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Problem
(Woolf, 2004)
These errors in addressing extant risks arguably are more threatening to health than lapses in
safety. Although “To Err Is Human” (1) suggested that 44 000 to 98 000 Americans die each
year because of medical errors, more careful analyses suggest that only a fraction of these deaths,
perhaps fewer than 5%, are causally linked to errors (18-20). Only a subset of adverse drug
events, the first concern of the patient safety movement, causes serious harm (21). A cohort
study of Medicare beneficiaries noted 5 life-threatening or fatal preventable adverse drug events
for every 1000 person-years of observation (22).
Human errors are one main source for accidents in any industry including health care. According
to Reason,
particularly important is the identification of cognitive processes common to a wide variety of
human error types. These errors are differentiated into variable and constant6 errors and are
classified as active and latent failures.
(Erickson, 2014)
Definition
Patient safety is a discipline in the health care sector that applies safety science methods toward
the goal of achieving a trustworthy system of health care delivery. Patient safety is also an
attribute of health care systems; it minimizes the incidence and impact of, and maximizes
recovery from, adverse events. This definition acknowledges that patient safety is both a way of
doing things and an emergent discipline. It seeks to identify essential features of patient safety.
(Wong, 2017)
checklists are associated with a reduction in overall complications in surgical patients. Surgical
safety checklists provide a means to safeguard patients and minimize risk through increased team
cohesion and coordination. Importantly checklists should be used to augment, and not replace,
other initiatives that contribute to a safety culture
Penggunaan ceklis pada pasien dengan tindakan bedah secara umum akan menurunkan
komplikasi. Ceklis keselamatan operasi menyediakan keselamatan pasiendan meminimalisasikan
resiko dengan meningkatkan keterpaduan dan koordinasi antar team
2) The response team (efferent limb). The response team most frequently comprises ICU-trained
personnel and equipment. Team composition varies on the basis of local needs and resources but
generally uses one of the following models: medical emergency teams (METs), which include a
physician; rapid-response teams, which do not include a physician; and critical care outreach
teams, which follow up on patients discharged from an ICU but also respond to all ward patients.
3) An administrative and quality improvement component. This team collects and analyzes event
data and provides feedback, coordinates resources, and ensures improvement or maintenance
over time.
Essential specimen handling steps. Blue items are physician-specific responsibilities; pink items
are nursing staffespecific responsibilities.
(Kim et al., 2015)
The most logical process to improve patient safety in health care systems is proposed below:
1.Identify current issues regarding patient safety
2.Revise systems, education, and training to address known patient safety issues
3.Educate health care professionals about the importance of patient safety concepts. Establish a
system of checks and balances to reduce medical errors. Ensure practical application of patient
safety concepts (training)
4.Enhance patient interaction to reduce errors
•Blood safety
1. Promotion of optimal hand hygiene associated with procedures for collection, processing, and
use of blood products
2. Promotion of donor skin antisepsis to prevent blood contamination
3. In-service education and training on safe transfusion practices at the bedside
•Clinical procedures
1. Specific education programs promoting safety in surgical procedures, tailored to the major
needs of the countries
2. Surgical hand preparation using either antimicrobial soap and water or alcohol-based handrub
to reduce infections associated
with surgical procedures
3. Access to safe emergency surgical care: availability and actual usage of procedures and
equipment for a specific set of clinical procedures
Key characteristics of the SEIPS (Systems Engineering Initiative for Patient Safety) model
include:
(1) description of the work system and its interacting elements
(2) incorporation of the well-known quality of care model developed by Donabedian (1978)
(3) identification of care processes being influenced by the work system and contributing to
outcomes
(4) integration of patient outcomes and organizational/employee outcomes
(5) feedback loops between the processes and outcomes, and the work system (see Fig. 1).
It would be desirable that the Learning Objective Catalogue for Patient Safety in Undergraduate
Medical Education serves as a foundation for constructive, professional deliberation with the
topic at the individual faculties and initiates numerous curricular structures.
improve team communication may be the next major advance in improving patient
outcomes
(Weller et al., 2014)
With increasing complexity and even more specialisation of skills, the current healthcare
environment demands effective communication and teamwork to reliably deliver best patient
care.
The relationship between team communication and patient safety4 has increased the emphasis
placed on training future health professionals to work within teams.7–9 However, few studies
have sought to demonstrate that prepractice interprofessional team training is effective in
building the foundations for later practice within healthcare teams
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