patient safety
play

Patient safety HAMAD ALQAHTANI Professor of Surgery Consultant - PowerPoint PPT Presentation

Nov 17, 2023 •296 likes •481 views

Patient safety HAMAD ALQAHTANI Professor of Surgery Consultant Hepatobiliary Surgeon College of Medicine King Saud University Pati tient safety in incidents 1. These are preventable events that may cause unnecessary harm to the

  1. Patient safety HAMAD ALQAHTANI Professor of Surgery Consultant Hepatobiliary Surgeon College of Medicine King Saud University

  2. Pati tient safety in incidents 1. These are preventable events that may cause unnecessary harm to the patient. 2. Patient safety has become a will established healthcare discipline with structured approaches which guarantee that all affected patients are cared for and informed.

  3. Cla lassification of pati tient safety in incidents Adverse event. This is an incident that leads to patient harm. Near miss. This is an incident which could have caused unaccepted consequences but did not occur, either by chance or by preventing the occurrence of the event in appropriate time. No-harm event. This is an incident which occurs but did not harm the patient.

  4. Common causes of f adverse events in in healthcare The most common factors that result in patient safety incidents are inadequate communication between: 1. The members of medical staff 2. The medical staff and the patients or the members of the patient family.

  5. Causes of patient safety in incidents A. Human factors • Inadequate patient evaluation. • Delay or error in the diagnosis. • Inappropriate use or interpretation of investigations. • Error in doing an investigations, procedure, or treatment. • Inappropriate follow up or monitoring of the treatment. • Lack of experience. • Work over load and pressure of time. • Psychological or personal reasons (e.g. depression or drug abuse). • Variation in patient and environment of the work place.

  6. B. System failures • Inadequate communication between the medical staff. • Inadequate levels of medical staff. • Shut down of the reporting systems. • Inadequate coordination between the staff at the handovers. • Similarities between the drugs. • Environment infrastructure and design. • Failure of the equipment, due to the lack of parts or skilled expertise. • Policies of cost-cutting taken by the health institute. • Inappropriate reporting systems of the incidents in patient safety.

  7. C. Medical complexity • A new advanced technologies (e.g. robotic surgery). • Side effects and interactions of medications. • Place of work (emergency room, operating theatres, intensive care unit)

  8. Patient safety in in th the real working conditions A. Communicating openly with patients and obtaining consent. B. The required information when obtaining the consent. • Details and accuracy of the diagnosis. • The goals and details of the planed procedure. • The possible complications of the planed procedure. • The possible prognosis. • Other treatment options, including the not to treat option. • Explanation of the advantages and possibility of success for each option. • The name of the responsible surgeon. • At any time, the patient can change his or her mind.

  9. C. Professional behaviour D. Communication between the medical staff F. Reporting adverse events and near misses F. Prescribing safely • Inadequate clinical evaluation. • Inadequate information about the drugs. • Errors in the calculation of the dose. • Unclear hand writing. • Confusion in the name of the patient or mixing up of drugs.

  10. Patient safety and the surgeon More than one cause of adverse events can be applied to many aspects of patient care during the perioperative period. The adverse events in the surgical practice that can potentially be committed by the treating surgeons in the patients care includes: • Prophylaxis errors. • Prescription errors. • Parenteral administration errors. • Awareness of situation, and teamwork errors. • Diagnostic and management errors. • Resuscitation errors. • Procedure technique and operative errors.

  11. Sit ituation awareness – id identifying teamwork errors • The wrong patient was taken to the operating room. • Wrong site or side of surgery. • Wrong procedure or surgery. • Communication failure about changes in the condition of the patient. • Retained swabs or instruments.

  12. Checklists Sign in Before induction of anaesthesia: This include 1. Confirmation of patient identity 2. Site and nature of procedure 3. Obtaining consent 4. Marking the site of procedure

  13. 5. Complete anaesthesia safety check • Functioning pulse oximeter on patient • Check for known allergy • Risk for difficult airway or aspiration with available equipment and assistance • Risk of blood loss more than 500ml with adequate intravenous access and fluids are available.

  14. Time out (before skin incision) 1. All team members must introduce themselves by name and role. 2. Nurse verbally confirm ➢ The identity of the patient ➢ Site and nature of the procedure ➢ Anticipated critical events surgeon should mention what are the critical steps, duration of the procedure, expected blood loss Anesthesia team should mention any patient-specific concerns Nursing team should review the sterility been confirmed, equipment is available, any issues or any concerns, antibiotic prophylaxis has been given within the last 60 minutes, essential imaging is displayed.

  15. Sign out (before the patient leaves the operating room) 1. Nurse should confirm verbally with the team: • The name of the procedure recorded • The instrument, sponge and needle counts are correct • Any equipment problems to be addressed. 1. The surgeon, anesthesia, and nurse review: • The concerns for recovery and management of the patient • The specimen is labeled including the patient name.

  16. Technical and operative errors • During the conduct of the operation • Judgement errors (e.g. failure or late decision making to convert difficult laparoscopic into an open surgery). • Technical errors (steps of surgical procedure are not followed or omitted) • Aggressive handling of tissues that result in tissues damage. • Misinterpretation (this is unique to minimally invasive surgery due to the misreading of a two-dimensional image) • Misuse of surgical instruments (e.g. diathermy) • Missed iatrogenic injury (e.g. bile duct injury or bowel perforation)

  17. Ethical aspect of surgery Informed consent • The surgical problem and the reasons why it needs surgery. • The proposed surgical procedure and how it might treat the surgical problem. • The expected complications of the proposed surgery. • The anticipated prognosis. • The alternative and potentially successful treatments. • The consequences of no treatment at all. Confidentiality

  18. THANK YOU

Recommend

The UCLPartners Patient Safety Programme: Update Peter Toohey, Patient Safety Improvement Manager,

The UCLPartners Patient Safety Programme: Update Peter Toohey, Patient Safety Improvement Manager,

The UCLPartners Patient Safety Programme: Update Peter Toohey, Patient Safety Improvement Manager, UCLPartners #QIinAKI #QIinSepsis @UCLPartnersPSP @pete_toohey Patient Safety Priority Matrix Together, Sepsis & AKI account for two thirds

146 views • 10 slides
Behavior Patient Safety Connection Behavior Patient Safety Connection Does Any Doubt Remain?

Behavior Patient Safety Connection Behavior Patient Safety Connection Does Any Doubt Remain?

Behavior Patient Safety Connection Behavior Patient Safety Connection Does Any Doubt Remain? Charlotte Jefferies Horty, Springer & Mattern Those Who Provide Care Impact and implications of disruptive behavior in the perioperative

403 views • 9 slides
prevention? Dr Frances Healey , RN, PhD, Deputy Director of Patient Safety (Insight) September

prevention? Dr Frances Healey , RN, PhD, Deputy Director of Patient Safety (Insight) September

Patient safety struggles and successes are there lessons we can apply to falls prevention? Dr Frances Healey , RN, PhD, Deputy Director of Patient Safety (Insight) September 2017 Aiming to cover Some patient safety culture Some ideas

555 views • 54 slides
The Role for Boards in Quality/Patient Safety 1 Carol Wagner Vice President Patient Safety

The Role for Boards in Quality/Patient Safety 1 Carol Wagner Vice President Patient Safety

The Role for Boards in Quality/Patient Safety 1 Carol Wagner Vice President Patient Safety Washington State Hospital Association Judi Brenes Board Member Southwest Washington Medical Center and Health System January 26, 2010 Presenters 2

668 views • 27 slides
Patient engagement in medication safety at the point of care September 15, 2016 Thank you to:

Patient engagement in medication safety at the point of care September 15, 2016 Thank you to:

Patient engagement in medication safety at the point of care September 15, 2016 Thank you to: World Health Organization Patients for Patient Safety Advisory Committee Patients for Patient Safety Canada Knowledge Transfer Working

871 views • 39 slides
Phlebotomy Safety for All Ages Safety Measures for Phlebotomy Patient Identification

Phlebotomy Safety for All Ages Safety Measures for Phlebotomy Patient Identification

Phlebotomy Safety for All Ages Safety Measures for Phlebotomy Patient Identification Preparing Equipment and Supplies Preparing Patient Post Phlebotomy Care Safety tips for specific age groups Safety for the Phlebotomist

707 views • 42 slides
Medical Education and Patient Safety: A Patient-Doctor Dialogue Maeve OBeirne Vincent Dumez

Medical Education and Patient Safety: A Patient-Doctor Dialogue Maeve OBeirne Vincent Dumez

Medical Education and Patient Safety: A Patient-Doctor Dialogue Maeve OBeirne Vincent Dumez Outline 1. Review the definition and scope of patient safety: Including challenges in community based practice and aging patients 2. Discuss

652 views • 50 slides
Patient Safety & Healthcare Transparency Health Watch USA sm 2015 Patient Safety Conference

Patient Safety & Healthcare Transparency Health Watch USA sm 2015 Patient Safety Conference

Patient Safety & Healthcare Transparency Health Watch USA sm 2015 Patient Safety Conference Disclaimer All information presented at this conference is the express opinion of the presenters, moderators and/or participants regarding

630 views • 5 slides
Health IT and Patient Safety Sponsored by Health IT and Patient Safety Visit www.advisenltd.com

Health IT and Patient Safety Sponsored by Health IT and Patient Safety Visit www.advisenltd.com

Health IT and Patient Safety Sponsored by Health IT and Patient Safety Visit www.advisenltd.com at the end of this webinar to download: Copy of these slides Recording of todays webinar 2 Many Thanks to our Sponsors! Riskonnect

700 views • 30 slides
Scale Up 4 Safety Wessex Patient Safety Collaborative Connecting and sharing across Wessex to

Scale Up 4 Safety Wessex Patient Safety Collaborative Connecting and sharing across Wessex to

Scale Up 4 Safety Wessex Patient Safety Collaborative Connecting and sharing across Wessex to improve patient safety Wessex PSC is looking to partner with up to 5 teams in 17/18 to support patient safety scale up projects across Wessex Partners

544 views • 10 slides
GS1 STANDARD for PATIENT SAFETY Cholatip Pongskul, MD 2 3 Patient safety Magnitude Incidence

GS1 STANDARD for PATIENT SAFETY Cholatip Pongskul, MD 2 3 Patient safety Magnitude Incidence

1 GS1 STANDARD for PATIENT SAFETY Cholatip Pongskul, MD 2 3 Patient safety Magnitude Incidence Medication 1 in 10 43 Million $ 42 Billion As many as 1 in 10 Approximately 43 million Medication error cost an patients are harmed

446 views • 20 slides
Patient Safety 101 for Physicians Resident Core Curriculum Retreat March 5 & 7, 2012

Patient Safety 101 for Physicians Resident Core Curriculum Retreat March 5 & 7, 2012

Patient Safety 101 for Physicians Resident Core Curriculum Retreat March 5 & 7, 2012 Partners Patient Safety Leaders Outline Brief Introduction and Objectives Background and details of safety reporting Video Break into groups

434 views • 21 slides
Patient safety and healthcare associated infections Report from the Commission to the Council

Patient safety and healthcare associated infections Report from the Commission to the Council

Patient safety and healthcare associated infections Report from the Commission to the Council Council Recommendation 2009/C 151/01 Actions for Member States: Develop national policies on patient safety Inform and empower patients

191 views • 16 slides
How the new network of NHS Medication Safety Officers and Medical Device Safety Officers are

How the new network of NHS Medication Safety Officers and Medical Device Safety Officers are

How the new network of NHS Medication Safety Officers and Medical Device Safety Officers are affecting patient safety 9 th December 2015 April 2015 Dr David Gerrett Senior Pharmacist Patient Safety NHS E Agenda 1. Scene setting 2. MSO and

1.02k views • 43 slides
Building a Culture of Patient Safety in Todays Healthcare Environment A Discussion of the

Building a Culture of Patient Safety in Todays Healthcare Environment A Discussion of the

Building a Culture of Patient Safety in Todays Healthcare Environment A Discussion of the Tools and Healthcare Policies Driving Improvements in Patient Safety PANELISTS Paul Hiltz, MHA, FACHE Kelly E. Curry Discus uss toda odays

596 views • 24 slides
Moving into the Future: Promoting safe patient handling for worker and patient safety in

Moving into the Future: Promoting safe patient handling for worker and patient safety in

Moving into the Future: Promoting safe patient handling for worker and patient safety in Massachusetts Hospitals In healthcare, the primary ethical imperative is First, do no harm. Although we have traditionally applied this obligation

453 views • 26 slides
Ensuring patient safety is on our health data agenda A/Prof. Farah Magrabi Leader, Patient

Ensuring patient safety is on our health data agenda A/Prof. Farah Magrabi Leader, Patient

Ensuring patient safety is on our health data agenda A/Prof. Farah Magrabi Leader, Patient Safety Informatics Australian Institute of Health Innovation, Macquarie University Fellow, Assuring Autonomy International Programme University of York

788 views • 39 slides
OPTIMAL CONCEPT OF INFECTION CONTROL FOR PATIENT SAFETY IN HOSPITALS The French comitment Dr

OPTIMAL CONCEPT OF INFECTION CONTROL FOR PATIENT SAFETY IN HOSPITALS The French comitment Dr

Czech Presidency conference The microbial threat to patient safety in Europe France OPTIMAL CONCEPT OF INFECTION CONTROL FOR PATIENT SAFETY IN HOSPITALS The French comitment Dr Valrie SALOMON Head of Department E2 healthcare

406 views • 16 slides
A re-design evaluation from the real world Annemarie Hellebek MD phd Head of Patient Safety

A re-design evaluation from the real world Annemarie Hellebek MD phd Head of Patient Safety

A re-design evaluation from the real world Annemarie Hellebek MD phd Head of Patient Safety Capital Region of Denmark Assistant professor University of Copenhagen Consultant, The Danish Society for Patient Safety Member of EMA- NRG Group since

410 views • 11 slides
Helping Leaders Blink Correctly Split-second decisions have patient safety implications. than

Helping Leaders Blink Correctly Split-second decisions have patient safety implications. than

Patient Safety Helping Leaders Blink Correctly Split-second decisions have patient safety implications. than esthetic judgment. Now I real- problematic. It is not uncommon, for In 1983, the J. Paul Getty Museum in California was approached

79 views • 3 slides
Never Events EU Patient Safety Exchange 2013 Definition Never Events are defined as serious,

Never Events EU Patient Safety Exchange 2013 Definition Never Events are defined as serious,

Never Events EU Patient Safety Exchange 2013 Definition Never Events are defined as serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented by healthcare

306 views • 12 slides
Patient Adherence & Patient Safety Bernard Vrijens, PhD Chief Science Officer, WestRock

Patient Adherence & Patient Safety Bernard Vrijens, PhD Chief Science Officer, WestRock

October 2015 Patient Adherence & Patient Safety Bernard Vrijens, PhD Chief Science Officer, WestRock Healthcare Associate Professor of Biostatistics University of Lige, Belgium Adherence is Key to Therapeutic Success Effective

579 views • 16 slides
The business case of unsafe The business case of unsafe care care 16 billion injections a

The business case of unsafe The business case of unsafe care care 16 billion injections a

Health care causes harm to patients Better knowledge for safer care GCC Conference on Patient Safety 6-8 April 2009 Research for Patient Safety Itziar Larizgoitia Head Research & knowledge Management Patient Safety WHO The business case

318 views • 4 slides
WHATS NEXT? NEXT STEPS TO IMPLEMENTING THE OB HEMORRHAGE PATIENT SAFETY BUNDLE GLOBAL AIM

WHATS NEXT? NEXT STEPS TO IMPLEMENTING THE OB HEMORRHAGE PATIENT SAFETY BUNDLE GLOBAL AIM

WHATS NEXT? NEXT STEPS TO IMPLEMENTING THE OB HEMORRHAGE PATIENT SAFETY BUNDLE GLOBAL AIM WEST VIRGINIA COLLABORATING PARTNERS WILL ENGAGE ALL OBSTETRICAL UNITS/FACILITIES IN THE AIM OBSTETRICAL HEMORRHAGE PATIENT SAFETY INITIATIVE.

436 views • 12 slides

More recommend