MOD 9 - Patient Safety Essentials

Patient Safety Incident

An event or circumstance which could have resulted, or did result, in unnecessary harm to a patient

fundamental basis for improving safety lies in

creating more effective work environments and high performing teams

Improving patient safety requires:

• Moving from a focus on blame towards a focus on improvement; 

• A shared responsibility to design safer systems; 

• Complex interventions, not simple solutions; and 

• A focus on improving teamwork, communication, and situational awareness to be successful

Challenges in achieving these goals

• Improvement initiatives and patient safety activities are often seen as added work for teams in an already busy environment.  

• Clinicians need to be willing to adopt and reliably perform clinical tasks. 

• Often, organizational cultures and teams do not support safety-positive behaviours

How many hospital stays in Canada involve at least one harmful event

One in 17 hospital stays

Safety is a way of

thinking, acting and relating to others and is a part of everyday work

types of impacts patients and caregivers may experience

• Physical impact 

• Psychological or emotional impact

• Social and behavioral impact (reluctance to seek help due to negative experience)

• Financial impact

% of patients who experienced harmful events reported some form of long term impact

73%

Harm After Harm / Compounded Harm

when a patient safety incident is insensitively or inappropriately managed resulting in an added burden of harm to the patient and caregivers

organizational impacts and potential implications due to patient safety incident

1. Reputational: employees of an organization losing confidence in the organization to meet healthcare needs

2. Human Resources: decrease in trust between healthcare providers and the organization

3. Financial: increase in in-hospital and post-discharge healthcare costs

team is a group of people who

trust each other, not just a group working together

Engagement capable environments Three Main Pillars

1. Patient Partners: actively encouraged to participate

2. Staff and Healthcare Teams: prepared and supported to engage with patients

3. Organizational Leaders: provide clear direction for patient engagement

Disclosure

process by which a patient safety incident is communicated to the patient and caregiver by healthcare providers

Myth of Why Things go Wrong

Patient safety incidents are caused by irresponsible healthcare providers

Fact of Why Things go Wrong

underlying problems that place individuals at risk of error

Most human errors are caused by

the system or design problems in the work environment

Natural Mapping

Good Natural Mapping

• should be intuitive and make life easier

Bad Natural Mapping

• may lead to frustration, confusion, and safety incidents

two primary types of weaknesses

active failures

• mistakes

• slips

• violations

• lapses

latent conditions (dormant issues waiting to occur)

Hierarchy of Effectiveness

1. Forcing functions and restraints: making mistakes impossible to occur

2. Automation and Computerization: good for repetitive tasks

3. Simplification and standardization

4. Reminders, checklists and double-checks

5. Rules and policies

6. Training and education

Human Factors

field of study dedicated to understanding how and why humans make mistakes and how to ultimately improve human performance

three distinct Indigenous Peoples recognized by the Canadian Constitution

First Nations, Inuit and Métis

Systemic racism is embedded

in our ways of working, through structures such as policy development, historic practices and pre-established biases and attitudes

distinctions-based approach

a way of working with First Nations, Inuit and Métis which recognizes each community’s distinct cultures, histories and priorities

Sixties Scoop

period through the 1960s where thousands Indigenous children were removed from their families and communities to be fostered or adopted into predominantly non-Indigenous

process of reconciliation requires four elements

1. awareness of the past, 

2. acknowledgement of the harm that has been inflicted, 

3. atonement for the causes, and

4. action to change behaviour.  

reconciliation

• an ongoing process of establishing and maintaining a mutually respectful relationship between Aboriginal and non-Aboriginal peoples in this country

• a journey, not an outcome nor destination

The 6 components of incident analysis

1. Before the incident: developing an incident management plan

2. Immediate response: immediately working to care/support the patient & caregivers + ensure the safety of other patients affected

3. Prepare for analysis:

4. Analysis process

5. Follow through

6. Close the loop

3rd Component: Prepare for Analysis

1. documentation of known facts related to the incident

2. selecting an analysis method

3. clearly define and understand team membership, roles, and responsibilities

4. coordinate meetings

5. collect info

Three Basic Types of Analysis

1. Comprehensive: for complicated and complex incidents that caused catastrophic harm

2. Concise: succinct, yet systematic way for low or moderate severity of harm

3. Multi-incident: for reviewing several incidents at once by grouping them in themes

5th Component: Follow Through

• feedback loops: to share learnings

• ways in sharing these learnings

• learning is shared externally

• informing the public

Absence of harm is not the same as

the presence of safety

Advancing safety needs to be a balance of

preventing harm and creating safety

• adding curiosity

• listening

• observing

• perceiving

5 Dimensions of Safety Measurement and Monitoring

1. Has patient care been safe in the past? 

2. Are our clinical systems and processes reliable? 

3. Is care safe today? 

   • promotes early identification of problems

   • Safety huddles

4. Will care be safe in the future? 

5. Are we responding and improving?

• capturing and integrating safety information

• learning from it

• responding to it 

past harm

the measurement of multiple types of harm, over time, to help assess whether care has been safe in the past and is becoming safer