What Does Patient Safety Have to Do with Medical Errors? DR. NADIA - - PowerPoint PPT Presentation

▶
what does patient safety have to do with medical errors
SMART_READER_LITE
LIVE PREVIEW

What Does Patient Safety Have to Do with Medical Errors? DR. NADIA - - PowerPoint PPT Presentation

Dec 30, 2023 484 likes •720 views

What Does Patient Safety Have to Do with Medical Errors? DR. NADIA AL-KANDARY Head of Pathology Section Kuwait Ministry of Interior Forensic Medicine Department As part of our extensive program and with CPD hours awarded based on actual time

slide-1
SLIDE 1

What Does Patient Safety Have to Do with Medical Errors?

  • DR. NADIA AL-KANDARY

Head of Pathology Section Kuwait Ministry of Interior Forensic Medicine Department

slide-2
SLIDE 2

ME Forum 2019 Orientation

As part of our extensive program and with CPD hours awarded based on actual time spent learning, credit hours are offered based on attendance per session, requiring delegates to attend a minimum of 80% of a session to qualify for the allocated CPD hours.

  • Less than 80% attendance per session = 0 CPD hours
  • 80% or higher attendance per session = full allotted CPD hours

Total CPD hours for the forum are awarded based on the sum of CPD hours earned from all individual sessions. Conflict of Interest The speaker(s) or presenter(s) in this session has/have no conflict of interest or disclosure in relation to this presentation.

slide-3
SLIDE 3

MEDICAL ERRORS ARE SYMPTOMS OF DEEPER TROUBLE

Medical Errors – the New View

slide-4
SLIDE 4
slide-5
SLIDE 5

DO YOU REMMEBER PATIENT: X Y Z?

slide-6
SLIDE 6

Medical Errors

Is a preventable adverse effect of care, whether or not it is evident or harmful to the patient.

Medical Malpractice

  • Occurs when a hospital, doctor or other health care

professional, through a negligent act or omission, causes an injury to a patient

  • Elements of 4 “D’s “:
  • Duty.
  • Deviation.
  • Direct Causation.
  • Damage.
slide-7
SLIDE 7

Measuring Medical Errors in Health Care

  • CDCP relies on death certificate.
  • CDCP doesn’t consider ME as a cause of death.
slide-8
SLIDE 8

Achieving a 99% level of quality means accepting a 1% error rate

slide-9
SLIDE 9

Medical Malpractice claims are dealt with at the Forensic Medicine Authority.

  • By evaluating :
  • Access patient clinical records.
  • External and Internal examination

(Autopsy).

slide-10
SLIDE 10

10

Medical Errors

  • Delayed or missed diagnoses
  • Medication errors
  • Wrong side surgery
  • Wrong patient surgery
  • Equipment failure
  • Patient identity
  • Transfusion errors
  • Mislabeled specimen
  • Patient falls
  • Laboratory errors
  • Radiology errors
  • Procedural error
  • Lost, delayed, or failures to follow up

reports

  • Retention of foreign object following

surgery

  • Contamination of drugs, equipment
  • Intravascular air embolism
  • Failure to treat neonatal

hyperbilirubinemia

  • Stage lll or lV pressure ulcers acquired

after admission

  • Wrong gas delivery
  • Retention of foreign body
slide-11
SLIDE 11

5 common patient safety rules we see being violated by hospitals

  • Patient information and labeling
  • Poor Communication
  • Not following up on a test that was ordered.
  • Not consulting with the appropriate specialist.
  • Relying on other staff
slide-12
SLIDE 12

Strategies to reduce medical errors

  • Adopt a structure for handoff

conversations

slide-13
SLIDE 13
  • Following protocol is crucial to prevent

mistakes.

Strategies to reduce medical errors

slide-14
SLIDE 14
  • Get pharmacists more directly

involved in patient treatment.

Strategies to Reduce Medical Errors

slide-15
SLIDE 15
  • Work to reduce infections.

Strategies to Reduce Medical Errors

slide-16
SLIDE 16
  • Avoid diagnostic error.

Strategies to Reduce Medical Errors

slide-17
SLIDE 17
  • Make electronic health records (EHR)

systems

Strategies to Reduce Medical Errors

slide-18
SLIDE 18
  • Proper reporting system for errors

Strategies to Reduce Medical Errors

slide-19
SLIDE 19
  • A balanced workload

Strategies to Reduce Medical Errors

slide-20
SLIDE 20

20

A Culture of Safety

31,033 Pilots, Surgeons, Nurses and Residents Surveyed*

*Sexton JB, Thomas EJ, Helmreich RL, Error, stress and teamwork in medicine and aviation: cross sectional surveys. BrMedJour, 3-18-2000.

% Positive Responses from: Pilots Medical

Is there a negative impact of fatigue on your performance? 74% 30% Do you reject advice from others? 3% 45% Is error analysis system-wide? 100% 30% Do you think you make mistakes? 100% 30% Easy to discuss/report mistakes? 100% 56%

slide-21
SLIDE 21

Association Between Evening duty and Higher Mortality Rates in the Pediatric Intensive Care Unit

Yeseli Arias, Doublas S. Taylor, and James P. Marcin Pediatrics 2004; 113: 530-534

0.4 4.1 0.9 3.9 1.2 1.8 0.9 1.9

0.5 1 1.5 2 2.5 3 3.5 4 4.5 Sepsis Cardiac Disease Cardiac Arrest Time of Birth* Day Night

slide-22
SLIDE 22

“…there are some patients we cannot help, there are

none we can

harm...”

  • -Dr. Ken Stahl

CONCLUSION