1. PROMOTING PATIENT SAFETY BY PREVENTING MEDICAL ERRORS Safety concerns facing health care systems today

2. Objectives Describe the magnitude of medical errors and the effect on patient safety Identify processes to approach error reduction and prevention Recognize error prone situations/processes Identify the safety needs of special populations

3. Objectives cont. Describe processes to improve patient outcomes Explain what each of us can do to protect patients and ourselves from accidental injury

4. Magnitude of the Problem

5. DEFINITIONS  ERRORS: “the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim”.  A. Error of execution: Correct action does not proceed as intended  B. Error of planning: Original intended action is not correct

6. ADVERSE EVENT THOSE EVENTS THAT CAUSE AN INJURY TO A PATIENT AS A RESULT OF MEDICAL INTERVENTION OR INACTION ON THE PART OF THE HEALTHCARE PROVIDER WHERE THE INJURY CANNOT REASONABLY BE SAID TO BE RELATED TO THE PATIENT’S UNDERLYING MEDICAL CONDITION

7. Healthcare professionals must: Have a process in place to – Scrutinize & Evaluate those instances where a medical error occurred – Identify system improvements that have the potential to prevent future adverse events

8. ROOT CAUSE ANALYSIS Focus on process and system factors Document a risk-reduction strategy Focus an internal corrective action plan: include measurement of the effectiveness of process and system improvements to reduce risk

9. JCAHO Root Cause Analysis: focus primarily on systems and processes Should progress from special causes in clinical processes to common causes in organizational process Repeatedly dig deeper by asking “why?”

10. Analysis continued Identify changes that can be made in systems and processes “Thorough” and “credible” (JCAHO standards defined

11. ERROR REDUCTION AND PREVENTION PATIENT SUICIDE OPERATIVE AND POST-OPERATIVE COMPLICATIONS MEDICATION ERRORS WRONG-SITE SURGERY PATIENT FALLS OTHER CONSIDERATIONS FOR PATIENT SAFETY

12. CONCLUSION Each of us must responsibly ACTIVELY PARTICIPATE UNDERSTAND THE GOAL PRESERVE OUR SYSTEM CORRECT THE PROBLEM