7 HOSPITAL PATIENT SAFETY DESIGN Dr. ADIB A YAHYA, MARS 9 JUNI 2017

STATE – OF – THE - ART PATIENT SAFETY

despite all the known power of modern medicine to cure and ameliorate illness, hospitals were not safe places for healing. Instead, they were places fraught with risk of patient harm

Historically hospitals were 4 4 Historically hospitals were not the safest places William Penn – first US hospital in 1713. Movement away from regulation. Examples = derm procedures, cataract surgery, long term acute care, assisted living. Result is less up front cost for the payor, perhaps more reimbursement for the provider, and decreased patient safety. 4 4 4

“TO ERR IS HUMAN” CORRIGAN, KOHN AND DONALDSON US ACADEMY OF SCIENCES / INSTITUTE OF MEDICINE, 2000 1984 New York -2.9% of admissions suffered an adverse event, 58% of which were preventable 1992 Colorado and Utah - 3.7% of admissions suffered an adverse event, 53% of which were avoidable Over 33.6Mn US hospital admissions pa between 44,000 and 98,000 avoidable deaths occur 8th most frequent cause of death ahead of AIDS (16,516 deaths pa), breast cancer (42,297 deaths pa) and motor car accidents (43,458 deaths pa) Total cost to the US economy of avoidable deaths due to healthcare error $17 - $29 Bn pa HRRI.Healthcare Risk Resources International

Building a Safer Health System (1999/2000) To Err is Human: Building a Safer Health System (1999/2000) IOM Study of Medical Errors

Contributary Factors Influencing Clinical Practice Organisational & Corporate Culture Defence Barriers Task Management Decisions/ Organisational Processes Error Producing Conditions Error Violation Producing Conditions Violation Latent Failures (“BLUNT END”) Active Failures ( “sharp end “ ) -Procedure Professionalism Team Individual Environment Equipment PATIENT TASK AND TECHNOLOGY INDIVIDUAL TEAM WORK ENVIRONMENT Emergency Diagnose Pemeriksaan Pengobatan Perawatan Planning, Designing , Policy-making, Communicating Adapted from Reason (revised)

Thought leaders in health care offered persuasive arguments that errors could be reduced by redesigning systems and processes using human factors principles. These could reduce mistakes through design features, including standardization, simplification, and the use of constraints (which is a design characteristic that makes error impossible) Initially, perhaps, blunt-end factors were typically thought of as organizational policies and processes that shaped the behavior of individuals at the sharp end-point of service

PENGERTIAN Patient safety (WHO/Europe | Patient safety) The simplest definition of patient safety is the prevention of errors and adverse effects to patients associated with health care. Keselamatan Pasien Rumah Sakit – KPRS Suatu sistem dimana RS membuat asuhan pasien lebih aman. (KKP-RS PERSI 2005)

Key Concepts Human fallibility / “ to err is human “ Anatomy of error / incident types System approach “ Just Culture “ / no blaming culture Organizational Learning by reporting 10

The role of hospital design in patient safety “We shape our buildings and afterwards our buildings shape us.” -WINSTON CHURCHILL, MAY 10, 1941

Hospital design refers to the physical environment that includes : - the indoor environment (e.g. noise, air quality and lighting), - the interior design (e.g. furniture, fixtures and materials) and - the configuration (e.g. relative locations and adjacencies of spaces) of a hospital.

Factors Influencing the Built Environment With human factors in mind, there are several aspects of the built environment that should be considered. The following design elements were identified as critical in ensuring patient safety and quality care, based on the six quality aims of the Institute of Medicine’s report, Crossing the Quality Chasm: A New Health System for the 21st Century: • Patient-centeredness, including - using variable-acuity rooms and single-bed rooms - ensuring sufficient space to accommodate family members - enabling access to health care information - having clearly marked signs to navigate the hospital • Safety, including - applying the design and improving the availability of assistive devices to avert patient falls - using ventilation and filtration systems to control and prevent the spread of infections - using surfaces that can be easily decontaminated - facilitating hand washing with the availability of sinks and alcohol hand rubs - preventing patient and provider injury - addressing the sensitivities associated with the interdependencies of care, including work spaces and work processes

• Effectiveness, including - use of lighting to enable visual performance - use of natural lighting - controlling the effects of noise • Efficiency, including - standardizing room layout, location of supplies and medical equipment - minimizing potential safety threats and improving patient satisfaction by minimizing patient transfers with variable-acuity rooms • Timeliness, by - ensuring rapid response to patient needs - eliminating inefficiencies in the processes of care delivery - facilitating the clinical work of nurses • Equity, by - ensuring the size, layout, and functions of the structure meet the diverse care needs of patients

According to the model of system accidents proposed by Reason, research has shown that Hospital design may : - directly impact safety in hospitals. - indirectly impact safety by triggering adverse events that cause harm to patients and staff. - impact safety in hospitals by working as a barrier to harmful events.

Adverse events in hospitals are related to both active and latent failures. - Active failures are unsafe acts (slips, lapses, fumbles, mistakes and procedural violations) committed by the individuals in direct contact with the patient. - latent failures create local conditions that in specific situations may lead to active failures. Latent failures may become embedded within systems as a result of wrong decisions made by designers, builders, procedure writers and top level management .

Direct impacts on patient safety Aspects of hospital design such as air quality, lighting, patient room design and other interior design elements can directly impact safety outcomes such as nosocomial infections, patient falls and medical errors. Air quality and nosocomial infections Single bedrooms and nosocomial infections Lighting conditions and patient outcomes Lighting conditions and medical errors Noise in hospitals and patient outcomes Hospital design and patient falls

Impact of the environment on staff working conditions A poorly designed physical environment creates latent conditions such as staff stress, fatigue, annoyance, burnout and lack of handwashing compliance that may potentially lead to adverse events in hospitals. Noise in hospitals and staff outcomes Variable acuity patient rooms and transfers Unit layout and staff effectiveness Accessibility to handwashing stations and handwashing compliance

Environmental barriers/defenses to healthcare accidents The environment potentially acts as a defense to adverse events by providing opportunities for staff and families to prevent accidents before they occur. Visibility to patients Presence of family

Contributary Factors Influencing Clinical Practice Organisational & Corporate Culture Defence Barriers Task Management Decisions/ Organisational Processes Error Producing Conditions Error Violation Producing Conditions Violation Latent Failures (“BLUNT END”) Active Failures ( “sharp end “ ) Environmental barriers/defense - Visibility to patients - Presence of family Emergency Diagnose Pemeriksaan Pengobatan Perawatan Impact of the environment on staff working conditions : Noise in hospitals and staff outcomes Variable acuity patient rooms and transfers Unit layout and staff effectiveness Accessibility to handwashing stations and handwashing compliance Direct impacts on patient safety : Air quality and nosocomial infections Single bedrooms and nosocomial infections Lighting conditions and patient outcomes Lighting conditions and medical errors Noise in hospitals and patient outcomes Hospital design and patient falls Adapted from Reason (revised)

Direct impacts on patient safety Air quality and nosocomial infections Airborne infections are spread when dust and pathogens are released during hospital construction and are caused by contamination and malfunction of hospital ventilation systems . fungal load in the air may be linked to humidity, temperature and construction activity . High-efficiency particulate air (HEPA) filters can be highly effective in preventing airborne infections in hospitals . Air contamination is least in laminar airflow rooms with HEPA filters, and this approach is recommended for such areas as operating-room suites and ultraclean rooms for immunocompromised patients. Lower rates of surgical site infections in the newer operating rooms with laminar flow ventilation systems and automatically closing doors

Single bedrooms and nosocomial infections single-bed patient rooms with high-quality HEPA filters and with negative or positive pressure ventilation are more effective in preventing air-borne pathogens. multibed rooms are more difficult to decontaminate and have more surfaces that act as a reservoir for pathogens. On the basis of the study findings, the 2006 American Institute of Architects Guidelines for Design and Construction of Healthcare Facilities has adopted the single bed room as the standard for all new construction in the United States

Single rooms now required in new hospitals in 40+ U.S. states “In new construction, the maximum number of beds per room shall be one . .” 2006 Guidelines for Design and Construction of Health Care Facilities (section 3.1.1.1, p. 40) Published by: The Facility Guidelines Institute American Institute of Architects U.S. Department of Health and Human Services

Lighting conditions and patient outcomes different psychological and physiological effects of lighting in hospitals, some of which may be directly related to patient safety. For example, ‘ICU psychosis’ in adult patients can be partly attributed to bright or constant lighting conditions in ICUs that lack night/day cues. A similar phenomenon has been described among children in pediatric ICUs . the mortality rate may be higher in dull patient rooms, poor lighting conditions may negatively impact physiological developments among infants . studies suggest that lighting conditions should be considered more carefully in the design of patient care areas of a hospital.

Lighting conditions and medical errors Performance on visual tasks gets better as light levels increase . errors in dispensing medications in a high volume outpatient pharmacy were significantly lower at an illumination level of 146 foot-candles (2.6%) as opposed to the baseline level of 45 foot candles (3.8%). 58% of all medication errors among hospital workers occurred during the first quarter of the year when daylight hours were less. importance of appropriate lighting levels for complex tasks requiring excellent vision