Euroanesthesia 2025 Flashcards
(24 cards)
1
Good afternoon!
I would like to thank the Euroanesthesia Organization Committee and the NASC for the kind invitation to discuss the topic “Enhancing Patient Safety through Patient Safety Education and Organizational Learning
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Regarding my disclosures: I’m Instructor of Advanced Patient Safety Course in Portugal.
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Why is Patient Safety so important?
We have data that shows patient safety should be a major concern:
In 1999 the report “To err is human estimate that between 44,000–98,000 annual U.S. deaths were associated with medical error”
Although debated, Makary’s 2016 publication argued that medical error could be the third leading cause of death in the U.S.
According to the WHO (2024), unsafe care results in over 3 million deaths worldwide each year — and remarkably, half of this harm is preventable.
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- I asked ChatGPT to compare the estimated number of deaths from COVID-19 and from medical error, between 2020 and 2025.
- And this is the result. This is just an illustrative comparison, not a direct scientific analysis.
- It looks like that the numbers are very close. COVID-19 deaths are decreasing but deaths related to medical error are not decreasing.
- Are we professionals, hospitals, and governments as committed to patient safety as we were to COVID-19?
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Anaesthesiology should be proud of its pioneering role in patient safety and in implementing measures to reduce harm related to anaesthesia. Three key milestones in this journey were the publication of the Helsinki Declaration, the paper Ten Years of the Helsinki Declaration and now Helsinki Declaration2.0”
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Patient safety is a multi-dimensional process, today I will only discuss two aspects of it: Patient Safety Education and Organizational Learning
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Patient safety education is one of the key principles of the Helsinki Declaration, as well as Helsinki Declaration 2.0, which was launched last Sunday.
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The WHO, in the Global Patient Safety Action Plan 2021–2030, also define health worker education as a strategic objective.
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Patient safety education has been implemented at undergraduate level in some universities, as well as in some anesthesiology residency programs and in continuing medical education or recertification.
Some countries, such as Australia, have developed national frameworks that recommend patient safety training for all healthcare professionals.
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Patient safety education has been implemented through different educational models.
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- There are studies showing that patients safety education can improve knowledge, skills, and attitudes related to safety—
- Educational interventions can and also improve patient safety culture among healthcare professionals.
- However, we need more evidence to support the beneficial impact on patient outcomes.
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Unfortunately, training in patient safety has not yet been universally implemented
According to WHO
* Only 20% of countries have incorporated patient safety into their undergraduate and postgraduate professional education
* Only 25% of countries provide specialized in-service training courses on patient safety
* And only 14% of countries report sufficient training capacity.
These are global numbers, the situation in Europe is probably slight better.
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- Educating healthcare professionals is essential, but it is also crucial to promote organizational learning, which means
- creating systems that enable institutions to learn from both their mistakes and their successes.
- Healthcare organizations with strong learning cultures exhibit higher levels of care coordination and improved patient outcomes
- Helsinki Declaration promotes this vision by recommending that all institutions prepare annual safety reports, participate in national audits, and promote the standardization of good practices
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Organizational learning implies that institutions:
1. Adopt a just culture, where professionals feel safe to report incidents without fear of unfair punishment. Open communication and interprofessional collaboration are encouraged
2. Collect data on safety (adverse events, near-misses, process indicators),
3. Analyze them systematically,
4. And adjust practices based on these lessons.
5. Confirm changes work
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There are some barriers to Organizational learning:
* Blame Culture
* Lack of Psychological Safety
* Poor Leadership Commitment
* Ineffective Incident Reporting Systems
* Inadequate Feedback Loops
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The ESAIC Patient Safety and Quality Committee is doing an excellent job in developing educational activities for patient safety training
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So far, this committe has created three different courses.
* The Essential Patient Safety Course, an online course available on ESAIC Academy
* The Advanced Patient Safety Course, that I will talk about next.
* The Patient Safety and Quality Masterclass, an onsite 3-day course.
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The Advanced Patient Safety Course is a live one day and half course that teaches important topics like patient safety tools, human factors and incident analyses.
It uses interactive group work and videos of key scenarios, followed by debriefing, to bring examples of critical situations to life.
The participants receive in advance a manual with great content and resources.
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This course is an excellent tool to educate professionals about patient safety because it has a great format and strong scientific content. Additionally, it can be implemented by national societies, enabling the exponential training of anesthesiologists and other professionals. In this way, the PSQC is empowering national societies.
After attending the APSC, potential instructors take a Train-the-Trainer course. Following an agreement with the national society, the course can then be launched in the country. In this way, a standardized course is implemented at the national level, in the local language, with the recognition of the ESAIC.
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Last March, we held the first edition of the APSC in Portugal, with the support of the Portuguese Society of Anesthesiology, which believed in the project from the very beginning.
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The APSC is being implemented in different countries across Europe and South America.
The APSC is being implemented in other countries across Europe.
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ESAIC is promoting other initiatives to improve the quality of care, patient safety and organizational learning, such as the PRiPSAIC and SAFEST projects.
PRiPSAIC focuses on establishing peer-review networks between hospitals to foster shared learning and continuous improvement, based on the principles of the Helsinki Declaration.
The SAFEST project aims to harmonize perioperative care standards by developing standardized practices, assessment tools, and educational resources to reduce adverse events and strengthen the safety culture.
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To finalize my presentation, I would like to reinforce that:
* Medical errors remain a major cause of preventable harm in healthcare
* Education is essential to improving patient safety
* Organisational learning turns experience into lasting improvements
* The Advanced Patient Safety Course is a powerful tool for training the anaesthesia community
* PRiPSAIC and SAFEST projects can support institutions in improving safety and quality of care.
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I want to thank to Prof. Benedikt Preckel and Prof. Daniel Arnal
