Week 3 - Near Misses and Sentinel Events

Why do we track issues?

improvement

Safe Client Care Strategies

to ensure successful implementation of patient safety strategies; clear policies, leadership capacity, data to drive safety improvements, skilled health care professionals and effective involvement of patients in their care, are all needed

Why do we report near misses events/sentinel events?

tracking

Another study has estimated around ___-______ of all adverse events resulting from unsafe care, and the years lost to disability and death (known as disability adjusted life years, of DALYs) occur in LMICs

two-thirds

Each year, 134 million adverse events occur in hospitals in low and middle-income countries (LMICs), due to ______ ____, resulting in 2.6 million deaths.

unsafe care

Globally, as many as 4 in 10 patients are harmed in primary and outpatient health care. Up to ___ of harm is preventable. The most detrimental errors are related to diagnosis, prescription and the use of medicines.

80%

Human Error

- a mature health system takes into account the increasing complexity in health care settings that make humans more prone to mistakes - think of the technology, equipment, virtual communication methods, among other complexities that are involved with healthcare

Examples of Safe Communication

- bedside reports - SBAR - team rounding - ticket to ride communication - verbal/telephone order readback

Unsafe Surgical Procedures

- cause complications in up to 25% of patients - almost 7 million surgical patients suffer significant complications annually - 1 million of whom die during or immediately following surgery

Sepsis

- frequently not diagnosed early enough to save a patient's life - resistant to antibiotics - can rabidly lead to deteriorating clinical conditions - affects an estimated 31 million people worldwide - causes over 5 million deaths per year

Sentinel Events

- in 2005, 70% of sentinel events were caused by communication breakdowns, and 50% of those occurred during patient handoff - as a result, the JC introduced a national safety goal in 2006, which became a standard in 2009, requiring standardized hand-off communication

Medication Errors

- leading cause of injury and avoidable harm in health care systems How much do you think medication errors cost globally? - $42 billion

Health Care-Associated Infections

- occur in 7 out of 100 hospitalizations in high-income countries - occur in 10 out of 100 hospitalizations in low and middle-income countries

Venous Thromboembolism (Blood Clot)

- one of the most common and preventable causes of patient harm - contributes to one third of the complications attributed to hospitalization - estimated 3.9 million cases in high income countries - estimated 6 million cases in low and middle-income countries

The Burden of Harm

every year, millions of patients suffer injuries of die because of unsafe an poor-quality health care. Many medical practices and risks are associated with health care are emerging as major challenges for patient safety and contribute significantly to the burden of harm due to unsafe care

Investments in reducing patient harm can lead to significant financial savings, and more importantly better _______ ________. An example of prevention is engaging patients, if done well, it can reduce the burden of harm by up to 15%

patient outcomes

In high-income countries, it is estimated that one in every ten patients i harmed while receiving hospital care. The harm can be caused by a range of adverse events, with nearly 50% of them being __________.

preventable

What is a Sentinel Event?

a safety occurrence that affects a patient and causes death, serious permanent or temporary injury, or requires interventions to sustain life

Patient Safety

according to the World Health Organization "pt safety is a health care discipline that emerged with the evolving complexity in health care systems and the resulting rise of patient harm in health care facilities. It aims to prevent and reduce risks, errors and harm that occur to patients during provision of health care. A cornerstone of the discipline is continuous improvement based on learning from errors and adverse events/"

The occurrence of adverse events due to unsafe care is likely one of the ten leading causes of _____ and __________ in the world.

death; disability