Patient Safety

Question 1

What does patient safety encompass?

Answer 1

• preventing errors
• learning from errors which do occur
• built upon a culture of safety which involves health care professional, organisations and patients

Question 2

How to prevent errors?

Answer 2

Surgical Safety Checklist

Question 3

Checklist before induction of anaesthesia?

Answer 3

Confirm patient identity, site, procedure, consent
Site Marked
Anesthesia safety check
Pulse oximeter on patient and functioning
Allergies?
Is airway difficult?
Risk of >500ml blood loss?

SITE

Question 4

Checklist before skin incision?

Answer 4

Confirm team members introduced themselves - name and role
Surgeon, anesthetist and nurse verbally confirm patient, site, procedure
Anticipate critical events
Antibiotic prophylaxis given

SPEAK UP

Question 5

Checklist before patient leaves operating room?

Answer 5

Recorded name of procedure
Instruments, sponge, needle all counted
Label specimen
Any equipment problems
Reviewed key concerns for recovery and management of patient

SPONGES

Question 6

NatSSIPs

Answer 6

National Safety Standards for Invasive Procedures

- site is marked!!

Question 7

Example of error prevention?

Answer 7

Wristbands - showing allergy

Question 8

Example of improving safety when things do go wrong?

Answer 8

Fail safe mechanisms

Self inflating bag/mask valves in case entire machine breaks

Question 9

Error reduction stratgies

Answer 9

Improving human performance = cognitive aids, double checks, reduce interruptions, enhance teamwork
Reducing latent error (due to systems/routines = provide visual cues, decrease look alike/sound alike drugs/equipment, simplify
Maximize safety with technology & improve human responses to threats = fail safe inflating bag, call bells, USS guided insertions, AB propphylaxis before surgery, robotics in surgery

Question 10

How to learn from errors?

Answer 10

• report them regardless = DATIX (reporting system)
• investigated
• root cause analysis
• preventative measures put in place

Question 11

Categories of errors

Answer 11

Incidents
Serious Incidents
near misses
Near events

Question 12

never Events

Answer 12

Serious largely preventable patient safety incidents

Should not occur if available preventative measures have been implemented

Question 13

Examples of never events

Answer 13

Surgical = wrong site surgery
General = misplacement of naso/oro gastric tubes
Unintentional connection of patient requiring oxygen to an air flowmeter

Question 14

Example of prevention of errors on the wards?

Answer 14

Checklists

Protocols