Safety Flashcards
(200 cards)
1
Q
Where does patient safety happen?
A
The ultimate locus of patient safety is the microsystem, which is the immediate environment in which care occurs, such as the operating room or emergency department.
2
Q
What is the ‘sharp end’ in patient safety?
A
The ‘sharp end’ refers to the patient-caregiver interactions where failures of safety emerge and where patients are harmed.
3
Q
What is the relationship between microsystems and patient safety?
A
Patient safety is irreducibly a matter of systems, and the microsystem is where the successes or failures of all systems to ensure safety converge.
4
Q
How does unpredictability affect microsystems?
A
The microsystem is inherently unpredictable and can be influenced by other microsystems, leading to unpredictable outcomes.
5
Q
What is high-reliability design?
A
High-reliability design is the fundamental mechanism for achieving patient safety, integrating all components of health care delivery into a reliable system.
6
Q
What does complexity theory say about high-reliability design?
A
Complexity theory notes that open, interacting systems will produce chaos or unpredictable events, but high-reliability designs remain resilient in such situations.
7
Q
What is the ‘Swiss cheese’ model?
A
The ‘Swiss cheese’ model of accident causation describes a multilayered system where failures within each layer must align for an error to occur.
8
Q
What are error traps in health care?
A
Error traps are unpredictable situations in which errors are highly likely, highlighting the complexity and open nature of health care delivery.
9
Q
Who has pioneered practical approaches to safety systems design?
A
Practical approaches have been pioneered by the Institute for Healthcare Improvement (IHI), the Agency for Healthcare Research and Quality (AHRQ), and the WHO’s World Alliance for Patient Safety.
10
Q
What is a unique feature of illness progression?
A
Illness care begins when something has already gone wrong, and failure to provide the correct intervention can cause harm to the patient.
11
Q
What can a missed diagnosis of meningococcal meningitis result in?
A
It usually results in patient death.
12
Q
What does patient safety discipline acknowledge?
A
It acknowledges the need to include harm due to omission of action, as well as harm due to actions taken.
13
Q
What makes systems design in health care a unique challenge?
A
The vast diversity of possible etiologies and manifestations of illness.
14
Q
How can systems be designed to meet patient needs?
A
Most conditions are common, allowing for optimal design, with options for tailored treatment when necessary.
15
Q
What is patient safety dependent on?
A
It is dependent on open learning and a culture of openness to all relevant perspectives.
16
Q
What does patient safety espouse?
A
Continuous cycles of learning, reporting of adverse events, dissemination of lessons learned, and establishing trusted cultures.
17
Q
What is the goal of patient safety pioneers?
A
To move ‘beyond blame’ and achieve a culture trusted to be just.
18
Q
What do patient safety advocates reject?
A
They reject the traditions of social standing and privileged knowledge that shield practitioners from accountability.
19
Q
What does patient safety embrace?
A
Organizational and personal accountability while moving beyond blame.
20
Q
What is essential to the concept of patient safety?
A
Trustworthiness.
21
Q
Why is the health care system designed for patient safety considered trustworthy?
A
It holds itself accountable to applying safety sciences optimally, despite the inevitability of errors.
22
Q
What does patient safety prevent?
A
Avoidable adverse events by focusing on systems and interactions.
23
Q
Where does patient safety happen?
A
The ultimate locus of patient safety is the microsystem, the immediate environment in which care occurs.
24
Q
What is patient safety?
A
Patient safety is a relatively new discipline within the health care professions, focusing on reducing risks and harm to patients during health care delivery.
25
What disciplines contribute to patient safety methods?
Patient safety methods come largely from cognitive psychology, human factors engineering, and organizational management science.
26
How does patient safety relate to health care quality?
Patient safety is a subject within health care quality, emphasizing the need for reliable systems in health care.
27
What is the nature of patient safety in relation to systems design?
Patient safety is a property that emerges from systems design and must be an attribute of the health care system.
28
What are the two conditions of risk in health care?
The first condition of risk is illness, and the second is the therapeutic intervention.
29
What is the significance of therapeutic risk?
Therapeutic risk can be significant, such as during complex surgeries like cardiac transplantation.
30
What does patient safety demand in terms of system design?
Patient safety demands the design of systems to make risky interventions reliable.
31
What are the two tenets of complexity theory relevant to patient safety?
1. The greater the complexity of the system, the greater the propensity for chaos. 2. In open, interacting systems, unpredictable events will happen.
32
What is the goal of high-reliability design in health care?
High-reliability design aims to create systems that can withstand both predictable and unpredictable failures.
33
What components are included in safety systems?
Safety systems include the design of materials, procedures, environment, training, and the culture among people operating in the system.
34
How do leaders of high-reliability organizations view adverse events in medicine?
They often view the level of adverse events in medicine as so high that they consider the health industry to be in a state of chaos.
35
What is a unique feature of patient care?
Patient care is highly personal and often requires health care workers to cross significant personal boundaries.
36
What do professional ethics in health care protect?
Professional ethics protect patient integrity, including confidentiality and physical privacy.
37
What is a conflict that arises in patient safety designs?
There can be a conflict between the need for transparency and vigilance for optimal patient care and the need to protect patient privacy.
38
What is a unique aspect of illness progression?
Illness naturally progresses, which is a defining characteristic of patient care.
39
What is patient safety?
Patient safety is a relatively new discipline within the health care professions, focusing on preventing harm to patients during health care delivery.
40
What disciplines contribute to patient safety methods?
Patient safety methods come largely from cognitive psychology, human factors engineering, and organizational management science.
41
How is patient safety related to health care quality?
Patient safety is a subject within health care quality, emphasizing the need for reliable systems in health care.
42
What is the nature of risk in health care?
Illness presents the first condition of risk, while therapeutic interventions represent the second condition of risk.
43
What is the relationship between risk and safety in therapeutic interventions?
Risk and safety are flip sides of the therapeutic coin, necessitating reliable system designs for risky interventions.
44
What are the two tenets of complexity theory relevant to patient safety?
1. Greater system complexity increases the propensity for chaos. 2. Unpredictable events will occur in open, interacting systems.
45
What do safety systems in health care include?
Safety systems include the design of materials, procedures, environment, training, and the culture among people operating in the system.
46
How do leaders of high-reliability organizations view adverse events in health care?
They consider the level of adverse events in medicine to be so high that many view the health industry as existing in a state of chaos.
47
What is high-reliability design?
High-reliability design is a concept that, while not originally developed for health care, shares essential features with health care's complex and unpredictable nature.
48
What is a unique feature of patient care?
Patient care is highly personal, requiring health care workers to cross significant personal boundaries to provide care.
49
What ethical considerations are involved in patient care?
Health professions have developed codes of professional ethics to protect patient integrity, including confidentiality and physical privacy.
50
What is a challenge in balancing patient safety and care?
The need for transparency and vigilance for optimal patient care can conflict with the restrictions needed to protect patient integrity.
51
What is the natural progression of illness?
By definition, illness progresses naturally, which is a unique feature that affects patient safety considerations.
52
What is patient safety?
Patient safety is a relatively new discipline within the health care professions, focusing on preventing harm to patients during health care delivery.
53
What disciplines contribute to patient safety methods?
Patient safety methods come largely from cognitive psychology, human factors engineering, and organizational management science.
54
How is patient safety related to health care quality?
Patient safety is a subject within health care quality, emphasizing the need for reliable systems in health care.
55
What is the nature of risk in health care?
Illness presents the first condition of risk, while therapeutic interventions represent the second condition of risk.
56
What is the relationship between risk and safety in therapeutic interventions?
Risk and safety are flip sides of the therapeutic coin, necessitating reliable system designs for risky interventions.
57
What are the two tenets of complexity theory relevant to patient safety?
1. Greater system complexity increases the propensity for chaos. 2. Unpredictable events will occur in open, interacting systems.
58
What do safety systems in health care include?
Safety systems include the design of materials, procedures, environment, training, and the culture among people operating in the system.
59
How do leaders of high-reliability organizations view adverse events in health care?
They consider the level of adverse events in medicine to be so high that many view the health industry as existing in a state of chaos.
60
What is high-reliability design?
High-reliability design is a concept that, while not originally developed for health care, shares essential features with health care's complex and unpredictable nature.
61
What is a unique feature of patient care?
Patient care is highly personal, requiring health care workers to cross significant personal boundaries to provide care.
62
What ethical considerations are involved in patient care?
Health professions have developed codes of professional ethics to protect patient integrity, including confidentiality and physical privacy.
63
What is a challenge in balancing patient safety and care?
The need for transparency and vigilance for optimal patient care can conflict with the restrictions needed to protect patient integrity.
64
What is the natural progression of illness?
By definition, illness progresses naturally, which is a unique feature that affects patient safety considerations.
65
What is the definition of safety according to the Institute of Medicine (IOM)?
Safety is defined as 'freedom from accidental injury.'
66
What challenge exists in defining patient safety?
The challenge lies in distinguishing safety from quality, which some see as important while others dismiss it as semantics.
67
What was the widely accepted definition of quality adopted by the IOM in 1998?
'Quality of care is the degree to which health care services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.'
68
What are the three categories of health care quality problems?
The three categories are underuse, overuse, and misuse.
69
How is misuse defined in the context of health care?
Misuse is defined as the preventable complications of treatment.
70
What observation did Leape and Berwick make regarding patient safety?
They observed that the lines between overuse, underuse, and misuse categories have blurred, noting that both underuse and overuse can place patients at risk for injury.
71
What did the National Patient Safety Foundation identify as the key property of safety?
The key property of safety emerges from the proper interaction of components of the health care system.
72
What is the goal of patient safety as defined by the National Patient Safety Foundation?
'The avoidance, prevention, and amelioration of adverse outcomes or injuries stemming from the process of care.'
73
How is patient safety defined in this document?
Patient safety is a discipline in the health care sector that applies safety science methods toward the goal of achieving a trustworthy system of health care delivery.
74
What does the definition of patient safety acknowledge?
It acknowledges that patient safety is both a way of doing things and an emergent discipline.
75
Why does the field of patient safety exist?
It exists in response to evidence that adverse medical events are widespread and preventable, aiming to minimize adverse events and eliminate preventable harm.
76
What is the definition of safety according to the Institute of Medicine (IOM)?
Safety is defined as 'freedom from accidental injury.'
77
What challenge exists in defining patient safety?
The challenge lies in distinguishing safety from quality, which some see as important while others dismiss it as semantics.
78
What was the widely accepted definition of quality adopted by the IOM in 1998?
'Quality of care is the degree to which health care services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.'
79
What are the three categories of health care quality problems?
The three categories are underuse, overuse, and misuse.
80
How is misuse defined in the context of health care?
Misuse is defined as the preventable complications of treatment.
81
What observation did Leape and Berwick make regarding patient safety?
They observed that the lines between overuse, underuse, and misuse categories have blurred, noting that both underuse and overuse can place patients at risk for injury.
82
What did the National Patient Safety Foundation identify as the key property of safety?
The key property of safety emerges from the proper interaction of components of the health care system.
83
What is the goal of patient safety as defined by the National Patient Safety Foundation?
'The avoidance, prevention, and amelioration of adverse outcomes or injuries stemming from the process of care.'
84
How is patient safety defined in this document?
Patient safety is a discipline in the health care sector that applies safety science methods toward the goal of achieving a trustworthy system of health care delivery.
85
What does the definition of patient safety acknowledge?
It acknowledges that patient safety is both a way of doing things and an emergent discipline.
86
Why does the field of patient safety exist?
It exists in response to evidence that adverse medical events are widespread and preventable, aiming to minimize adverse events and eliminate preventable harm.
87
What ushered in the managed care era?
Rising and apparently uncontrollable health care costs, coupled with increasing evidence of poor quality, ushered in the managed care era, along with demands from the public for accountability.
88
What raised troubling questions about health care?
Increased media exposure of preventable medical errors raised troubling questions that propelled a search for new solutions.
89
What was the significance of Leape's earlier publication?
Leape's earlier publication of the theoretical possibility of applying industrial human-factors engineering concepts to health care provided a new type of thinking.
90
What was the first conference on patient safety?
The first conference on patient safety and systems error was held at the Annenberg Center for Health Sciences in 1996.
91
What did thought leaders begin to rethink?
Thought leaders began to carve a new way of understanding risk, reaffirming relationships with patients, and addressing shocking realities presented by epidemiologic studies.
92
What improvements did anesthesiology make a decade earlier?
Anesthesiology made substantial improvements by applying systems thinking translated from methods used in aviation and mechanical engineering.
93
What was a key focus of early attempts at systems change?
Early attempts at systems change revealed dysfunctional relationships between clinicians and other workers.
94
What became foundational for the new field of patient safety?
Training in teamwork became a foundational building block for the new field of patient safety.
95
How did the discipline of patient safety redefine health care delivery?
The discipline of patient safety rejected the concept of health care delivery as an exclusive dominion of the medical profession over the patient-physician relationship.
96
What does patient safety encompass?
Patient safety includes patient-centered care, the biomedical model, interdisciplinary teams, families, and the technical and administrative aspects of health care delivery.
97
Why is defining patient safety important?
As the intellectual history of patient safety developed, it became increasingly important to define patient safety and examine different assumptions.
98
How did the Institute of Medicine define safety?
The Institute of Medicine defined safety as 'freedom from accidental injury.'
99
What is the current status of defining patient safety as a discipline?
Patient safety as a discipline or field of inquiry and action has not been fully defined to date in the major consensus statements.
100
What was essential for the development of effective medical treatments?
The scientific method was essential in that development.
101
What is the three-phase approach to establishing the efficacy and safety of new medical therapies?
Phase 1: clinical trials to assess safety; Phase 2: clinical trials to ascertain efficacy; Phase 3: trials to compare it with another standard intervention.
102
What was critical to the process of establishing medical efficacy and safety?
The dependence on the randomized clinical trial as the touchstone of the scientific method.
103
How did society's perception of medicine change over time?
Society recognized that medicine merited its standing as a profession with specialized expertise.
104
What changes occurred in medical education due to the growth of medical sciences?
The early apprenticeship model was supplemented by requirements for didactically acquired knowledge before the apprenticeship.
105
What role did professional groups like ACGME and the Joint Commission play?
They served quasi-government oversight and public protection roles in certifying hospitals and health care delivery systems.
106
What challenge did the medical field face regarding accountability?
The realization that health care needed to be accountable for learning from error was harder to grapple with.
107
What marked the transition from the industrial era to the service industry era in health care?
Beginning in the first half of the 20th century, the industrial era phased into the service industry era.
108
What was the primary focus of the health care paradigm during the 20th century?
The paradigm remained focused on the patient-physician relationship and the therapy's point of application.
109
What issues prompted the shift to the managed care era?
Rising health care costs and increasing evidence of poor quality.
110
What was the focus of earlier forms of systems thinking in medicine?
Earlier forms of systems thinking focused on the biologic systems within the individual patient, rather than on care and interactions between individuals in the environment of care.
111
What are two examples of earlier medical concepts?
The notion of humors and the understanding of the circulatory system are two examples from the period prior to the modern scientific era.
112
How did the scientific method influence systems thinking in medicine?
As the scientific era began, systems thinking within physiology continued, helping clinicians adopt a systems understanding of health care delivery.
113
What are blunt-end factors in health care?
Blunt-end factors were initially thought of as organizational policies and processes that shaped individual behavior at the sharp end of service.
114
What extra-organizational factors influence health care?
Extra-organizational factors include regulators, payers, insurance administrators, economic policymakers, and technology suppliers.
115
How should health care be viewed in terms of systems?
Health care must be seen as an open system, with policy considered a feature of that system.
116
What is the significance of sharing information about medical errors?
Sharing information about medical errors is essential for effective patient safety outcomes and can lead to better industry-wide lessons.
117
What cultural change is encouraged in health care organizations?
There is an encouragement to build high-reliability organizations that refrain from assigning blame for mistakes and incentivize learning.
118
What ethical principle is central to the call for safety in health care?
The central medical professional imperative is to 'above all, do no harm,' emphasizing the value of nonmalfeasance.
119
What historical challenge did early Western medical traditions face?
Early Western medical traditions faced the challenge of securing societal trust while keeping medical knowledge secret and dealing with dubious practices.
120
What was the primary method to secure trust in early medicine?
The primary method was to root out charlatans amidst dubious medical methods.
121
What major shift occurred in patient safety thinking?
The understanding of errors shifted from a single cause, legalistic framework to a systems engineering design framework.
122
What was the traditional assumption about errors in health care?
The traditional approach assumed that well-trained, conscientious practitioners do not make errors.
123
What toxic effect did the blame culture have in health care?
Practitioners rarely revealed mistakes, leading to low reporting and making learning from errors nearly impossible.
124
What realization prompted a change in thinking about patient safety?
The realization that adverse events often occur because of system breakdowns, not simply individual ineptitude.
125
What are 'latent' errors according to James Reason?
'Latent' errors are upstream defects in the design of systems, organizations, management, training, and equipment.
126
What is a 'forcing function' in system design?
A forcing function is a design characteristic that makes error impossible, such as incompatible connectors in medical equipment.
127
How can errors in health care be reduced according to thought leaders?
Errors can be reduced by redesigning systems and processes using human factors principles, including standardization and simplification.
128
What was a significant change in the 1990s regarding medical injury?
Medical injury was acknowledged as occurring far more often than previously realized, with most deemed preventable.
129
What are some examples of systems changes in health care?
Examples include using better intravenous pumps and training doctors and nurses to work better in teams.
130
What did the shift to viewing health care as a system entail?
It involved applying engineering design concepts to health care delivery.
131
What is patient safety?
Patient safety is a discipline in health care that applies safety science methods to achieve a trustworthy system of health care delivery.
132
What does patient safety aim to minimize?
Patient safety aims to minimize the incidence and impact of adverse events.
133
What is the essential focus of action in patient safety?
The essential focus of action in patient safety is the microsystem.
134
Who are the practitioners of patient safety?
Practitioners of patient safety include all health care workers, patients, and advocates.
135
What are the four domains of patient safety?
The four domains of patient safety are recipients of care, providers, therapeutics, and methods.
136
What realization about hospitals emerged in the 1990s?
The realization was that hospitals, despite their ability to cure illness, were not safe places for healing.
137
What has contributed to the global awareness of patient safety?
The World Health Organization's World Alliance for Patient Safety has contributed to global awareness.
138
What is a fundamental requirement for adopting new patient safety approaches?
A clear articulation of its premises and manifestations is a fundamental requirement.
139
What does the paper aim to provide regarding patient safety?
The paper aims to offer a definition, description, and model of patient safety.
140
What is the goal of the Joint Commission?
The goal is to improve patient safety and work towards zero harm in healthcare.
141
What does the Joint Commission study?
They study emerging patient safety issues and implement evidence-based methods to address them.
142
What resources does the Joint Commission offer?
They offer best practices, reference materials, and resources related to patient safety.
143
What is the Speak Up program?
An award-winning program that promotes patient safety and has reached over 40 countries.
144
What are National Patient Safety Goals?
Goals set by the Joint Commission to enhance patient safety in healthcare settings.
145
What are Sentinel Events?
Unexpected events in healthcare that result in death or serious physical or psychological injury.
146
What should you do regarding cookies on the Joint Commission website?
You can change your cookie settings or read the Privacy and Cookie Statement for more information.
147
What is the primary focus of The Joint Commission?
The Joint Commission focuses on health care quality and patient safety.
148
How long has The Joint Commission been in operation?
The Joint Commission has been in operation for more than 60 years.
149
How many health care organizations and programs has The Joint Commission accredited or certified?
The Joint Commission has accredited or certified nearly 21,000 health care organizations and programs.
150
When was The Joint Commission established?
The Joint Commission was established in 1951.
151
What is the approach of The Joint Commission in achieving its milestones?
The Joint Commission reaches its milestones gradually, year by year, one facility at a time.
152
What was adopted by the Seventy-second World Health Assembly in May 2019?
Resolution WHA72.6 on 'Global action on patient safety' was adopted.
153
What is the purpose of World Patient Safety Day?
World Patient Safety Day, observed annually on 17 September, aims to improve patient safety through global solidarity and action.
154
What is the goal of the Global Patient Safety Action Plan 2021-2030?
The goal is to achieve the maximum possible reduction in avoidable harm due to unsafe health care globally.
155
What does the Global Patient Safety Action Plan envision?
It envisions a world in which no one is harmed in health care, and every patient receives safe and respectful care, every time, everywhere.
156
What is the WHO Flagship initiative 'A Decade of Patient Safety 2021-2030'?
It is a transformative initiative to guide and support strategic action on patient safety at global, regional, and national levels.
157
What does the WHO's Director-General need to develop according to the resolution WHA72.6?
A global patient safety action plan with the involvement of WHO Member States, partners, and other relevant stakeholders.
158
What are the factors leading to patient harm in health care?
Factors include system and organizational factors, technological factors, human factors and behavior, patient-related factors, and external factors.
159
What are system and organizational factors?
These factors include the complexity of medical interventions, inadequate processes and procedures, disruptions in workflow and care coordination, resource constraints, inadequate staffing, and competency development.
160
What are technological factors?
Technological factors involve issues related to health information systems, such as problems with electronic health records or medication administration systems, and misuse of technology.
161
What are human factors and behavior?
These include communication breakdown among health care workers, ineffective teamwork, fatigue, burnout, and cognitive bias.
162
What are patient-related factors?
Patient-related factors consist of limited health literacy, lack of engagement, and non-adherence to treatment.
163
What are external factors affecting patient safety?
External factors include the absence of policies, inconsistent regulations, economic and financial pressures, and challenges related to the natural environment.
164
What is the system approach to patient safety?
It emphasizes that most mistakes leading to harm are due to system or process failures rather than individual health care workers' practices.
165
What is required for understanding errors in medical care?
A shift from a blaming approach to a system-based thinking is required, recognizing poorly designed system structures and processes.
166
What constitutes a safe health system?
A safe health system prioritizes safety through leadership commitment, safe working environments, improved competencies, patient engagement, and incident reporting.
167
What are the benefits of investing in patient safety?
Investing in patient safety positively impacts health outcomes, reduces costs related to patient harm, improves system efficiency, and restores community trust in health care.
168
What is the WHO response to patient safety?
The WHO advocates for global action on patient safety.
169
What are the factors leading to patient harm in health care?
Factors include system and organizational factors, technological factors, human factors and behavior, patient-related factors, and external factors.
170
What are system and organizational factors?
These factors include the complexity of medical interventions, inadequate processes and procedures, disruptions in workflow and care coordination, resource constraints, inadequate staffing, and competency development.
171
What are technological factors?
Technological factors involve issues related to health information systems, such as problems with electronic health records or medication administration systems, and misuse of technology.
172
What are human factors and behavior?
These include communication breakdown among health care workers, ineffective teamwork, fatigue, burnout, and cognitive bias.
173
What are patient-related factors?
Patient-related factors consist of limited health literacy, lack of engagement, and non-adherence to treatment.
174
What are external factors affecting patient safety?
External factors include the absence of policies, inconsistent regulations, economic and financial pressures, and challenges related to the natural environment.
175
What is the system approach to patient safety?
It emphasizes that most mistakes leading to harm are due to system or process failures rather than individual health care workers' practices.
176
What is required for understanding errors in medical care?
A shift from a blaming approach to a system-based thinking is required, recognizing poorly designed system structures and processes.
177
What constitutes a safe health system?
A safe health system prioritizes safety through leadership commitment, safe working environments, improved competencies, patient engagement, and incident reporting.
178
What are the benefits of investing in patient safety?
Investing in patient safety positively impacts health outcomes, reduces costs related to patient harm, improves system efficiency, and restores community trust in health care.
179
What is the WHO response to patient safety?
The WHO advocates for global action on patient safety.
180
What percentage of patients experience medication-related harm in health care?
Medication-related harm affects 1 out of every 30 patients in health care.
## Footnote
More than a quarter of this harm is regarded as severe or life threatening.
181
What percentage of preventable patient harm is reported in surgical settings?
10% of preventable patient harm in health care was reported in surgical settings.
## Footnote
Most adverse events occur pre- and post-surgery.
182
What is the global rate of health care-associated infections?
The global rate of health care-associated infections is 0.14%, increasing by 0.06% each year.
## Footnote
These infections result in extended hospital stays, long-standing disability, and avoidable deaths.
183
What is sepsis?
Sepsis is a serious condition that occurs when the body's immune system has an extreme response to an infection, causing damage to its own tissues and organs.
## Footnote
23.6% of sepsis cases managed in hospitals were found to be health care associated.
184
What percentage of physician-patient encounters experience diagnostic errors?
Diagnostic errors occur in 5-20% of physician-patient encounters.
## Footnote
Harmful diagnostic errors were found in a minimum of 0.7% of adult admissions.
185
What are the most frequent adverse events in hospitals?
Patient falls are the most frequent adverse events in hospitals.
## Footnote
Their rate of occurrence ranges from 3 to 5 per 1000 bed-days.
186
What is venous thromboembolism?
Venous thromboembolism, or blood clots, is a highly burdensome and preventable cause of patient harm.
## Footnote
It contributes to one third of the complications attributed to hospitalization.
187
What are pressure ulcers?
Pressure ulcers are injuries to the skin or soft tissue that develop from prolonged pressure.
## Footnote
They affect more than 1 in 10 adult patients admitted to hospitals.
188
What risks are associated with unsafe transfusion practices?
Unsafe transfusion practices expose patients to serious adverse transfusion reactions and transfusion-transmissible infections.
## Footnote
The average incidence of serious reactions is 12.2 per 100,000 distributed blood components.
189
What can result from patient misidentification?
Failure to correctly identify patients can lead to catastrophic adverse effects, such as wrong-site surgery.
## Footnote
A report identified 409 sentinel events of patient identification out of 3326 incidents.
190
How many injections are administered worldwide each year?
Each year, 16 billion injections are administered worldwide.
## Footnote
Unsafe injection practices pose significant risks to patients.
191
What percentage of patients is harmed in health care?
Around 1 in every 10 patients is harmed in health care, resulting in more than 3 million deaths annually due to unsafe care.
## Footnote
In low-to-middle income countries, as many as 4 in 100 people die from unsafe care.
192
What percentage of harm in health care is preventable?
Above 50% of harm (1 in every 20 patients) is preventable; half of this harm is attributed to medications.
193
What is the estimated harm rate in primary and ambulatory settings?
Some estimates suggest that as many as 4 in 10 patients are harmed in primary and ambulatory settings, while up to 80% of this harm can be avoided.
194
What are common adverse events that may result in avoidable patient harm?
Common adverse events include medication errors, unsafe surgical procedures, health care-associated infections, diagnostic errors, patient falls, pressure ulcers, patient misidentification, unsafe blood transfusion, and venous thromboembolism.
195
How does patient harm affect global economic growth?
Patient harm potentially reduces global economic growth by 0.7% a year, with indirect costs amounting to trillions of US dollars each year.
196
What is the benefit of investing in reducing patient harm?
Investment in reducing patient harm can lead to significant financial savings and better patient outcomes. An example is patient engagement, which can reduce the burden of harm by up to 15%.
197
What is the fundamental principle of health care?
"First, do no harm" is the most fundamental principle of any health care service.
198
How is patient safety defined?
Patient safety is defined as the absence of preventable harm to a patient and reduction of risk of unnecessary harm associated with health care to an acceptable minimum.
199
What does the broader health system context of patient safety include?
It includes a framework of organized activities that creates cultures, processes, procedures, behaviours, technologies, and environments in health care that consistently and sustainably lower risks and reduce the occurrence of avoidable harm.
200
What percentage of patients is affected by medication-related harm?
Medication-related harm affects 1 out of every 30 patients in health care.
