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Patient safety 
Capt kalaivani R
The first requirement of 
any Hospital is that it does 
the sick 
“NO HARM”. 
Florence Nightingale
 Are we following the longstanding cornerstone 
of medicine “Do NO Harm”? 
 Are we unintentionally harming patients whom 
we are seeking to help? 
 Do we know the burden of unintended death 
and morbidity due to preventable adverse 
events?
DEFICIT OF QUALIFIED 
HEALTH-CARE PROVIDERS 
 The deficit in 57 countries are estimated 
to be 2.4 million doctors, nurses and 
midwives.
DEVELOPED NATIONS: 1 IN 10 PTS HARMED
DEVELOPING COUNTRIES: RISK 
HIGHER
 63% of all injections administered are unsafe 
• 22% reuse 
• 20% unsterile equipment 
• 54% wrong technique
 On an average there is one medication 
error every day for every inpatient
MEDICATION ERRORS 
 Confusing drug names 
 Illegible handwriting 
 Similar packing 
 Similar clinical use 
 Look Alike Sound Alike – LASA medications
WRONG PROCEDURE/ 
SURGERY/SITE 
About 50% adverse events occurring 
among in patients result from 
surgery
1.4 M PEOPLE SUFFER HAI
WHICH PATIENTS ARE MORE 
AT RISK…???? 
 Complex surgery 
 Multiple Medical 
conditions 
 Emergencies 
 Geriatric patients 
 Pediatric patients 
 Any patient who 
cannot perform ADL 
(Acts of Daily Living) 
 A physically / 
mentally challenged
Failure of a planned action to be 
completed as intended or the use 
of a wrong plan to achieve an aim, 
do not all result in injury. 
HEALTH CARE ERROR
NEAR MISS 
An event that almost happened or an 
event that did happen but no one knows 
about. 
If the person involved in the 
near miss does not come forward, no one 
may ever know it occurred.
Nursing 
shortage 
Lack of 
standards 
Malfunctioning 
instruments 
Poor leadership 
and teamwork 
Poor infection 
control practices 
Poor 
communication 
Poor 
infrastructure
What is Patient Safety ? 
 “Patient safety is a health care discipline 
that emphasizes the reporting ,the analysis 
and prevention of medical error that often 
leads to adverse health care events.” 
WHO 
 “Patient safety is defined as prevention of 
harm to the patients” 
Institute of Medicine (IOM)
Objectives of Patient Safety 
 Create patient safety culture 
 Increase hospital accountability towards 
its patients and society 
 Decrease adverse events in hospitals 
 Implement programmes to prevent the 
recurrence of adverse events
WAYS TO
Patient Safety Practices 
Reduce the risk of adverse events 
related to exposure to medical care 
across a range of diagnoses or 
conditions.
Proper Training
CNE
MEDICATION ADMINISTRATION 
Right Patient Right Drug 
Right 
Dose 
Right 
Route 
Right Time Right Documentation
Patient Safety Solutions 
 Look-Alike, Sound-Alike Medication Names 
 Patient Identification 
 Communication During Patient Hand-over 
 Performance of Correct Procedure at Correct 
body site 
 Control of Concentrated Electrolyte Solutions
 Assuring Medication Accuracy at 
Transitions in Care 
 Avoiding Catheter and Tubing Mis- 
Connections 
 Single Use of Injection Devices 
 Improved Hand Hygiene to Prevent Health 
Care-associated Infection
 Reduce the risk of patient harm from falls. 
 Report critical results of tests and diagnostic 
procedures on a timely basis 
 Identify patients at the risk of suicide 
 Prevention of pressure ulcers
Absence of evidence is not the 
evidence of absence 
Always look for what is wrong before 
looking 
who is wrong 
Yes…it is necessary
Thank you

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Patient safety

  • 1. Patient safety Capt kalaivani R
  • 2. The first requirement of any Hospital is that it does the sick “NO HARM”. Florence Nightingale
  • 3.  Are we following the longstanding cornerstone of medicine “Do NO Harm”?  Are we unintentionally harming patients whom we are seeking to help?  Do we know the burden of unintended death and morbidity due to preventable adverse events?
  • 4. DEFICIT OF QUALIFIED HEALTH-CARE PROVIDERS  The deficit in 57 countries are estimated to be 2.4 million doctors, nurses and midwives.
  • 5. DEVELOPED NATIONS: 1 IN 10 PTS HARMED
  • 7.  63% of all injections administered are unsafe • 22% reuse • 20% unsterile equipment • 54% wrong technique
  • 8.  On an average there is one medication error every day for every inpatient
  • 9. MEDICATION ERRORS  Confusing drug names  Illegible handwriting  Similar packing  Similar clinical use  Look Alike Sound Alike – LASA medications
  • 10. WRONG PROCEDURE/ SURGERY/SITE About 50% adverse events occurring among in patients result from surgery
  • 11. 1.4 M PEOPLE SUFFER HAI
  • 12. WHICH PATIENTS ARE MORE AT RISK…????  Complex surgery  Multiple Medical conditions  Emergencies  Geriatric patients  Pediatric patients  Any patient who cannot perform ADL (Acts of Daily Living)  A physically / mentally challenged
  • 13. Failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim, do not all result in injury. HEALTH CARE ERROR
  • 14. NEAR MISS An event that almost happened or an event that did happen but no one knows about. If the person involved in the near miss does not come forward, no one may ever know it occurred.
  • 15. Nursing shortage Lack of standards Malfunctioning instruments Poor leadership and teamwork Poor infection control practices Poor communication Poor infrastructure
  • 16. What is Patient Safety ?  “Patient safety is a health care discipline that emphasizes the reporting ,the analysis and prevention of medical error that often leads to adverse health care events.” WHO  “Patient safety is defined as prevention of harm to the patients” Institute of Medicine (IOM)
  • 17. Objectives of Patient Safety  Create patient safety culture  Increase hospital accountability towards its patients and society  Decrease adverse events in hospitals  Implement programmes to prevent the recurrence of adverse events
  • 19. Patient Safety Practices Reduce the risk of adverse events related to exposure to medical care across a range of diagnoses or conditions.
  • 21. CNE
  • 22. MEDICATION ADMINISTRATION Right Patient Right Drug Right Dose Right Route Right Time Right Documentation
  • 23. Patient Safety Solutions  Look-Alike, Sound-Alike Medication Names  Patient Identification  Communication During Patient Hand-over  Performance of Correct Procedure at Correct body site  Control of Concentrated Electrolyte Solutions
  • 24.  Assuring Medication Accuracy at Transitions in Care  Avoiding Catheter and Tubing Mis- Connections  Single Use of Injection Devices  Improved Hand Hygiene to Prevent Health Care-associated Infection
  • 25.  Reduce the risk of patient harm from falls.  Report critical results of tests and diagnostic procedures on a timely basis  Identify patients at the risk of suicide  Prevention of pressure ulcers
  • 26. Absence of evidence is not the evidence of absence Always look for what is wrong before looking who is wrong Yes…it is necessary