The document discusses patient safety and medical errors. It provides statistics showing that medical errors are a leading cause of death and injury. Between 44,000 to 98,000 people in the US die each year due to preventable medical errors. The document examines types of medical errors and their costs. It analyzes strategies to improve patient safety, including establishing mandatory reporting systems, implementing a culture of safety, and meeting quality standards to prevent harm. The overarching message is that focusing on system improvements, rather than blame, can help reduce medical errors and enhance patient outcomes.

1. Abdalla Ibrahim
Accreditation Specialist
Healthcare Surveyor
2014
Email: abdallaibrahim@hotmail.com

2. Does healthcare service is safe as it
should be and can be??
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4.  First Do No Harm is a 1997
American television film.
 About a boy whose
severe epilepsy, unresponsive to
medications with terrible side
effects, is controlled by
the ketogenic diet.
 Aspects of the story mirror the
Director Jim Abrahams' own
experience with his son Charlie.
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5. Estimated extent of medical injuries
 3.7% (1114 Out of 30 121) patients admitted to 51
acute care hospitals in NewYork state reported adverse
events/injuries caused by medical management
 A subsequent analysis of the same data found that 69%
of injuries were caused by preventable errors. (The
Harvard Study, USA, 1984)
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6.  Adverse events occurred at a rate of 2.9 percent.
 Death resulted in 8.8 percent of adverse events due to
negligence.
 The total proportion of adverse events causing death
was 6.6 percent.
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8.  “At least 44,000 people, and perhaps as many as
98,000 people, die in hospitals each year as a
result of medical errors that could have been
prevented”. (IOM Report,1999)
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9.  The total number of estimated admissions in USA in 1997 was 33.6
million.
 When the results of the NewYork study are applied (13.6 percent
of adverse events leading to death) the number of deaths due to
adverse events was 98 000.
 When the Utah/Colorado results are used (6.6 percent of adverse
events leading to death) the number of deaths was estimated to be
44 000.
 This is the claim that 44 000 to 98 000 people die each year due to
medical errors, making medical errors the 8th leading cause of
death in the United States.
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10.  16.6% of 14 179 admissions to 28 hospitals in New
South Wales and South Australia in 1995 developed an
adverse event and resulting in permanent disability in
13.7% of patients and death in 4.9%
 51% of adverse events were considered to have been
preventable.
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13. Can we afford the losses of
a daily airplane crash?
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15. DEFINITION
 The failure of a planned
action to be completed as
intended
OR
 The use of a wrong plan to
achieve an aim. (IOM, 1999)
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16. DEFINITION
“A preventable adverse effect of
care,whether or not it is evident
or harmful to the patient.
(Wikipedia)
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17. Is it a “ BAD APPLE” problem?!!
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18.  The majority of medical errors do not result
from individual irresponsibility or the actions of
a particular group
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19. More Commonly, Errors Are Caused By:
These lead people to make mistakes or fail to
prevent them.
Faulty System
Faulty Process
Faulty Condition

21. SOURCE: Leape, Lucian; Lawthers, Ann G.; Brennan, Troyen A., et al. Pr e-venting Medical Injury. Qual Rev Bull. 19(5):144–149, 1993.
Diagnostic Treatment prevention

22. Communication Equipment System

23. DIAGNOSTIC ERROR
 Error or delay in diagnosis
 Failure to employ indicated
tests
 Use of outmoded tests or
therapy
 Failure to act on results of
monitoring or testing
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24. TREATMENT ERROR
 Performance error of
operation, procedure, or test
 Administration error of
wrong treatment, dose or
method
 Delay in treatment or in
responding to an abnormal
test
 Inappropriate or not
indicated care
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25. PREVENTIVE ERROR
 Failure to provide
prophylactic treatment
 Inadequate monitoring or
follow-up of treatment
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26. OTHER FAILURE
 Communication
 Equipment failure
 Other system failure
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27. Common Medical Errors

28. Adverse
Drug Event
Miss matched
Transfusion
Surgical
Injury
Wrong Site Restraint-
related
injuries
No
proper
Photos
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29. Fall Burn Pressure
Ulcer
Mistaken
Patient
identities
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30. High error rates with serious
consequences occurs in:
A/E
O/R
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31. High error rates with serious
consequences occurs in:
ICU
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32. Cost of Error
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33. Errors are costly in terms of:
 Loss of trust in the health care system
 Diminished satisfaction by both patients and health
professionals.
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34.  Total costs estimated between $17 billion and
$29 billion per year in the USA.
 This Cost includes the expense of:
• additional care necessitated by the errors
• lost income
• lost productivity
• disability
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35.  Physical and Psychological
Discomfort.
 Poor Satisfaction
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36.  Loss of morale
 Frustration
 Inability to provide best
care
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37.  Work & school
absenteeism
 Lower worker productivity
 Lower levels of population
health status
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38. Strategy for Improvement
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39. Strategy for Improvement
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40. The USA response to the IOM
Report
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41. Establish National focus on Patient
Safety
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42.  Establish Mandatory reporting system
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43.  Raising Performance Standards and
Expectation on Safety
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44.  Implement Patient Safety
Culture
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45. harder to do wrong and
easier to do it right
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46. Yes, it may be part of human nature to err, but it is
also part of human nature to:
• Create solutions
• Find better alternatives
• And meet the challenges ahead.
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47. People must be alert and held responsible for their actions. But
when an error occurs, blaming an individual does little to make the
system safer and prevent someone else from committing the same
error.
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48. The pathway to the
desired Patient Safety
is Quality Performance
in Healthcare Services.
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49. Healthcare organization should
implement the Patient Safety
goals and required practices
included in the Quality
Standards of Excellence to do its
basic function:
Improve Quality of Life
& Do NO Harm.
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