Professor, Dr. NeerajBedi, MD,MPH, MBA.

Presentation Title

“Patients Safety : Key Issues and Challenges !”

Author’s Name :Prof.Dr.NeerajBedi,

Keywords: (Patient Safety, Patients Safety Incidents, Medical Errors, Healthcare Associate
Infections)

Abstract

Patient safety is a public health issue of global concern. Recently the countries have increasingly
recognized the importance of improving patient safety. Estimates show that in developed
countries as many as one in 10 patients is harmed while receiving hospital care. .The risk of
health care-associated infection in some developing countries is as much as 20 times higher than
in developed countries The harm can be caused by a range of medical errors leading to
adverse/sentinel events. More than 50% patients safety incidents are preventable. Modern health
care presents the most complex safety challenge of any activity on Earth. This is because Health
Care earlier was simple, ineffective and safe but now it is complex, effective but very unsafe.
Unsafe outcomes have serious adverse social and economic impact on patients, their families as
well on clinicians and organization. The economic benefits of improving patient safety are
astonishing. Evidence based medicine show that increased hospitalization stay, litigation costs,
infections acquired in hospitals, lost income, disability and medical expenses have cost some
countries between US$ 6 billion and US$ 29 billion a year. The patients safety incidents are
mainly due to the systems failure in leadership, policy and procedures, communication and
available resources. The patient safety international goals can be achieved by implementing the
various quality management standards and adopting various accreditation exercises in health
care settings.

Biography :

The author is a dedicated and experienced Medical professional with a teaching, training,
research and administrative experience of 26 years in the Public Health domain in the field of
Epidemiology, Preventive Medicine, Community Medicine, Hospital Administration and

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Management.Presently working as Senior Faculty in Community Medicine, Medical College,
Bhopal.The author is also involved in Quality Assurance and Risk Management activities related
to the hospital management. In addition to basic Medical Qualification (MBBS) and Doctorate in
Community Medicine (MD) obtained Masters of Public Health (MPH) from Manchester
Metropolitan University, UK, Hospital Management qualifications MBA, Quality Management and
Accreditation of Health Care Organizations and hospital management experience. A qualified
National Accreditation Board for Hospitals and Health Care Providers (NABH) assessor, an
agency giving accreditation to hospitals in India. The career highlights the award of International
WHO Fellowship in Hospital Administration and WHO Fellowship in Management of Malaria Field
Operations. The author is also awarded with “Pride of India Award” from H E Dr. Ahmed Salem
Al-Washishi, Ambassador – League of Arab States Mission at a function organized by Citizens
Integration Pace Society, New Delhi, the “Jewel of India Award” by Chief Justice of India,
ShriG.S.Verma, organized by Indian Solidarity Council and the “Eminent Citizen of India Award”
in from National and International Compendium New Delhi for his outstanding contribution in the
field of the health management field.

Authors Address and mail address

B-104, Chinar Woodland, ChunaBhatti, Kolar Road, Bhopal. M.P. 462016

[email protected], [email protected]

Mobile- 9425019905

“Patients Safety : Key Issues and Challenges !”

Introduction :

 Patient safety is a public health issue of global concern. Recently the countries have
increasingly recognized the importance of improving patient safety. The shared goals of
health care is to deliver the highest quality of care to all our patients . The health
care service is timely, efficient, clean with no harm/complications, cure/control of disease
and value for money. It should be ethical &trustworthy and most importantly patients
should feel safe. The goals also include satisfaction of all staff and stakeholders and
meet business objectives of cost, revenueand quality. The health care now is very
complex, effective but very unsafe. Earlier it was simple, ineffective but safe.

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Burden of Unsafe Care :

 The burden of unsafe care is not well known in developing countries. However, good data
is available from developed countries. But estimates show that in developed countries as
many as one in 10 patients is harmed while receiving hospital care. .The risk of health
care-associated infection in some developing countries is as much as 20 times higher
than in developed countries. Unsafe blood products are likely major cause of harm in
some developing countries with reasonable good data from select nations as per WHO.
However, better data are required from developing/transitional countries regarding
patients safety among pregnant women and newborns. Only 53% of deliveries in
developing countries are attended by skilled health professional. 16 billion injections a
year with 39.6% with syringes and needles are reused and extent of harm caused by
unsafe injections is unknown. 5-15% of HIV infections are due to unsafe blood in
developing countries as well Hepatitis B&C, Syphilis , Malaria, Chagas disease and West
Nile fever are at high risk. The extent of harm is unknown. The deficiency of qualified
health care providers is estimated to be 2.4 million doctors, nurses and paramedics. This
result in poor quality of care provided due to fatigue, production pressure causing high
risk of mistakes.
Social and economic aspects of Unsafe Care

 The social and economic aspects adversely affects not only the Patients but families
,Clinicians and organizations too. The patients are disappointed as perceived
promise not fulfilled and harm leading to permanent disability and death occur. Of course
the discomfort is there due to prolonged stay/distress. The families also suffer from
sudden bereavement and agony as a earning member lost. The Clinicians may have
shatteringexperience with low morale, loss of organizational/peer respect, loss of
reputation, loss Of career. Some may facecriminal litigations,costs and life long
distress.The Organization may be surrounded by media scandals with loss of community
respect and society reputation. This may result into service disruption and reduced
inflows of the patients including costs and litigations.

 Medical Errors

A medical error can be defined as the failure of planned actions to achieve their intended
outcome or a deviation between what was actually done and what should have been
done.About 50% errorsoccur among Inpatients result from Surgery.Then comes
Medication Errors, Therapeutic Mishaps, Diagnostic Errors. The most common non-
operative events leading to diagnostic error is that 50% medical equipment are not
functional at any given point of time in health care settings.

 Patients Safety Incidents :

A patient safety incident (PSI) is any unintended/unexpected incident that could have or
did lead to harm for one or more persons. An adverse event or incident can lead to harm
lasting for more than 2 weeks, disability or even death. A patient safety incident could
have caused damage but didn’t fortunately , it is called near-miss event. While the event
caused the damage but it was not serious or long lasting, it is called adverse event. The
patient safety incident which led to major enduring loss of function for 2 weeks or more or
death is called Sentinel event. The Joint Commission International root cause analysis
for sentinel events revealed communication, training, staffing and patients assessment
were the leading causes for events. All humans make errors and the ability to make

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 mistakesallows human beings to function- no human is 100% perfect. The most of
medicine is complex (technology) and uncertain. Most errors result from the systemfailure
like poor leadership, no or poor compliance of policies and procedures, lack of resources
like manpower, money and materials, and most importantly poor communication and
examples--inadequate training, long working hours, ampoules that look the same, lack of
checks, and many others.
The individual error amount to only the minority of cases from negligence or misconduct.
It will not solve the problem--it will probably in fact make it worse because it fails to
address the problem and doctors/medical team will hide errors. It may destroy many
doctors/health care professionals inadvertently. There is an need to develop a
“Culture”that does not advocate aname, Blame and shame policy along with train, Train
and Training aspects. The health care settings should supportazero tolerance for
intentional risk taking.Most importantly the organization should deal a fair treatment for
the individuals making errors regardless of outcomes and frequency of errors.

 Conclusions :

The patients safety in health care settings can be achieved by developing Patients
Safety culture , implementing Quality Standards and Accreditation Exercises ,
Continuous Measurement of Quality by (Clinical Indicators) and reducing Medical
Errors by Quality and Risk Management. Human resource management includes
change management to accept the medical errors and no punitive action against
erring medical professionals by authorities and Government. The health care settings
should try to improve the system than blaming individuals.

 References :

1. Executive Summary: Institute of Medicine (US): To err is Human : Building a safer health
system. Washington, National Academy Press 2000
2. Reason J. Human Error: Models and management. BMJ 2000; 320: 786-790.
3. Leape LL. Error in Medicine. JAMA 1994; 272: 851-1857.
4. WHO website: who.int/patient safety