Patient Safety Take a little time to read through these slides, where a question is asked stop and consider it for a few moments before going on to the next slide. Sometimes things go wrong and you need to understand why things can go wrong and what to do if they do.

Everyone makes mistakes! The fact that all human beings make mistakes has been known for centuries:- “To err is human” said St Augustine about 640AD Alexander Pope added to the statement some 350 years ago saying “To err is human, to forgive divine”

Others have also acknowledged in inevitability of human errors “Human beings, who are almost unique in having the ability to learn from experience of others, are also remarkable for their apparent disinclination to do so” Douglas Adams 1952-2001 “If you are not criticised you may not be doing much” Donald Rumsfelt 1932-

So what happens in hospitals? A Patient safety incident or PSI is: “…any unintended or unexpected incident or error which could have, or did, result in harm for one or more patients”. National patient safety agency

What percentage of UK hospital admissions involve a PSI? Approximately 10% of hospital admissions in the United Kingdom (UK) involve an adverse incident, at least half are judged preventable with ordinary standards of care, while around one third lead to disability or death. Studies worldwide have uncovered similar outcomes in acute hospital settings. Vincent C and Neale G. BMJ 2001   National Patient safety agency. World Health Organisation.. 2009

Approximately what percentage of prescriptions written by doctors in training doctors involve an error? 8 - 10% of medication orders written by doctors in training contain an error. Doran et al. 2009

What percentage of PSIs in hospitals involve a communication issue? The majority of incidents involve some element of communication failure.

Which of the following factors increase the likelihood of medical error? Excess workload Tiredness Noisy environment Poor training All of the above

All of these factors affect the risks of PSIs occurring . Job Staffing Equipment workload Individual Skills Stress Attitudes Organisation Training Safety culture Teamwork Performance

How can we help? If you are tired admit it and ask for help If you feel stressed upset or worried don’t keep it to yourself If you don’t know something ask don’t guess If you notice that someone else is struggling offer to help or tell someone senior Make sure you get enough sleep, especially when on nights If you notice something not working properly report it Don’t be too proud to ask for help if you are too busy Look after each other

Which of the following factors most reduce the likelihood of medical error? Feeling valued in the team Having a protocols folder Staff who are prepared to share concerns about others’ performance

The following helps Good team working, where everyone feels a valued member makes everyone feel able to share worries, and ask for help makes care safer Having and using protocols reduces the chance of errors. We must be prepared to disclose concerns about performances of others

What should you do if you make an error? The patient is the first concern – ensure safety and tell someone supervising you The patient has a right to know Report the incident formally- NHS D&G can then ensure that the factors which contributed to your mistake are addressed and reduce the chance of something similar happening again.