8 Safety
8 Safety
8 Safety
Prof. AhmedAlbarrak
College of Medicine,
King Saud University
Color coding:
Important
Notes
EMR
Vertical
CBC
ultrasound
Appendicitis
EHR: horizontal, across multiple organizations, and lifelong. Discharge report will have important information about
EMR: only one organization the patient, allergies, blood type, procedures, diagnosis,
EHR has broader information appendecto and serious diseases
EMR has more information my
We can’t say one is larger than the other fever
X ray
culture
discharge
• Examples:
• adverse drug events
• surgical injuries and wrong-site surgery
• restraint-related injuries or death
• falls
• pressure ulcers
Do No Harm
Medical Errors !
The Harvard study of Patient Safety
• A Study of the impact of medical errors:
Err is Human;
• The Institute of Medicine (IOM) study “To
Err is Human; Building a Safer Healthcare
System”
• Adverse events occur in 2.9 to 3.7% of all
hospitalizations
• 44,000 to 98,000 patients dies a year as a
result of medical errors
• Source at
http://books.nap.edu/openbook.php?isbn=
0309068371
• Institute of Medicine (IOM) estimated that around 98,000
patients die each year as a consequence of preventable
errors. Likewise, a study of two UK hospitals found that
11% of admitted patients experienced adverse events of
which 48% of these events were most likely preventable if
the right knowledge was applied.
Annual AccidentalDeaths
Medical errors are 1st-5th most common cause of death in the world
The difference is that RTA are numbers while medical errors are
estimates (underreported)
Pressure ulcers are considered a direct error
3rd
leading cause of Death in USA ?
Medical Errors
1200 per day / 50 per hour
• The total number of Americans dying prematurely from
medical errors was about 400,000 per year* This number highly increasing
since the 90s
50000
40000
data
30000 knowledge
utilization
20000
10000
When a mistake has been made you have to make it visible, not by
showing it on social media, but by reporting/documenting it. Try
not to mention the name of the person who made the mistake.
Event ‘Management’
Action in order:
• Prevent failure but if you can’t,
• Make failure visible and
• Prevent adverse effects of failure or
• Mitigate the adverse effects
• Learn from all events
The point of documenting medical errors is not to blame anyone, but to learn from past mistakes and
avoid making them in the future.
Ex. Someone wrote a wrong prescription? Why was the mistake made? A junior wrote the prescription.
Why was he the one who wrote it? A consultant wasn’t available. We got to the root of the problem
which was shortage of staff. (Root cause analysis)
Which patients are most at risk of medication error?
• Simplification
• Standardization different standards in different countries
• Environment/product improvements
• Training
• Teamwork
• Communication
Selected Resources forPatient
Safety Information
• Agency for Healthcare Research and
Quality www.ahrq.gov
• Institute of Medicine of the National
Academies www.iom.edu
• The Joint Commission
www.jointcommission.org
• Institute for Safe Medication Practices
www.ismp.org
• National Patient Safety Foundation
http://npsf.org/
• JCAHO “Speak Up” program
• http://www.jcaho.org/general+public/patient+safety/speak+up/index.htm
• Also WHO
NationalAcademy of Science’s Institute of Medicine
(IOM)
Informatics team:
Deema Alfaris
Lina Alshehri
Luluh Alzeghayer
Munira Alhussaini
Moneerah Alomari
Raghda Alqassem
Renad Alqahtani
Rifan Hashim
Samar Alotabi
Sara Alqahtani
Sara Alkhalifah
Special thanks to Ahmed Alyahya