(1) Patient Safety and Quality of Care

Patient safety

preventing harm to patients.

Know these words:

• Avoid preventable harm

• Reduce unnecessary harm

• Reduce harm to an acceptable minimum

Quality of care

 health services that increase the chance of desired health outcomes.

3 parts of high-quality care

Part	Meaning
Evidence-based	Based on best treatments/guidelines
Patient-centered	Fits the patient’s needs/preferences
Safe	Does not cause unnecessary harm

Patient Safety vs Quality of Care

Type of care	Possible?	Meaning
Safe but low-quality care	✅ Yes	It may not harm patient, but it may not be evidence-based or patient-centered
Unsafe but high-quality care	❌ No	High-quality care must be safe

You can have safe but low-quality care, but you cannot have high-quality care that is unsafe.

safe but low-quality care - example (JUST READ)

A patient gets antibiotics for an upper respiratory infection.

It may be safe if:

• Allergies were checked

• Drug interactions were checked

But it may be low quality if:

• Infection was viral

• Antibiotic was not needed

• It was not evidence-based

• It could contribute to antibiotic resistance

Error

 doing something wrong or failing to do the right thing.

Error - examples (JUST LOOK)

• Wrong medication

• Wrong dose

• Not checking allergy

• Not checking kidney function

• Not reviewing chart

• Poor communication

Near miss

• unsafe situation happened, but patient was not harmed.

• Mistake happened, but it was caught in time.

Near miss - examples (JUST LOOK)

• Technician fills wrong medication.

• Pharmacist catches it before it reaches patient.

• Patient does not get harmed.

Adverse event

patient injury caused by medical care.

Adverse Event

Can lead to:

• Extra monitoring

• Extra treatment

• Longer hospital stay

• Hospitalization

• Permanent harm

• Death

Preventable Adverse Event

Could have been avoided.

Preventable Adverse Event - example (JUST LOOK)

Example:

• Elderly patient has kidney disease.

• Patient gets normal antibiotic dose.

• Dose is too high because kidney function was not checked.

• Patient develops kidney failure.

Could be prevented by:

• Reviewing chart

• Asking patient about medical history

• Checking serum creatinine

• Checking CrCl

• Medication reconciliation

• Pharmacist reviewing dose

Non-Preventable Adverse Event

Happened even though care was appropriate.

Non-Preventable Adverse Event - example (JUST LOOK)

• Patient gets correct medication.

• Dose is correct.

• Medication has known nausea side effect.

• Provider weighed benefit vs risk.

• Patient still gets severe nausea.

Non-Preventable Adverse Event

Key idea:

Even when providers make the best decision with the information they have, patients can still have side effects because no medication has zero risk for every person.

What is the  Historical Patient Safety Report called?

To Err Is Human

To Err Is Human

• Published in 1999

• Started the national focus on patient safety

• Focused on preventable medical errors

• Early strategies focused on:

  • Inpatient setting

  • Education of current healthcare professionals

  • Education of future healthcare professionals

 Progress in Patient Safety (JUST LOOK)

• Better awareness of errors

• More patient safety education

• More technology

• More automation

• Electronic health records

• More double-checks

• Better infection prevention

• Better communication systems

• More error reporting

But professor also said: There is still more work to be done in patient safety.

 Role of Pharmacists in Patient Safety (JUST LOOK)

• Checking correct medication

• Checking correct dose

• Checking allergies

• Checking drug interactions

• Checking kidney function / CrCl

• Doing medication reconciliation

• Reviewing charts

• Asking questions when unsure

• Counseling patients

• Catching errors before they reach patient

• Reporting errors and near misses

Pharmacists are part of the healthcare team that helps ensure…

patient safety.

Role of Patients in Patient Safety

Patients are important because:

• They know their own body/history.

• They know what treatment they can follow.

• They can share missing information.

• They can ask questions.

• More engaged patients usually have better outcomes.

Barriers for patients:

• Lack of knowledge

• Low motivation

• Being very sick

• Fear/confusion

• Not knowing how to advocate for themselves

 Barriers to Safe Patient Care

Barrier	Meaning
Organizational culture	Workplace may not prioritize safety
Business vs patient care	Pressure to move fast/save money
Patient vulnerability	Patients may be sick, scared, or unable to advocate
Poor teamwork	Communication problems cause mistakes
Burnout/staffing issues	Tired or understaffed workers may miss things
Fear of reporting	People may fear punishment or blame