complex issue with many corresponding challenges — for example, health literacy and ensuring that patients are given materials and information in a way that they can understand it. There needs to be considerable education and training of health professionals, as well as the creation of shared decision making tools. But there is great promise to improving patient safety by having patients more directly involved.”

Others includes:

  • Infections as a result of medical procedures
  • Slip-and-fall accidents among patients in a hospital or long-term care facility
  • Failure to implement personal protective equipment at appropriate times
  • Failure to ensure proper standards of sanitization in clinical facilities or patient rooms
  • Errors with the prescription, administration, or management of medications

Read Also: 3 Ways to stop bleeding

Importance of Patient Safety

According to the latest scorecard report from the Agency for Healthcare Research and Quality, improved patient safety procedures contributed to a 13% decrease in hospital-acquired conditions, such as injuries and infections, from 2014 to 2017. These procedures saved 20,700 lives and $7.7 billion in medical costs. These statistics highlight the fundamental importance of patient safety.

Providing High-Quality Care: One of the primary benefits of patient safety efforts is that they yield higher standards of clinical care. For example, safeguards against misdiagnosis ensure that patients are treated for the correct underlying condition; they help providers ensure they’re treating the root illness, not just a peripheral symptom or side effect.

These efforts, along with enhanced hospital discharge procedures, can improve care for patients with chronic conditions as well as help lower hospital readmission rates. Additionally, a patient safety program can help ensure that all of a patients’ physical and emotional needs are taken into account, even if their treatment involves a prolonged stay in a healthcare facility.

Preventing Risk: Patient safety programs help minimize preventable infections or injuries.

Patient Infections: Medical teams that have strict facility sterilization and sanitization policies may see lower rates of patient infections, including pneumonia or surgical site infections. Hand hygiene and patient screening processes can also help reduce infection rates.

Patient Injuries: Nurses and physical therapists can rely on patient safety protocols to keep patients from injuring themselves during rehabilitation, whether by overexertion or by placing too much strain on an area still tender from surgery. Even during brief walks around a hospital floor, patients who are still weak may be prone to slipping and falling without proper assistance.

Medication Errors: Medical facilities that enact medication management protocols can help reduce drug errors, which can occur at prescribing and dispensing stages and may result in additional patient interventions or serious patient harm.

Protecting Sensitive Patient Information: Patient safety also involves informational safety. A primary goal of a patient safety initiative is ensuring that all sensitive patient information related to their medical history or finances is kept secure. This helps save the patient from embarrassment, frustration, or financial loss, and helps the organization guard against potential regulatory issues.

Minimizing Costs: Patient safety errors cost medical organizations money. Providers may have to expend additional resources and manpower to resolve injuries or infections that could have been avoided. Meanwhile, significant lapses in patient safety, including information breaches, may result in costly patient lawsuits. Errors can also harm a facility’s quality ratings, which could result in lower patient volumes or reduced reimbursement rates. Patient safety protocols can reduce unnecessary expenses, minimize legal risk, and improve a hospital’s reputation.

Patient Safety and Quality Improvement Act of 2005 Statute and Rule

The Patient Safety and Quality Improvement (PSQI) Act enacted in July 2005 constitutes the basis for significant opportunity to improve patient safety in the health care system by creating a voluntary error reporting system. The PSQI Act creates an unprecedented opening to prospectively prevent injury through analysis of mistakes and close calls that have been voluntarily reported by providers and ensures legal protection for providers who report information about errors and injury to a Patient Safety Organization. This paper provides an overview of the main features of the PSQI legislation, describes essential components of a national patient safety reporting system, discusses what events to report, and identifies what lessons can be learned from aviation safety reporting systems.

The WHO 10 Facts of Patient Safety

Fact 1: One in every 10 patients is harmed while receiving hospital care

Estimates show that in high-income countries, as many as one in 10 patients is harmed while receiving hospital care. The harm can be caused by a range of adverse events, with nearly 50% of them considered preventable.

A study on the frequency and preventability of adverse events across 26 hospitals in eight low-and middle-income countries, showed the adverse event rate to be around 8%. Of these events, 83% were preventable, while about 30% were associated with death of the patient.

Fact 2: The occurrence of adverse events due to unsafe care is likely one of the 10 leading causes of death and disability across the world

The occurrence of adverse events, resulting from unsafe care, is likely to be one of the 10 leading causes of death and disability worldwide. Recent evidence suggests that 134 million adverse events occur each year due to unsafe care in hospitals in low- and middle-income countries (LMICs), resulting in 2.6 million deaths annually.

Another study has estimated that around two-thirds of all adverse events resulting from unsafe care, and the years lost to disability and death (known as disability adjusted life years, or DALYs), occur in LMICs.

Fact 3: The occurrence of adverse events due to unsafe care is likely one of the 10 leading causes of death and disability across the world

The provision of safe services is extremely important across all levels of health care, including in primary and outpatient (ambulatory) care, where the bulk of services are offered. Globally, as many as four out of 10 patients are harmed while receiving health care in these settings, with up to 80% of the harm considered to have been preventable. The most detrimental errors are related to diagnosis, prescription and the use of medicines.

Harm in primary and ambulatory care often results in hospitalization. It has been found, that across Organisation for Economic Co-operation and Development (OECD) countries, patient harm may account for more than 6% of hospital bed days and more than 7 million admissions.

Fact 4: At least 1 out of every 7 Canadian dollars is spent treating the effects of patient harm in hospital care

A minimum of 1 out of every 7 Canadian dollars is spent treating the effects of patient harm in hospital care. Recent evidence shows that 15% of total hospital expenditure and activities in Organisation of Economic Co-operation and Development (OECD) countries is a direct result of adverse events, with the most burdensome events being blood clots (venous thromboembolism), bed sores (pressure ulcers) and infections.

It is estimated that the total cost of harm in these countries alone amounts to trillions of US dollars every year.

Fact 5: Investment in patient safety can lead to significant financial savings

Investment in improving patient safety can lead to significant financial savings and more importantly better patient outcomes. This is because the cost of prevention is typically much lower than the cost of treatment due to harm. As an example, in the United States alone, focused safety improvements led to an estimated US$ 28 billion in savings in Medicare hospitals between 2010 and 2015.

Greater patient involvement is the key to safer care. Engaging patients is not expensive and represents a good value. If done well, it can reduce the burden of harm by up to 15%, saving billions of dollars each year– a very good return on investment.

Fact 6: Unsafe medication practices and medication errors harm millions of patients and costs billions of US dollars every year

Unsafe medication practices and errors – such as incorrect dosages or infusions, unclear instructions, use of abbreviations and inappropriate prescriptions – are a leading cause of avoidable harm in health care around the world. Globally, the cost associated with medication errors has been estimated at US$ 42 billion annually, not counting lost wages, productivity, or health care costs. This represents almost 1% of global expenditure on health.

Medication errors may occur when weak medication systems and/or human factors such as fatigue, poor working conditions, or staff shortages affect prescribing, storage, preparation, dispensing, administration and monitoring practices. Any one or a combination of these can result in severe patient harm, disability and even death.

Fact 7: Inaccurate or delayed diagnosis is one of the most common causes of patient harm and affects millions of patients

Diagnostic error, that is the failure to identify the nature of an illness in an accurate and timely manner, occurs in about 5% of adults in the United States outpatient care settings. About half of these errors have the potential to cause severe harm. A study of primary care clinics in Malaysia established the occurrence of diagnostic errors at 3.6%.

In the United States, extensive autopsy research performed in the past decades has shown that diagnostic errors contribute to approximately 10% of patient deaths. Furthermore, medical record reviews demonstrate that diagnostic errors account for 6–17% of all harmful events in hospitals.

Evidence from low- and middle-income countries is limited, however, it is estimated that the rate is higher than in high-income countries as the diagnostic process is negatively impacted by factors such as limited access to care and diagnostic testing resources.

Fact 8: Hospital infections affect up to 10 out of every 100 hospitalized patients

Out of every 100 hospitalized patients, at any given time, seven in high-income countries and 10 in low- and middle-income countries will acquire one or more health care-associated infections (HAIs). Hundreds of millions of patients worldwide are affected by HAIs each year. People with methicillin-resistant Staphylococcus aureus (MRSA), a bacterium increasingly found in hospital settings that is resistant to most antibiotics, are estimated to be 64% more likely to die than people with a non-resistant form of the infection.

Regardless of a country’s income level, different types of interventions, including appropriate hand hygiene, can reduce HAI rates by up to 55%.

Fact 9: More than 1 million patients die annually from complications due to surgery

Findings by WHO suggest that, globally, surgery still results in high rates of illness, disease and death. Unsafe surgical care procedures cause complications in up to 25% of patients. Almost 7 million surgical patients suffer significant complications annually, 1 million of whom die during or immediately following surgery.

As a result of improved patient safety measures, deaths related to complications from surgery have decreased in the past 50 years. Nevertheless, they remain two to three times higher in low- and middle-income countries than in high-income countries.

Fact 10: Medical exposure to radiation is a public health and patient safety concern

Worldwide, there are more than 3.6 billion x-ray examinations performed every year, with around 10% of them occurring in children. Additionally, there are over 37 million nuclear medicine and 7.5 million radiotherapy procedures annually. Inappropriate or unskilled use of medical radiation can lead to health hazards, both for patients and staff.

Radiation errors involve overexposure to radiation and cases of wrong-patient or 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 10 000 treatment courses.

Read Also: What is food safety and why is it important?

Strategies to Improve Patient Safety

Allow patients access to EHR data, clinician notes

Facilitating patient access to health information and clinician notes is an effective method for preventing medical record misinformation. When patients can look at their EHR data, they can spot inaccuracies in medication history or prescription errors.

Care for hospital environment

Ensuring hospital cleanliness is a clear-cut method for preventing adverse patient safety events. Facility staff should make sure all areas in the hospital or office are sanitary to protect patients from hospital-acquired conditions (HACs).

Create a safe patient experience

Building a positive patient experience is about more than simply making the patient happy. Ensuring patient safety and that the patient does not experience preventable harms are equally important to the patient experience.

Create simple and timely appointment scheduling

Creating a simple appointment scheduling process is key for ensuring patients receive care in a timely fashion. When patients cannot access necessary treatment, they may become increasingly sick while waiting for an appointment.

Encourage family and caregiver engagement

Promoting family and caregiver engagement can likewise support patient safety by adding yet another set of eyes looking for inaccuracies in patient care.

 

OTHER SIMPLE TIPS

PRACTICE OF PATIENT SAFETY

1. Be aware of Look-Alike, Sound-Alike Medication Names.
2. Proper Patient Identification.
3. Explain in Detail During Patient Hand/Take- Overs.
4. Performance of Correct Procedure at Correct Body Site.
5. Careful About Electrolyte Imbalance.
6. Assuring Proper Treatment During Shifting.
7. Avoid Catheter and Tubing, Wrong Connections .
8. Single Use of Injection Syringes.
9. Improved Hand Hygiene to Prevent Health Care- Associated Infections .
10. Proper Disposal of BioMedical Waste (BMW)and Good House Keeping.
11 Practice Surgical Safety Guide Lines.

TIPS FOR IMPROVING PATIENT SAFETY
1. Constitution of Patient Safety Committee.
2. Develop clear policies and protocols for patient safety.
3. Discuss regularly patient safety initiative within hospital staff.
4. Orientation, Re-orientation hospital staff on patient safety.
5. Encourage transparency in the regular death review.
6. Non- punitive incident reporting by staff.
7. Each department to devise their own patient safety protocols.
8. Investigate each accident/ incident reported and take remedial measures.
9. Review, monitor & evaluate. safety procedures regularly.

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