1. Introduction to Patient safety
Dr. Mohammad Aman Khan
Department of Community Health Sciences
Peshawar Medical College, Peshawar

2. The students will be introduced to
Patient safety WHO vision and mission
Safety sciences
Patient safety influenced by different factors
Patient safety
Human factors in patient safety
System approach to patient safety ??

3. عَنِ ابْنِ عَبَّاسٍ، قَالَ:لَا ضَرَرَ، وَلَا ضِرَارَ
{المعجم الكبير للطبراني}
نہ ابتد اءً نقصان پہنچایا جائےاور نہ ردِّ عمل میں ۔

4. W H O Patient Safety Vision
A world where every patient receives safe health care, without risks and harm, every time, everywhere.

5. Mission
To facilitate sustainable improvements in patient safety and managing risks to prevent patient harm.

6. Dawn.com 13.10.17 TOBA TEK SINGH/LAHORE:
Three minor girls died allegedly hours after they were administered anti-measles vaccine at a rural health centre at Chak 262-GB, Marthan Wala, in Rajana area.
Seven Steps

7. Understanding safety science as a concept.
Safety is the absence of undesirable events and accidents. (Adverse events)
Safety science can be viewed as knowledge about safety related issues, and the development of concepts, theories, principles and methods to understand, assess, communicate and manage safety.

8. Adverse Event
1. An injury that was caused by medical management or complication instead of the underlying disease and that resulted in prolonged hospitalization or disability
2. An undesired patient outcome that may or may not be the result of an error.
3. An event or omission arising during clinical care and causing physical or psychological injury to a patient.
4. A negative consequence of care that results in unintended injury or illness which may or may not have been preventable.

9. Reference The Conceptual Framework for the
International Classification for Patient Safety
Version 1.1
TECHNICAL ANNEX 2
Glossary of Patient Safety Concepts and
References
January 2009

10. Patients and Communities Demand
Availing “Quality Health Care”

11. Quality
the standard of something as measured against other things of a similar kind;
the degree of excellence of something.
a product has good quality when it "complies with the requirements specified by the client".

13. What is human factors in patient safety?
Understand human factors and its relationship to patient safety

14. Human factors definition
the study of all the factors that make it easier to do the work in the right way
apply wherever humans work

15. Human factors aviation nuclear power
Importance of human factors has been recognized for a long time in:
aviation
nuclear power

16. Importance in health care?
only recently been acknowledged as an essential part of patient safety
a major contributor to adverse events in health care
all health-care workers need to have a basic understanding of human factors principles

17. Human factors experts
design improvements in the workplace and the equipment to fit human capabilities and limitations
make it easier for the workers to get the work done the right way
decrease the likelihood of errors occurring
Human factors ‘engineers’
- discover and apply information about human behaviour, abilities, limitations, and other characteristics to the design of tools,
machines, systems, tasks, jobs, and environments for productive, safe, comfortable and effective human use.

18. The range of workers
good human factors design in health care accommodates the health care team
not just the calm, rested experienced clinician
also for inexperienced health-care workers who might be stressed, fatigued and rushing

19. Examples order medications electronically hand off information
move patients
If all of these tasks become easier for the health-care provider, then patient safety can improve.

20. Avoidable confusion is everywhere…
US Department of Veteran affairs

21. Health care is increasingly complex
The Institute of Medicine report reminds us that health care is probably the most complex of human endeavours!
Gaba

22. Human factors design principles
Psychomotor
Hands
Input Devices
Buttons
INTERFACE
Senses
- Vision Hearing
Output
- Display Sound
This slide illustrates how we interact with equipment - and indeed human factors engineering is in part the study of the human machine interaction.
But actually this slide represents how we interact with everything - using our eyes, ears, fingers, hands …
Our senses take in inputs, then we rely on our memory and knowledge to process the information and then make decisions and formulate a response
HFE recognizes that we can make errors at each step of this process …
US Department of Veteran affairs

23. Human factors acknowledges: assumes that errors will occur
the universal nature of human fallibility
the inevitability of error
assumes that errors will occur
designs things in the workplace to try to minimize the likelihood of error or its consequences

24. Traps in health care? look-alike and sound-alike pharmaceuticals
equipment design
e.g. infusion pumps

25. We cope quite well with complexity
Health-care workers are quite good at compensating for some of the complex and unclear design of some aspects of the workplace
equipment
physical layouts

26. Because the human brain is ….
very powerful
very flexible
good at finding shortcuts (fast)
good at filtering information
good at making sense of things

27. Sometimes though our brain is
“too clever” …

28. The fact that we can misperceive situations despite the best of
intentions is one of the main reasons
that our decisions and actions can
be flawed such that …

29. Human beings make “silly” mistakes
Regardless of their experience, intelligence, motivation or vigilance, people make mistakes
Activity
Think about and then discuss with your colleagues any “silly” mistakes you have made recently when you were not in your place of work or study - and why you think they happened
Detailed story + reason why.

30. The context of health care
When errors occur in the workplace the consequences can be a problem for the patient
a situation that is relatively unique to health care
Detailed story + reason why.

31. One definition of “human error” is “human nature”
Error is the inevitable downside
of having a brain!

32. What is an error? A definition that may be easier to remember is:
the failure of a planned action to achieve its intended outcome
a deviation between what was actually done and what should have been done
Reason
A definition that may be easier to remember is:
“Doing the wrong thing when meaning to do the right thing.”
All common situations for inexperienced staff.

33. Situations associated with an increased risk of error
unfamiliarity with the task*
inexperience*
shortage of time
inadequate checking
poor procedures
poor human equipment interface Vincent
All common situations for inexperienced staff.
* Especially if combined with lack of supervision

34. Individual factors that predispose to error
limited memory capacity
further reduced by:
fatigue
stress
hunger
illness
language or cultural factors
hazardous attitudes

35. blood alcohol content of 0.1%
Fatigue
24 hours of sleep deprivation has performance effects ~
blood alcohol content of 0.1%
Dawson – Nature, 1997

36. ‘Death by overwork’: occupational hazard for Japan’s media
Pakistan today

37. Stress and performance
Area of “optimum” stress
Performance level
The optimum level of performance is reached when the level of arousal is neither too high or too low.
Boredom is a problem if we are doing a highly automated and repetitive task, e.g. transcribing medication charts:
may be easy to commit a transcribing error
Low stress Boredom
High stress Anxiety, panic
Stress level
The relationship between stress and performance
Yerkes, R. M., & Dodson, J. D. (1908) The relation of strength of stimulus to rapidity of habit-formation.
Journal of Comparative Neurology and Psychology, 18,

38. Don’t forget ….
If you’re
H ungry
A ngry
L ate or
T ired ….. H A L T

39. A performance-shaping factors “checklist”
I Illness
M Medication
prescription, alcohol & others
S Stress
A Alcohol
F Fatigue
E Emotion
Here is a useful acronym to consider prior to entering the workplace each day.
It is borrowed (surprise, surprise) from the aviation industry!
Jensen, 1987

40. Safety Cycle in Health Care

43. Seven Steps in patient safety
1. Build a safety culture that is open and fair 2. Lead and support your staff in patient safety 3. Integrate your risk management activity 4. Promote reporting 5. Involve patients and the public 6. Learn and share safety lessons 7. Implement solutions to prevent harm

44. (A greater harm is eliminated by [tolerating] a lesser harm)
اَلضَّرَرُ الْأَشَدُّ يُزَالُ بِالضَّرَرِ الْأَخَـــفِّ
(A greater harm is eliminated by [tolerating] a lesser harm)
کم تر نقصان کو گوارہ کرکے بڑے نقصان سے بچا جایئگا۔
مثلاّ ایک شخص کو اس بات پر مجبور کیا جائے کہ یا تو وہ دوسرے کو قتل کردے یا مال برباد کردے تو اس کیلئے مال کے تلف کرنے کی اجازت ہوگی ’ قتل کرنے کی اجازت نہ ہوگی ۔ (بدائع الصنائع)
حاملہ عورت کے بطن میں بچہ مرجائےاور اس کے سوا کوئی چارہ نہ ہوگاکہ اسے ٹکڑے ٹکڑےکاٹ کر نکالا جائےورنہ ماں کی جان کیلئے خطرہ ہو تو اس کیلئے ایسا کرنا درست ہوگا ۔(فتاویٰ قاضیخان علی الہندیہ)

45. Thank You