Introduction to Patients

Safety and Informatics

Outline
• KEY DIMENSIONS OF HEALTHCARE QUALITY
• SAFETY AND PATIENT SAFETY
• SWISS CHEES MODEL OF ACCIDENT CAUSATION
• CLINICAL INCIDENTS AND CLINICAL RISKS
• APPLICATION OF INFORMATICS IN HEALTH CARE DELIVERY
• ROLE OF HEALTH INFORMATICS IN PATIENT SAFETY
• RISK MANAGEMENT POCESS
• MEASURES FOR PATIENT SAFETY AND RISK MANAGEMENT
• LIMITATIONS OF HEALTH INFORMATICS IN PATIENT SAFETY

10/12/2023 Patient Safety 2

 Objectives
After completing this lecture you should:
– Define and describe the key elements of patient safety,
informatics and clinical risk management
– Differentiate between the different types of clinical incidents
– Describe the advantages of health informatics in maintaining
patient safety
– Demonstrate selected Clinical Risk Management processes
applied to health care settings
– Identify the limitations of health informatics in patient safety
– Practice several specific behaviors to foster a culture of safety
in health care settings

10/12/2023 Patient Safety 3

The key dimensions of healthcare quality
Safety
Safety is a state in which hazards
and conditions leading to physical,
psychological or material harm are
controlled in order to preserve the health
and well-being of individuals and the
community.
Introduction to Patient Safety
Significant numbers of patients are
harmed due to their health care, either
resulting in permanent injury, increased length
of stay (LOS) in health-care facilities, or even
death.
There are more deaths annually as a
result of health care than from road accidents,
breast cancer and AIDS combined in US.

10/12/2023 Patient Safety 6

Defining Patient Safety
“Patient safety is the avoidance of
unintended or unexpected harm to people
during the provision of health care”
“The reduction of risk of unnecessary harm
associated with health care
to an acceptable minimum”
“The prevention of errors and adverse effects
to patients associated with health care”
(WHO, World Alliance for Patient Safety 2009).

10/12/2023 Patient Safety 8

Defining patient safety

Patient safety is “the environment,

infrastructure and technology emphasizing
the reporting, analysis and prevention of
medical errors and adverse events that
might cause a patient „harm‟.”

10/12/2023 Patient Safety 9

Areas of Patient Safety

• Medical Safety
• Surgical Safety
• Electrical Safety
• Laboratory safety
• Blood Safety
• Fire Safety
 Principles of Patient safety

• Medical Accuracy:
 Correct procedure at correct site
 Right patient
 Matching care elements
• Prevent patient transition errors
• Appropriate precautions
Patient Safety might Encompass:
• Patient fall
• Medication errors
• Adverse drug effects
• Identification errors
• Incomplete patient info & Document errors
• Suicide/ Intended self harm/ Bodily harm
• Diagnostic errors and equipment failure
• Treatment delays
• Unsafe surgical procedures / injections
• Post Operative complications:
Sepsis ,
Hospital associated Infections,
Venous thromboembolism etc.
 Patient Safety might also Encompass:
• Human Factors:
Variation in training & Experience
Lack of knowledge & Memory Lapse
Fatigue, Anxiety, Stress etc.
• System failures:
Lack of communication / Non reporting
Infrastructure failure etc
Mislabeling and misplacement
• Many others
Environmental distractions
Contaminated food
Sources of System Error
All errors can be divided into two main groups:
• Active errors or human error are committed by frontline staff
and tend to have direct patient consequences.
– Example, giving the wrong medication, treating the wrong
patient or the wrong anatomical site, or not following the
correct policies and procedures.
• Latent or system errors are those errors that occur due to a
set of external forces and indirect failures involving
management, protocols/ processes, organizational culture,
transfer of knowledge, and external factors
– Example :
understaffed wards or inadequate equipment.

10/12/2023 Patient Safety 14

"Swiss cheese" model of accident causation

10/12/2023 Patient Safety 15

 "Swiss cheese" model of accident causation
Systems have many holes from:-
Active failures and Latent conditions
• These holes are continuously opening, shutting,
and shifting their location.
• Hole in any one slice, do not normally cause harm,
because the other intact slices prevent hazards
from reaching the potential victim.
»Only when the holes in many layers
momentarily line up does the
trajectory of accident opportunity
reach the victim causing the
Damage.
10/12/2023 Patient Safety 16
 The concept of Clinical incident:
A clinical incident is an event or
circumstance resulting from health care
which could have, or did lead to
unintended harm to a person, loss or
damage, and / or a complaint.
(deviation from standard of care and safety)

10/12/2023 Patient Safety 17

Adverse Clinical incidents leading to Patient Harm

• Near Miss
• Adverse events
– Sentinel Events
– Medication Errors
– ADR
 Types of
Clinical incident
Near miss:
Is any situations that
did not cause harm to
patients (that did not
reach the patient) , but
could have done.

10/12/2023 Patient Safety 19

 Types of Adverse Clinical incidents
1. Sentinel event:
A sentinel event is an unexpected
occurrence involving death or serious physical
or psychological injury, or the risk thereof.
Serious injury specifically includes loss of
limb or function.
Example:
Hemolytic transfusion reaction
Involving administration of blood
or blood products having major
blood group incompatibilities

10/12/2023 Patient Safety 20

 Types of Adverse Clinical incidents
2. Adverse Drug Reaction (ADR):
A response to a drug which is noxious and
unintended, and which occurs at doses
normally used in man for the prophylaxis,
diagnosis, or therapy of disease, or for the
modifications of physiological functions'.
( WHO,1972)

10/12/2023 Patient Safety 21

Adverse clinical incidents: Errors in Medication
Most errors are NOT a result of
Personal error or negligence,
but arise from system flaws or organizational failures
1. Prescribing errors
2. Omission errors
3. Dosing errors
4. Preparation errors
5. Wrong drug errors
6. Improper administration
7. Fragmented care errors

10/12/2023 Patient Safety 22

Methods used in hospitals for patient drug safety
1. Internal Medical Prescriptions written/ printed with daily
dose
2. Master Record of patient information in HIS Systems
available while prescribing.
3. Recognize and control high alert drugs and substances
4. Check and alarm for over dosing/ contra indications / drug
interactions
5. Check for drug allergy information
6. Inter departmental co-ordination (eg: pharmacy & ward)
7. Monitor long-term therapies (chemotherapy)
8. Notify aberrant and unnoticed test results
 How to maintain safety in clinical incident ?
Adherence to the Patient Safety Goals
Require Organizational Practice
• Falls prevention strategy
• Client verification
• Pressure ulcer prevention
• Understanding Medication
• Safe injection practices
• Antibiotic prophylaxis
• Safe surgical practices
during surgery
• Hand hygiene
• Control of High-alert
medications • Training eg: Infusion pumps
• Adverse reporting
• Avoid Dangerous -
• Preventive maintenance
abbreviations
• Transfer of client information
at transition points
• Patient Safety Culture…
 Patient Safety Culture
An integrated pattern of individual and organizational
behavior, based on a system of shared beliefs and
values, that continuously seeks to minimize patient
harm that may result from the process of care
delivery.

10/12/2023 Blame Culture Vs Just Culture

Patient Safety 26
 Patient Safety Culture
Eg: If a patient is found to have received the wrong medication
and suffered a subsequent allergic reaction,
Blame culture:
we look for the individual student, pharmacist, nurse or doctor
who ordered, dispensed or administered the wrong drug and
blame that person for the patient‟s condition and hold them
accountable
Just Culture:
we look for the system defect such as communication ,
protocols and processes for medication management,
in addition to this, also investigate the negligence or
recklessness of the worker

10/12/2023 Patient Safety 27

Measures to improve Patient Safety

• Encourage incident reporting

• Monitoring for improvement
• Solicit and use Patient input
• Ensure Safety of Health care Professionals also
 Defining informatics

Informatics is “the application of

computing technology, network protocols,
telecommunication mechanism and
software algorithms applied towards
improving the quality of a “Human
Service” process”

10/12/2023 Patient Safety 30

 Patient safety informatics
It is the process of gathering
analyzing and managing health data as
well as the use of medical principles in
conjunction with health IT systems to
ensure safe treatment and enable
health workers to make better
decisions. (WHO).
Safety & Improvement Through the Ages…
In 19th Century, Dr Ignaz Semmelwies, a Hungarian
physician, recognised by reviewing and collecting data,
that there was a difference in mortality rates in his
midwife led unit (lower rates of infection) than his
physician led unit (higher rates of infection).
 Informatics frameworks
used in hospitals for patient safety
1. Health information Governance
2. Safety risk identification
3. Stake Holder involvement
4. Informed decisions
5. Sufficient Training
6. Gradual Implementation
7. Continuous monitoring & evaluation of
patient outcome
8. Technology optimization and regular
updating
Application of Informatics

Three Basic Classification of

Informatics Application in Patient Safety:
• Hardware oriented
• Software oriented
• Predictive model oriented (BI)
 Application of Informatics
Hardware to ensure patient safety
Hardware, database and network distribute real-time
access to patient-specific data and evidence based
medical knowledge, to make right decision at the right
time.
 Automated ergonomic Motion-Beds to prevent bed sores
 Patient bracelet: Wireless devices enabling nurses to
perform safety checks during bedside medications.
 Bedside dispensing cabinet systems with digital technology:
 XXX Type Bandage: ideal for controlling hemorrhage.
 Global Network with synchronous treatment protocol
 Holographic Image Transportation
 Global Nursing Stations
 Application of Informatics
Hardware to ensure patient safety
 Application of Informatics
Software to ensure patient safety
 Patient response monitoring systems
 Risk Monitoring software data on nursing-sensitive indicators
 Intelligent Incident Reporting:
Not just for reporting but Decision Support
 Reporting of PSIs (Patent safety Indicators )
 Intelligent–Bilingual–Response Monitoring System:
with ‘No response’ message to next expert station –
collaborative healthcare.
 On-line real-time risk monitoring:
Software producing “leading indicators”
for ensuring patient safety
PROACTIVE & NOT REACTIVE
 Application of Informatics
Predictive Models to ensure patient safety
 Correlations: Between environmental variables and patient
safety violation incidences - eg: B/w 3rd , 4th & 8th Floors of EMCH
 Regression analysis:
Predict the independent variables in patient safety violations
like Language, age, Disease Type, primary physicians,
English instructions to non-English speaking patients, etc.
 Predictive analysis through multivariate and data mining :
based on patient demographics to find out “High risk” patients.
 Pattern Recognition:
Algorithm to recognize leading Indicators of safety
 Structural equation modeling or Path Analysis:
to gain additional insight into causes of -
“Safety Violations”
“if you know the cause you can prevent it”
 Role of Health informatics for Patient safety
The right information to the right person at the right time
• Records must be accessible
• Records must be integrated
• Records must be of a high quality
• Record must contain all relevant information
• Records must be patient accessible:
• Careful consideration to privacy and security issues
• System “warnings” and “pop-ups” are crucial
 Referrals must be
– communicated clearly
– acknowledged
– acted on
Impacts of Health informatics
1. Easy information Access
2. Better medical documentation
Adoption of Electronic Health Records
3. Reduction of Drug related Errors
4. Improved Public Health
5. Clinical Decision support
6. Better co-ordination of care
Confirmation messages for appointments
7. Improved compliance with practice
guidelines
8. Cost containment
 Limitations of Health informatics
IT is a crucial enabler in improving the quality and
safety of health service delivery, and in the move
towards a patient centred systems.
• However, “Health IT may cause harm if it is poorly
designed, implemented, or applied.
• IT can create new hazards in the already complex
delivery of health care.
• Technology does not exist in isolation from its operator –
the design and use of health IT are interdependent.
 Limitations of Health informatics
 In the dry language of systems and processes, of
transmission technologies and referral protocols, we can
miss the very human dynamics that give life to these
systems and processes.
 Whatever referral system is operating between
providers, it has to work for patients, who should have
justified confidence that referrals will lead to action in
sufficient time to treat preventable problems.
 Health informatics for the future
Future Informatics technology
1. Risk management
2. Better data tracking
3. Electronic patient portals
4. Telemedicine
5. Remote patient monitoring
6. Electronic incident reporting
7. Artificial intelligence and Machine Learning
Essays????
1. Write a short note on patient safety and explain its
importance in current health care scenario?
2. List down the examples of clinical incidents that can
harm to patient safety?
3. Write a short note on medication error and how
they can be prevented?
4. Discuss the different areas of Patient Safety and
ensuring measures. Briefly explain the future of
health informatics in patient safety?
Short Notes???????
1. Define patient safety?
2. What is an adverse event?
3. Differentiate between active errors and latent errors?
4. Define informatics / patient safety informatics?
5. Discuss the impacts and applications of Informatics
on patient safety?
6. What are the common sources of patient safety
issues in a hospital?
1. Which of the following is not an
important aspect of patient safety?

A. To provide quality health care

B. To ignore errors and carry forward the medical care.
C. To provide timely and efficient care
D. To report errors and associated risks
2. Which of the following error is an
unexpected occurrence?

A. Near Miss
B. Sentinel Event.
C. Adverse Event
D. All of the Above
3. Which of the following can be classified
as a medication error?

A. Incorrect Drug Administration

B. Incorrect Dose Administration
C. Incorrect Technique of Drug Administration
D. All of the Above.
4. Which of the following cannot be attributed
as a human error causing patient Harm?

A. Anxiety or Stress Due to Overwork

B. Diagnostic Errors.
C. Variation in Health Providers Experience
D. Fatigue
5. Which of these measures should be a
standard procedure for patient safety?

A. Washing Hands
B. Checking Patients ID Before Giving Medications
C. Thoroughly Explaining The Reasons For Any
Treatment / Test
D. All of the Above.
6. ______ involve overexposure to radiation due
to wrong patient and wrong site identifications?

A. Sepsis
B. Radiation Error.
C. Unsafe injection Practices
D. Diagnostic Errors
E. All of the Above
7. Which among the following is an
example for patient safety issue?

A. Health Care aasoociated Infections

B. Unsafe surgical Procedures
C. Diagnostic Errors
D. All of The Above.
8. All are actions to ensure fire safety,
EXCEPT?

A. Pre anesthetic Checkups.

B. No Loose wires or Connections
C. Safety fuses with each equipment
D. Electricity back up and battery
E. Fire Hydrant in all Buildings
9. Which of the following action ensure
Blood Safety?

A. Regular Pest control measures in hospital

B. Fire extinguisher points at regular distance in
hospital
C. Regular testing for HIV, Hepatitis and VDRL.
D. Prevention of Surgical Wound infections
10. _____ have far reaching potential and still
untapped application in many industries and
health care is no exception.
A. Artificial Intelligence
B. Machine Learning
C. Both.
D. None of the above
Reading References:
• A Ian Clement, SP Subashini. Health/Nursing
Informatics & Technology for BSc Nursing Students,
Frontline Publications: Hyderabad, Ed 1. 2022.
• Deepak Sethi, Sukhbir Kaur, Nursing Informatics and
technology (Computer for Nurses). Jaypee
Publications. New delhi. 2023
• Arashgeeth Kaur, Taranpreet Kaur. Textbook of Health
informatics & Technology. Vision Health Sciences
Publishers, Mohali Punjab. 2022

10/12/2023 Patient Safety 61

Bibliography
• Maamoun J,An Introduction to Patient Safety. Journal of
Medical Imaging and Radiation Sciences 40 (2009) 123-133
• Reason J.Human error: models and management. BMJ. 2000
Mar 18;320(7237):768-70.
• Sutker WL The physician's role in patient safety: What's in it
for me?. Proc (Bayl Univ Med Cent).2008 Jan;21(1):9-14.
• Sutker WL. The physician's role in patient safety: What's in it
for me? Proc (Bayl Univ Med ‎Cent). 2008 Jan;21(1):9-14‎
• Goode LD1, Clancy CM, Kimball HR, Meyer G, Eisenberg JM.
When is "good enough"? The role and responsibility of
physicians to improve patient safety. Acad Med. 2002
Oct;77(10):947-52.

10/12/2023 Patient Safety 62