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.
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”
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 1952-2001
“If you are not criticised you may not be
doing much” Donald Rumsfelt 1932-
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
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.. 2009
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
What percentage of PSIs in hospitals
involve a communication issue?
The majority of incidents involve
some element of communication
failure.
Which of the following factors
increase the likelihood of medical
error?
A.
B.
C.
D.
E.
Excess workload
Tiredness
Noisy environment
Poor training
All of the above
All of these factors affect the risks of PSIs
occurring .
• Staffing
• Equipment
• workload
Job
Individual
Organisation
• Skills
• Stress
• Attitudes
• Training
• Safety culture
• Teamwork
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
Which of the following factors most
reduce the likelihood of medical
error?
A.
B.
C.
Feeling valued in the team
Having a protocols folder
Staff who are prepared to share concerns
about others’ performance
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
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.
