What Does Patient Safety Have to Do with Medical Errors? DR. NADIA AL-KANDARY Head of Pathology Section Kuwait Ministry of Interior Forensic Medicine Department
As part of our extensive program and with CPD hours awarded based on actual time spent learning, credit hours are offered based on attendance per session, requiring delegates to attend a minimum of 80% of a session to qualify for the allocated CPD hours. • Less than 80% attendance per session = 0 CPD hours • 80% or higher attendance per session = full allotted CPD hours ME Forum 2019 Orientation Total CPD hours for the forum are awarded based on the sum of CPD hours earned from all individual sessions. Conflict of Interest The speaker(s) or presenter(s) in this session has/have no conflict of interest or disclosure in relation to this presentation.
Medical Errors – the New View MEDICAL ERRORS ARE SYMPTOMS OF DEEPER TROUBLE
DO YOU REMMEBER PATIENT: X Y Z?
Medical Errors Is a preventable adverse effect of care, whether or not it is evident or harmful to the patient. Medical Malpractice Occurs when a hospital, doctor or other health care • professional, through a negligent act or omission, causes an injury to a patient • Elements of 4 “D’s “: - Duty. - Deviation. - Direct Causation. - Damage.
Measuring Medical Errors in Health Care • CDCP relies on death certificate. • CDCP doesn’t consider ME as a cause of death.
Achieving a 99% level of quality means accepting a 1% error rate
Medical Malpractice claims are dealt with at the Forensic Medicine Authority. • By evaluating : - Access patient clinical records. - External and Internal examination (Autopsy).
Medical Errors • Delayed or missed diagnoses • Lost, delayed, or failures to follow up reports • Medication errors • Retention of foreign object following • Wrong side surgery surgery • Wrong patient surgery • Contamination of drugs, equipment • Equipment failure • Intravascular air embolism • Patient identity • Failure to treat neonatal • Transfusion errors hyperbilirubinemia • Mislabeled specimen • Stage lll or lV pressure ulcers acquired • Patient falls after admission • Laboratory errors • Wrong gas delivery • Radiology errors • Retention of foreign body • Procedural error 10
5 common patient safety rules we see being violated by hospitals • Patient information and labeling Poor Communication • • Not following up on a test that was ordered . • Not consulting with the appropriate specialist. • Relying on other staff
Strategies to reduce medical errors • Adopt a structure for handoff conversations
Strategies to reduce medical errors • Following protocol is crucial to prevent mistakes.
Strategies to Reduce Medical Errors • Get pharmacists more directly involved in patient treatment .
Strategies to Reduce Medical Errors • Work to reduce infections .
Strategies to Reduce Medical Errors • Avoid diagnostic error .
Strategies to Reduce Medical Errors • Make electronic health records (EHR) systems
Strategies to Reduce Medical Errors • Proper reporting system for errors
Strategies to Reduce Medical Errors • A balanced workload
A Culture of Safety 31,033 Pilots, Surgeons, Nurses and Residents Surveyed* *Sexton JB, Thomas EJ, Helmreich RL, Error, stress and teamwork in medicine and aviation: cross sectional surveys. BrMedJour, 3-18-2000. % Positive Responses from: Pilots Medical Is there a negative impact of fatigue on your 74% 30% performance? Do you reject advice from others? 3% 45% Is error analysis system-wide? 100% 30% Do you think you make mistakes? 100% 30% Easy to discuss/report mistakes? 100% 56% 20
Association Between Evening duty and Higher Mortality Rates in the Pediatric Intensive Care Unit Yeseli Arias, Doublas S. Taylor, and James P. Marcin Pediatrics 2004; 113: 530-534 4.5 4 4.1 3.9 3.5 3 2.5 Day 2 1.8 Night 1.9 1.5 1.2 1 0.9 0.9 0.5 0.4 0 Sepsis Cardiac Cardiac Time of Disease Arrest Birth*
CONCLUSION “…there are some patients we cannot help, there are none we can harm...” --Dr. Ken Stahl
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