1. 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.

2. 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”

3. 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
“If you are not criticised you may not be doing much” Donald Rumsfelt 1932-

4. 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

5. 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

6. 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

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

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

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

10. 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

11. 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

12. 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

13. 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.