What is patient safety? |
General view of what safety is – concepts and definitions |
Systems theory |
History of patient safety |
Adverse event |
Health errors* |
Failures in systems |
Difference between failures, violation, and error |
Human and economic costs associated with adverse events |
Causes of errors |
Swiss cheese model |
Culture of guilt |
Culture of safety |
Models of safety |
Patient-centered care |
Why applying human factors is important
for patient safety? |
Concepts of human fallibility and perfection |
Systems |
Ergonomics* |
Human factors |
Work environment and its “noises”* |
Fatigue and stress in professional performance |
Man-machine relations and safety in the use of equipment |
Communication strategies in the work environment |
Redesigning processes |
Understanding systems and the effect
of complexity on patient? |
Concepts and definition of systems and complex systems |
Healthcare system* |
Organizational structure* |
Work processes |
Failures in the system and mechanisms for investigation of
factors |
Defenses and barriers in the systems |
Comprehension and management of clinical risk |
Authority with responsibility |
Interdisciplinarity |
Highly trustworthy organizations |
Being an effective team player |
What is a team?* |
The different types of teams found in healthcare* |
Values, roles, and responsibilities* |
Styles of learning |
Hearing abilities |
Team coordination |
Effective leadership* |
Characteristics of successful teams |
Effective communication and communication tools* |
Conflict resolution |
Team work performance evaluation |
Learning from errors to prevent
harm |
Errors |
Main types of errors |
Violations, errors, near-misses |
Situations that increase the risks of errors |
Individual factors that predispose to error |
How to learn from errors |
Incident report |
Adverse event analysis |
Strategies to reduce errors |
Understanding and managing clinical
risk |
Risk management – definitions; |
How to understand and manage clinical risks* |
Notification of near-misses |
Report of errors |
Clinical monitoring* |
Training programs to evaluate clinical risks |
Notification* and monitoring of incidents |
Types of incidents |
Sentinel events |
Communication of risks and dangers at the work place |
Organization and work environment |
Credetialling, licensing, and accreditation |
Professional and individual responsibilities in risk
management |
Fatigue and stress |
Communication and poor communication |
Using quality improvement methods to
improve care |
Theory of knowledge |
Basic concepts of change |
Deming’s concepts |
Management system with focus on process improvement |
Continuous improvement |
PDSA/PDCA Cycle |
Quality tools: flow chart, Ishikawa chart, Pareto diagram, and
histogram |
Indicators* |
Variation, methods for quality improvement |
Result measures |
Process measures |
Compensation measures |
Clinical practice improvement |
Root cause analysis |
Analysis of modes and effects of failure |
Engaging with patients and carers |
The voice of the consumer |
Patient rights* |
Protection legislation for consumer protection and user rights
of the healthcare system* |
Complaints |
Fear |
Education* |
Principles of good communication* |
Communication tools: SPIKE, SEGUE, SPEAK UP |
Informed consent* |
Respect for the differences of each patient, as to religious,
cultural and personal beliefs, and as to individual needs* |
Patient privacy and autonomy |
Responsibility and family* |
Ways of involving the patients and professionals in
health-related decisions* |
Asking for forgiveness |
Open revelation process |
Legal implications of the error |
Infection prevention and control |
Healthcare-related infection* |
Precautions to prevent and control infections* |
Infections in the community* |
Transmission and cross transmission* |
Alerts of epidemics and pandemics |
Types of transmission* |
Risks of infection* |
Asepsis techniques* |
Aseptic* |
Standard precautions |
Economic cost associated with infection |
Individual protection equipment |
Instrument and equipment sterilization and disinfection
methods |
Multiresistant organisms* |
Antimicrobial resistance* |
Recommendations on the single use of devices |
Hand washing* |
Guidelines: for use of gloves, isolation, of the Centers for
Disease Control and Prevention |
Immunizations, vaccines* |
World Health Organization program: Clean Care is Safe Care;
campaigns for hand hygiene; control of antimicrobial use |
Patient safety and invasive
procedures |
Adverse events associated with surgical procedures and with
other invasive procedures |
Complications at the surgical site* |
Infection at surgical site* |
Infection control in surgical care* |
Preexisting factors for the occurrence of errors |
Communication failures among teams |
Verification processes |
Team work |
Surgical complications |
Surgical gowning |
Laterality |
Practices that reduce risks, such as time-out, briefing,
debriefings, assertiveness, and information transmission
systems |
Patient management in the operating room* |
Improving medication safety |
Medication system and prescription, distribution, and
administration process* |
Drugs* |
Control of antimicrobial use |
Medication regulation |
User access to the medications |
Notification system for adverse events |
Side effect |
Adverse reaction to the medication* |
Potential and real drug-drug and drug-food interaction |
Medication errors and their types |
Consequences for the Patient* |
Sources of error and prevention |
Patient monitoring and evaluation of clinical parameters* |
Prescription* |
Administration* |
The five “correct things” in the medication system |
Safe communication process among the teams to minimize
errors |
Use of technology in order to minimize errors |
Physical, cognitive, emotional, and social factors that
predispose towards patient vulnerability when using
medications |
Drug reconciliation |
High-vigilance medications (potentially dangerous or of high
risk) |