IENE5(Intercultural Education of Nurses in Europe Project 5) Introducing topic 3: Patient Safety

What is patient safety? “..prevention of errors and adverse effects to patients associated with health care.” World Health Organisation http://www.who.int/patientsafety/education/curriculum/Curriculum_Tools/en/index1.html

Why is patient safety important? The number of patient safety incidents (including injuries and deaths caused by medical errors) rises every year It has a detrimental economic impact (millions are spent on litigation and compensation) Pressure on NHS resources – iatrogenic harm can have long-term consequences, requiring further medical treatment. Therefore more beds may be needed Impact on staff morale

Why do patient safety incidents happen? The Swiss Cheese model (Reason,1990 ) A preventable accident or incident usually does not happen because of an individual’s mistake but because of ‘holes’ in layers of the system which let through problems; this leads to a perfect set of circumstances for an accident or incident to happen. Examples of such ‘holes’ might be: Poor reporting facilities, or incidents not being properly reported Inadequate procedures or processes, or faulty equipment (see Annie’s story) Rigid hierarchical structures which discourage staff from speaking up about poor care Toxic work culture and poor relationships between staff Staff burned out and fatigued due to overwork and staff shortages

Example of a poor system Rhode Island hospital was fined for 3 wrong-site brain surgeries in one year, one of which led to a patient’s death Investigations revealed poor system factors such as strong hierarchies (nurses too afraid to speak up), and inadequate procedures This led to a review and overhaul of procedures New reporting system allows staff to report all incidents including ‘near-misses’ so that they can be analysed and corrective action can be taken to avoid this type of incident in the future Adoption of ‘Just culture’ which takes system factors into account and does not automatically blame individual staff members who have made a mistake

Conclusions and relevance to other topics in the MOOC Patient safety is an extremely important topic as incidents occur every day and cost lives as well as draining healthcare organisations of resources. Many of these incidents are due to preventable factors such as not following procedures or poor staff training, which can be targeted (Wilson et al, 2012). Other ‘human’ factors such as communication may also play a part. There is a need for intervention to improve patient safety and reduce the number of injuries and deaths caused by medical errors. Patient safety is related to intercultural communication because poor intercultural communication can lead to misunderstandings between staff or between a staff member and a patient. This can lead to errors and mistakes that compromise safety. Colleagues from different disciplines and cultures must be able to work collaboratively and communicate effectively with each other. This will enable them to effectively care for their patients and avoid the incidence of medical errors.

Key resources World Health Organisation patient safety curriculum http://www.who.int/patientsafety/education/curriculum/Curriculum_Tools/en/index1.html National Patient Safety Agency – www.npsa.nhs.uk The Health foundation – patient safety resource centre