III.

Patient Safety
 Errors and Harm: *especially if combined with lack of supervision
o Are not intentional
o Not from failure of cutting edge medicine Individual factors that predispose to error
o Result from lapses in "basic" safety procedure  Limited memory capacity
 No counter-checking occurs  Further reduced by:
 Errors occur due to: o Fatigue
o Faulty systems, processes that lead people to  24 hours of sleep deprivation has effect
commit mistakes or fail to prevent them. performance effects = blood alcohol
o The fact that we are human.
content (BAC) of 0.1% 

Patient safety is a science that promotes the use of evidence-
based medicine and local wisdom to minimize the impact of human  Legal limit to drive = < 0.08%
error on quality patient care. Wrong-site/wrong- procedure o Stress
surgeries, retained sponges, unchecked blood transfusions, o Hunger
mismatched organ transplants, and overlooked allergies are all o Illness
examples of potentially catastrophic events that can be prevented o Language or cultural factors
by implementing safer hospital systems. o Hazardous attitudes
 NOT TOLERATED
Science of Human Factors  Lack of awareness
 Acknowledges:  Multi-tasking
o The universal nature of human fallibility
o The inevitability of error Systems and Design Factors That Can Lead to Errors
 Assumes that errors will occur.  Complexity
 Designs things in the workplace to try to minimize the o Too many steps
likelihood of errors or its consequences o Too many people (communication issues)
 Only recently has been acknowledged as an essential part of  Workload
patient safety. o Too heavy or too light (performance is best when
workload is moderate)
Human Factor: We cope quite well with complexity o Too much reliance on human vigilance/monitoring
 Poor Design
 Health-care workers are quite good at compensating for some
o Focus on functionality, ignoring the end-user
of the complex and unclear design of some aspects of the
workplace  Interruptions, Distractions, and Multitasking
o Equipment o Most common reason why errors occur
o Frequently associated with errors - up to 50% in
o Physical layouts
aviation studies
 Because the human brain is:
o Extremely common in healthcare - Emergency MDs
o Very powerful
experience up to 10 interruptions per hour
o Very flexible
o Good at finding shortcuts (fast)  Culture
o Authority structure impeding communication
o Good at filtering information
o Good at making sense of things o No assignment of responsibility

Human beings make "silly" mistakes Human Factor Engineering

 People make mistakes regardless of their experience,
intelligence, motivation, or vigilance.
 One definition of human error is "human nature".
 Humans by nature are prone to error.
 “The fact that we can misperceive situations despite the best
of intentions is one of the main reasons that our decisions and
actions can be flawed such that we make silly mistakes.”
 If you are not anticipating something to happen, you are liable
to miss it out, especially if you are just focusing on the main
task.
Errors and Mistakes
 Failure of a planned action to achieve its intended outcome
 Deviations between what was actually done vs what should
have been done 
 operating them.
 Doing the wrong thing when the right thing was meant to
be
 done.
Situations associated with an increased risk of error
 Unfamiliarity with the task*
 Inexperience*
o If not supervised, one must be very careful and
vigilant.
 Shortage of time
 Inadequate checking
 Poor procedure
 Poor human equipment interface
 “We cannot change the human condition, but we can change
the conditions under which humans work.” (Reason J. BMJ
2000;320:768-770)
Traps in Healthcare
Avoidable Confusion is Everywhere
 Look-alike and sound-alike pharmaceuticals
o Problem with many drugs is that pharmaceutical
companies want to package them with one look, but
unfortunately, it doesn't alert the user with regards to
the function of the medication.
o Eg. Two eye drops with totally opposite effects in
almost the same packaging)
 Equipment design
o Infusion pumps, different brands, different ways of
o Same button in two brands could mean two different
things
o If you are not sure how to operate one, ask for help.
Types of Medical Errors
Adverse Event
 Injury caused by medical management rather than the
underlying condition of the patient.
 Prolongs hospitalization, produces a disability at discharge, or
both.
 Classified as preventable or unpreventable.
 Most common type of medical error.
 Types: mild, moderate, severe.

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| 1.01 Lecture Topic
Negligence
 Care that falls below a recognized standard of care.
 Standard of care is considered to be care a reasonable
physician of similar knowledge, training, and experience
would use in similar circumstances.
 Breach from following a standard of care. Usually leads to law
suit.
 If the patient will be given non-standard care, it should be
discussed first and agreed upon by the patient and the doctor.
 Lawyers are fond of using this, and is usually charge against
doctors during court hearings.

Near Miss/Close Call/Good Catch

 An error that does not result in patient harm.
 Analysis of near misses provides the opportunity to identify
and remedy system failures before the occurrence of harm.
 It may have reached the patient but nothing happened, might
have been caught in time, or there was a second check by
another person.
 Eg. Underdosing, preparing the wrong medication and
catching it in time before it is given to the patient.

Sentinel Event
 An unexpected occurrence involving death of serious physical
or psychological injury.
 Something you don't want to happen.
 The injury involves loss of limb or function.
 This type of event requires immediate investigation and
response.
 Patient entered the hospital, patient was not supposed to die
from their illness but for some reason the patient dies.
 Root-Cause Analysis required
 Other examples:
o Hemolytic transfusion reaction involving
administration of blood or blood products having
major blood group incompatibilities.
o Wrong-site surgery
 Any surgical procedure performed on the
wrong patient, wrong body part, wrong
side of the body, or the wrong level of a
correctly identified anatomic site.
 Approximately 4000 wrong-site surgeries
in the US each year.
 Risk increases when there are multiple
surgeons involved in the same operation
or multiple procedures are scheduled or
performed on different areas of the body.
 Time pressure, emergency surgery,
abnormal patient anatomy, and morbid
obesity are also risk factors.
o A medical error or other treatment-related error
resulting in death.
o Unintentional retained surgical items.
 Refers to any surgical item found to be
inside a patient after he or she has left the
OR, thus requiring a second operation to
remove the item.
 Most common retained surgical item is a
surgical sponge.
 increased risk appeared to be related to
bypassing the surgical count in many of
these cases.
 "Falsely correct count" occurred in 21% to
100% of cases in which a retained surgical
item was found.

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