1. PROMOTING PATIENT SAFETY BY PREVENTING MEDICAL ERRORS
Safety concerns facing health care systems today

2. Objectives
Describe the magnitude of medical errors and the effect on patient safety
Identify processes to approach error reduction and prevention
Recognize error prone situations/processes
Identify the safety needs of special populations

3. Objectives cont. Describe processes to improve patient outcomes
Explain what each of us can do to protect patients and ourselves from accidental injury

4. Magnitude of the Problem

5. DEFINITIONS
ERRORS: “the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim”.
A. Error of execution: Correct action does not proceed as intended
B. Error of planning: Original intended action is not correct

6. ADVERSE EVENT
THOSE EVENTS THAT CAUSE AN INJURY TO A PATIENT AS A RESULT OF MEDICAL INTERVENTION OR INACTION ON THE PART OF THE HEALTHCARE PROVIDER WHERE THE INJURY CANNOT REASONABLY BE SAID TO BE RELATED TO THE PATIENT’S UNDERLYING MEDICAL CONDITION

7. Healthcare professionals must:
Have a process in place to
Scrutinize & Evaluate those instances where a medical error occurred
Identify system improvements that have the potential to prevent future adverse events

8. ROOT CAUSE ANALYSIS Focus on process and system factors
Document a risk-reduction strategy
Focus an internal corrective action plan: include measurement of the effectiveness of process and system improvements to reduce risk

9. JCAHO Root Cause Analysis: focus primarily on systems and processes
Should progress from special causes in clinical processes to common causes in organizational process
Repeatedly dig deeper by asking “why?”

10. Analysis continued
Identify changes that can be made in systems and processes
“Thorough” and “credible” (JCAHO standards defined

11. ERROR REDUCTION AND PREVENTION
PATIENT SUICIDE
OPERATIVE AND POST-OPERATIVE COMPLICATIONS
MEDICATION ERRORS
WRONG-SITE SURGERY
PATIENT FALLS
OTHER CONSIDERATIONS FOR PATIENT SAFETY

12. CONCLUSION Each of us must responsibly ACTIVELY PARTICIPATE
UNDERSTAND THE GOAL
PRESERVE OUR SYSTEM
CORRECT THE PROBLEM