PATIENT SAFETY

Patient safety is a serious global public health issue

o There is now growing recognition that patient safety and quality is a critical dimension of universal health coverage.

o Since the launch of the WHO Patient Safety Programme in 2004, over 140 countries have worked to address the challenges of unsafe care.

One in 10 patients may be harmed while in hospital

o Estimates show that in developed countries as many as 1 in 10 patients is harmed while receiving hospital care.

o The harm can be caused by a range of errors or adverse events.

Hospital infections affect 14 out of every 100 patients

admittedo Of every 100 hospitalized patients at any given time, 7 in developed and 10 in developing countries will acquire health care-associated infections (HAIs).

o Hundreds of millions of patients are affected worldwide each year.

o Simple and low-cost infection prevention and control measures, such as appropriate hand hygiene, can reduce the frequency of HAIs by more than 50%.

Most people lack access to appropriate medical devices

o There are an estimated 1.5 million different medical devices and over 10 000 types of devices available worldwide.

o The majority of the world's population is denied adequate access to safe and appropriate medical devices within their health systems.

o More than half of low- and lower middle-income countries do not have a national health technology policy which could ensure the effective use of resources through proper planning, assessment, acquisition and management of medical devices.

Unsafe injections decreased by 88% from 2000 to 2010

o Key injection safety indicators measured in 2010 show that important progress has been made in the reuse rate of injection devices (5.5% in 2010),

o While modest gains were made through the reduction of the number of injections per person per year (2.88 in 2010).

Delivery of safe surgery requires a teamwork approach

o An estimated 234 million surgical operations are performed globally every year.

o Surgical care is associated with a considerable risk of complications.

o Surgical care errors contribute to a significant burden of disease despite the fact that 50% of complications associated with surgical care are avoidable.

About 20%–40% of all health spending is wasted due to

poor-quality careo Safety studies show that

additional hospitalization, litigation costs, infections acquired in hospitals, disability, lost productivity and medical expenses cost some countries as much as US$ 19 billion annually.

o The economic benefits of improving patient safety are therefore compelling.

A poor safety record for health care

o Industries with a perceived higher risk such as the aviation and nuclear industries have a much better safety record than health care.

o There is a 1 in 1 000 000 chance of a traveller being harmed while in an aircraft.

o In comparison, there is a 1 in 300 chance of a patient being harmed during health care.

Patient and community engagement and

empowerment are keyo People’s

experience and perspectives are valuable resources for identifying needs, measuring progress and evaluating outcomes.

Hospital partnerships can play a critical role

o Hospital-to-hospital partnerships to improving patient safety and quality of care have been used for technical exchange between health workers for a number of decades.

o These partnerships provide a channel for bi-directional patient safety learning and the co-development of solutions in rapidly evolving global health systems.

Hospital partnerships can play a critical role

o Hospital-to-hospital partnerships to improving patient safety and quality of care have been used for technical exchange between health workers for a number of decades.

o These partnerships provide a channel for bi-directional patient safety learning and the co-development of solutions in rapidly evolving global health systems.

Introduction to Patient Safety:Definition

o Patient safety is a discipline in the health care sector that applies safety science methods toward the goal of achieving a trustworthy system of health care delivery. Patient safety is also an attribute of health care systems; it minimizes the incidence and impact of, and maximizes recovery from, adverse events (Emanuel et al., 2008) .

Introduction to Patient Safety: Background

o Adverse medical events are widespread and preventable (Emanuel et al., 2008) .

o Much unnecessary harm is caused by health-care errors and system failures.– Ex. 1: Hospital acquired infections from

poor hand-washing.– Ex. 2: Complications from administering

the wrong medication.

Introduction to Patient Safety:Goal

o Prevent and/or minimize the adverse events and eliminate preventable harm in health care.

o All health care professionals including nurses are responsible for ensuring patient safety

Introduction to Patient Safety:

This unit of patient safety will focus on Infection Control

Global Infection ProblemsAccording to WHO (2005),o On average, 8.7% of hospital patients suffer

health care-associated infections (HAI).o In developed countries: 5-10% o In developing countries:

– Risk of HAI: 2-20 times higher– HAI may affect more than 25% of patients

o At any one time, over 1.4 million people worldwide suffer from infections acquired while in hospital.

Health Care-Associated Infections (HAI)

According to WHO:o HAI is also called “nosocomial”.o HAI is defined as:

– an infection acquired in hospital by a patient who was admitted for a reason other than that infection.

– an infection occurring in a patient in a hospital or other health-care facility in whom the infection was not present or incubating at the time of admission.

Impacts of Health Care-Associated Infections (HAI)

HAI can: o Increase patients’ suffering.o Lead to permanent disability.o Lead to death.o Prolong hospital stay. o Increase need for a higher level of care.o Increase the costs to patients and

hospitals.

Preventing infections

Requires health care providers who have: – Knowledge of common infections and

their vectors– An attitude of cooperation and

commitment – Skills necessary to provide safe care

Required Knowledge

o Knowledge of the extent of the problem;o Knowledge of the main causes, modes of

transmission, and types of infections.

Required Attitudes

Being an effective team player.

Commitment to preventing HAIs

Required Skills

o Apply universal precautions*o Use personal protection methodso Know what to do if exposedo Encourage others to use universal

precautionso Report breaks in technique that increase

patient riskso Observe patients for signs and symptoms

of infection

One more important thing!

Protect YourselfProtect Yourself Be sure you have been immunized against

Hepatitis B since it is very easy to transmit!

Main Sources of Infection

o Person to person via hands of health-care providers, patients, and visitors

o Personal clothing and equipment (e.g. Stethoscopes, flashlights etc.)

o Environmental contaminationo Airborne transmissiono Hospital staff who are carriers o Rare common-source outbreaks

Campaigns to Decrease Infection Rates

o WHO “Clean hands are safer hands” campaign

o Centers for Disease Control and Prevention (CDC) “prevent antimicrobial resistance” campaign in health-care settings

o Institute for Healthcare Improvement (IHI) “5 million lives” campaign– Developing country focus

Main Routes for infections

o Urinary tract infections (UTI)– Catheter-associated UTIs are the most

frequent, accounting for about 35% of all HAI.

o Surgical infections: about 20% of all HAIo Bloodstream infections associated with the use

of an intravascular device: about 15% of all HAIo Pneumonia associated with ventilators:

about15% of HAI

Burke J Infection control-a problem for patient safety New Eng Journal of Medicine (February 13, 2003)

Types of Infections

Four Ways to Prevent HAI

1. Maintain cleanliness of the hospital.2. Personal attention to handwashing before

and after every contact with a patient or object.

3. Use personal protective equipment whenever indicated.

4. Use and dispose of sharps safely.

Prevention in Hospitals and Clinics

o Studies show infections are minimized when hospitals/clinics:– Are visibly clean;– Use increased levels of cleaning during

outbreaks;– Use hypochlorite and detergents during

outbreaks.

Prevention through Handwashing

o Handwashing: the single most important intervention before and after patient contact.

o Required knowledge and skills:– How to clean hands– Rationale for choice of clean hand

practice– Techniques for hand hygiene– Protect hands from contaminants– Promote adherence to hand hygiene

guidelines

Five moments for hand hygiene

o Before patient contacto Before an aseptic tasko After body fluid exposure even if wearing

gloves!o After patient contacto After contact with patient surroundings

Your 5 moments for HAND HYGIENE

How to Clean Hands

o Remove all wrist and hand jewelry.o Cover cuts and abrasions with waterproof

dressings.o Keep fingernails short, clean, and free from

nail polish.

Effective Handwashing Technique

o Wet hands under tepid running watero Apply soap or antimicrobial preparation

– solution must have contact with whole surface area of hands

– vigorous rubbing of hands for 10–15 seconds

– especially tips of fingers, thumbs and areas between fingers

o Rinse completelyo Dry hands with good quality paper towel.

How to use waterless handrubo Apply a palmful of product in cupped hando Rub hands palm to palm o Right palm over left hand with interlaced fingerso Palm to palm with fingers interlacedo Backs of fingers to opposing palms with fingers

intelockedo Rub between thumb and forefingero Rotational rubbing, backwards and forwards with

clasped fingers of right hand in left palm and vice versa

o Once dry your hands are safe.

Personal Protective Equipment

o Gloves, aprons, gowns, eye protection, and face masks

o Health care workers should wear a face mask, eye protection and a gown if there is the potential for blood or other bodily fluids to splash.

Personal protective equipment 2

o Masks should be worn – if an airborne infection is suspected or

confirmed– to protect an immune compromised

patient.

Gloves

Gloves must be worn for:o all invasive procedureso contact with sterile siteso contact with non-intact skin or mucous membraneso all activities assessed as having a risk of exposure

to blood, bodily fluids, secretions and excretions, and handling sharps or contaminated instruments.

Hands should be washed before and after gloving

Safe Use and Disposal of Sharps

o Keep handling to a minimum o Do not recap needles; bend or break after

useo Discard each needle into a sharps

container at the point of useo Do not overload a bin if it is fullo Do not leave a sharp bin in the reach of

children

Required Performance

Need to:o apply universal precautionso be immunized against Hepatitis Bo use personal protection methodso know what to do if exposedo encourage others to use universal

precautions

Act to Minimize Spread of Infection-1

Before contact with each and every patient:

– clean hands before touching a patient

– clean hands before an aseptic task

Act to Minimize Spread of Infection-2

After contact with each and every patient:

– clean hands after any risk of exposure to body fluids

– clean hands after actual patient contact

– clean hands after contact with patient surroundings

Encourage Others to Participate in Infection Control

May routinely observe staff who: – apply inadequate technique in

handwashing – fail to wash hands– routinely violate correct infection control

procedures

MOST COMMON CLINICAL RISKS AND PATIENT SAFETY INCIDENT TYPES IDENTIFIED 

o Acute Kidney Injury (AKI)o Antimicrobial Resistance (AMR) strategyo Caring for the acutely ill elderly safelyo Preventing avoidable deterioration

(including sepsis)o Improving the safety of discharge

o Falls preventiono Improving the safety of handovero Preventing healthcare associated infectionso Preventing medication errorso Preventing medical device errorso Mental health care safetyo Preventing pressure ulcerso Improving the safety of transition – children

& young people to adult careo Preventing avoidable venous

thromboembolism (VTE)o Patient safety in general practice

THE SEVEN STEPS TO PATIENT SAFETY

o Step 1 Build a safety culture Create a culture that is open and fair

o Step 2 Lead and support your staff Establish a clear and strong focus on patient safety throughout your organization

o Step 3 Integrate your risk management activity Develop systems and processes to manage your risks and identify and assess things that could go wrong

o Step 4 Promote reporting Ensure your staff can easily report incidents locally and nationally

o Step 5 Involve and communicate with patients and the public Develop ways to communicate openly with and listen to patients

o Step 6 Learn and share safety lessons Encourage staff to use root cause analysis to learn how and why incidents happen

o Step 7 Implement solutions to prevent harm Embed lessons through changes to practice, processes or systems

10 STEPS FOR PREVENTION OF HAI

Prevent central line-associated blood stream infections. Be vigilant preventing central line-associated blood stream infections by taking five steps every time a central venous catheter is inserted: owash your hands, ouse full-barrier precautions, oclean the skin with chlorhexidine, oavoid femoral lines, oand remove unnecessary lines

Re-engineer hospital discharges.  Create a simple, easy-to-understand discharge plan for each patient that contains a medication schedule, a record of all upcoming medical appointments, and names and phone numbers of whom to call if a problem arises.

Prevent venous thromboembolism. Eliminate hospital-acquired venous thromboembolism (VTE), the most common cause of preventable hospital deathsEducate patients about using blood thinners safely. Patients who have had surgery often leave the hospital with a new prescription for a blood thinner, such as warfarin brand name: Coumadin®), to keep them from developing dangerous blood clots. However, if used incorrectly, blood thinners can cause uncontrollable bleeding and are among the top causes of adverse drug events.

Limit shift durations for medical residents and other hospital staff if possible. oEvidence shows that acute and chronically fatigued medical residents are more likely to make mistakes. oEnsure that residents get ample sleep . oResidents who work 30-hour shifts should only treat patients for up to 16 hours and should have a 5-hour protected sleep period between 10 p.m. and 8 a.m.

Use good hospital design principles. oFollow evidence-based principles for hospital design to improve patient safety and quality. oPrevent patient falls by providing well-designed patient rooms and bathrooms and creating decentralized nurses' stations that allow easy access to patients. oReduce infections by offering singlebed rooms, improving air filtration systems, and providing multiple convenient locations for hand washing. oPrevent medication errors by offering pharmacists well-lit, quiet, private spaces so they can fill prescriptions without distractions. 

Measure your hospital's patient safety culture. Survey hospital staff to assess your facility's patient safety culture. Build better teams and rapid response systems. oTrain hospital staff to communicate effectively as a team. Insert chest tubes safely. Remember UWET when inserting chest tubes. The easy-to-remember mnemonic is based on a universal protocol from the Joint Commission and stands for: Universal Precautions (achieved by using sterile cap, mask, gown, and gloves); Wider skin prep; Extensive draping; and Tray positioning.