2. Patient Safety

8/12/2019 2. Patient Safety

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PATIENT SAFETY

Tim Bioetik


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Pasien safetyTindakan yang dilakukanorganisasi/individu untuk menjaga agarpasien tidak mengalami bahaya


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Introduction

Many patients are harmed by healthcare,both secondary and primary, and often thisharm is preventable

Adverse drug events are the commonestthreat to patient safety in secondary care

Failure and delay in diagnosis is thecommonest threat to patient safety inprimary care


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Banyak pasien yang dirugikan oleh pelayanan

kesehatanprimary health care/ secondaryhealth care| yang sebenarnya bisadicegah.

Yang paling sering membahayakanpasien pada

secondary health careefek samping obat|

primary health careketerlambatan dankegagalan diagnosis.


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Piramid harm Latent failureKesalahanorganisasi (secara organisir)kumpulan drkesalahan aktif

Active failurekesalahan individual .


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main types of error due

to human factors1. Slips

2. Lapses

3. Mistaken4. Violation


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Slips Kesalahan ini tidak disadari sampaipasien menimbulkan keluhan.| Sesuai

prosedur dengan orang kompeten murnikelalaian | penyebab: Capek, ngantuk dandiajak ngobrol.

Ex: Dalam meresepkan obat (pasien alergi obattertentu/salah meresepkan obt) efeksamping obat yang tidak diingankan timbul

baru menyadari kesalahannya apa.


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LapsesSudah ada prosedur (SOP) denganorang yang kompeten, tetapi memilih untuk

tidak melakukan prosedur tersebut karenasituasi tertentu.

Ex: Malam tahun baru, banyak pasien

kecelakaan, sehingga banyak pasien yangharus ditangani. Dalam menangani pasienyang begitu banyak, dokter memilih untuktidak mencuci tangan untuk setiap pasien

yang ditangani.


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Mistakendokter tidak kompeten pada suatukasus yang seharusnya dikuasai. Karena tidakpernah mempelajarinya atau pernahmempelajari tapi lupa, sehingga tidak dapatmelakukan tindakan pada pasien.

ViolationMalpraktekAda prosedur yangsesuai dengan orang yang kompeten

tetapi sengaja berbuat kesalahan.


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Early signs of a doctor in difficulties

The disappearing act: lateness; excessive sick leave; not answeringbleeps

Low work rate: slowness at making decisions, writing letters,finishing procedures

Ward/surgery rage: bursts of temper; shouting matches

Rigidity: poor tolerance of ambiguity; inability to compromise;difficulty prioritizing

Bypass syndrome: colleagues, nurses or patients find ways to avoidseeking his or her opinion or help

Career problems: difficulty with exams; uncertainty about career

choice Insight failure: rejection of constructive criticism; defensiveness;

counter-challenge


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Tanda awal dokter

bermasalahKehadiranterlambat; cuti sakit yang

berkepanjangan; tidak menjawab panggilan.

Kemampuan rendah

terlambat membuatkeputusan dan menyelesaikan prosedur.

Operasiemosional

Kekakuansulit untuk kompromi danmemprioritaskan


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Bypass syndrompasien/perawat menghindaruntuk meminta bantuannya

Karir

sulit menghadapi ujian, tidak yakinterhadap pilihan karinya

Insight failurega menerima kritikan,defensive.


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The main latent conditions

for failure

Inadequate trainingpelatihan yang tidak adekuat

Unworkable proceduresprosedur yang tidak bisadijalankan

Low standards of qualitystandar kualitas yang rendah

Poor or inadequate technologyteknologi yangburuk/tidak memadai

Unrealistic time pressureswaktu yang ga realistik

Understaffingstaf yang ga kompeten


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Causes of threats to patient safety

associated with diagnosis

Penyebabharmfull pada pasienberhubungan dengan diagnosis.


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Common difficulties in making a diagnosis in

both

primary and secondary care Patients may present at an early stage of an

illness when the symptoms and signs are ill-defi

ned and vague.

Patients (or their families) may present whenthey are at their limit of tolerance due either to

the level of symptoms or to their level of anxiety.

Problems are often complex and a mixture ofphysical, psychological and social factors.


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Kesulitan dalam membuat diagnosisada diprimary dan secondary health care.

1. Pasien datang

masih pada stage penyakitawalsehingga gejalanya masih samar.

2. Pasien (keluarganya)datangkalausudah dalam batas toleransinya

tergantung level gejala dan kecemasannya.

3. Masalahbiasanya kompleksgabungandari faktor fisik, psikologi dan sosial.


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Common errors in making a

diagnosis

Unwarranted fixation on a hypothesis

menyimpulkan hipotesis yang ga beralasan Premature closure of hypothesis generationterlalu cepat menyimpulkan hipotesis

Rule out syndrome


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Common factors other than disease that

may

infl uence diagnostic test results Age and sexusia dan umur

Body positionposisi tubuh

Laboratory errorlab. error


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Penyebab error dalam mendiagnosis :

Human errordokternya lelah/bekerja

berlebihan| tpberhubungan denganfaktor sistem.


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System error:

1. Staf yang kurang berpengalaman

2. Sistem pencatatan temuankurangadekuat

3. Penggunaan/ pemanfaatan pendapat

spesialist yang kurang adekuat4. Pembacaan radiografiinadekuat

5. Manajemen rutin yang buruk tidak

menggunakan protokol standar6. Assesment yang inadekuat sebelum di

exclude.


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Common identified causes of

errors in diagnosis

A. Human factors

Misdiagnosis can occur when the healthcareprofessional is tired or overworked. However,the reasons for this are related to underlyingsystem factors.


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B. System factors

Assessment by insuffi ciently experiencedstaff

Inadequate systems for recording fi ndings

Inadequate use of specialist opinion

Inadequate reading of simple radiographs

Poor management of routine situations, with

lack of use of standard protocols and bestpractice guidelines

Inadequate assessment before discharge


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Approaches that can reduce adverse

events associated with diagnosis

Take a history that concentrates on the key elements.

Assess the evidence and consider the possible range of

differential diagnoses.

Use diagnostic tests appropriately. It is important to be awareof the sensitivity and specifi city of the screening test.

A test with a high sensitivity will have fewer missed

diagnoses.

A test with a high specifi city will have fewer false alarms. A positive test when there is a low possibility of the disease is

more likely to be a false-positive.


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Carefully consider whether discharge from careis appropriate.

Obtain a second opinion if the problem remains

unexplained.


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The frequency and extent of errors

associated with

the use of medication in primary care Potential adverse drug reactions identifi ed in 0.13% of

prescriptions.

About 5% of admissions to hospital in UK due to an

adverse drug reaction. The adverse reaction resulted indeath in 2% of cases.

Between 13% and 51% of all reported adverse incidentsthat occur in primary care are related to medication.

About 20% of all claims identifi ed on medico-legaldatabases are related to medication.


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Common reasons for errors occurring: the

initial

prescription Inadequate knowledge of the patient and

their clinical condition

Inadequate knowledge of the drug Calculation errors

Drug name confusion

Poor (clinical and medication) history taking


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Penyebab eror saat

meresepkan obat.- Pengetahuan yang inadekuatterhadap

pasien dan kondisi klinisnya.

- Pengetahuan terhadap obat yang inadekuat.- Kesalahan perhitungan

- Kebingungannama obat

- Anamnesis terhadap riwayat klinis danpengobtan yang buruk


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How can threats to patient safety

associated with the use of medication be

reduced? Desicion to prescribekeputusan untuk

meresepkan

Medication reviews and monitoring

reviewdan monitoring

Patient Educationedukasi pasien

Improvements to the design of medicine

packagingmemperbaiki desain kemasanobat


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COMMUNICATION AND PATIENT

SAFETY


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The scope of communication in

patient safety

Communication is the basis to ensure the best process ofcare forthe patient, to share aims and goals of care withthe patient, and to share care with other professionals

involved. Communication in medicine often takes place under

stress and time pressures.

Communication can help us to cope with situations of

particular difficulty. Communication can improvecollaboration in the team and with professionalcolleagues, to master uncertainty, and to avoid hazardsto patient safety


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Communication problems

When doctors in this condition:

- Hurry

- Angry- Under stress


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Symptoms of disruptive communication

behaviour

Profane or disrespectful language

Sexual comments

Lack of control of own emotions (e.g. anger)

Criticizing staff in front of patients or co-workers

Negative comments on care provided by others

Inappropriate comments in case notes

Dishonesty, lack of self-criticism, concealment ofmistakes


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Identifi cation of communication problems causing

errors in systematic analysis of critical events: a checklist

Patient-related factors

- Are there barriers to communication (language,

understanding, attention)?

- Are there tensions in the doctorpatient relationship?

Task-related factors

- Are laboratory results correctly communicated and

understood?- Are there protocols and procedures for handovers?

Individual factors of staff members

- Are staff trained in communication skills?


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Cont

Team factors

- Do staff communicate effectively in the healthcare

team?

- Are there problems with formal (written) communication,such as legibility of messages?

Workplace factors

- Are there problems with workload, stress and frequent

interruptions?

Organizational and management factors

- Is there a culture of safety?

-Is there top-level commitment to adequate communicationwith the patients and within staff?


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The SBAR approach to communication in healthcare teams

First, the clinical staff need to state the Situation. Rather than

MrJones is out of breath, the staff need to state The reason I

am calling you is that Mr Jones in Room 301 is complaining of

shortness of breath, which he states he has never had before.

Second, is the Background: The background is, Mr Jones is a

57-year-old man who had abdominal surgery yesterday. He has

no history of cardiac or lung disease.

Third, is the Assessment: Ive noticed that his breath sounds

are decreased on the right side, hes having some pain, and Imwondering if he has developed a pneumothorax.

And fourth is the Recommendation: I think you need to come

in and see him right now.


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The culture of medical education

Competitiveness

Shame and blame

Lack of role models


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Methods for education and training in

effective

communication after a medical error orcomplaint Simulated patients on which to practise communication

skills

Observing complaints offi cers at work

Live encounters with patients and patient advocates toincrease awareness of the patient perspective

Live encounters with doctors who have had complaintsso as to talk about the emotional aspects and how they

coped both personally and professionally


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Cultural barriers in healthcare

Scepticism about proposed changes to improve patientsafety

Individual autonomy with lack of willingness to work

collaboratively High individual responsibility for actions with self-blame

for errors

Fear of complaints and litigation that leads to lack of

willingness to admit and discuss errors Hierarchical structure that blames individuals instead of

systems


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Important next steps for the improvement of

patient safety

Leadership

Conceptual clarity

Coherent policy

Focusing on developing and evaluating the effectivenessof interventions

Embedding safety within healthcare

2. Patient Safety

Documents