patient safety scenarios

Case Studies in Patient Safety: This publication is designed to provide accurate and authoritative information in regard to the Subject Matter ... Competencies. The scenarios are real; however, the names and photos used are … Patient Safety education scenarios build on the established success of patient stories in using narrative and qualitative data as powerful levers for improvement. In: Patient Safety Network [website]. Thrombosis: A major contributor to global disease burden. Any individuals and scenarios featured in the case studies throughout this product may be real or fictitious, but are used for instructional purposes only. In this case, the prescription passes through different levels of care starting with the doctor in the ward, then to the pharmacy for dispensing and finally to the nurse who administers the wrong medication to the patient. Current Estimates and Limitations. Unsafe transfusion practices expose patients to the risk of adverse transfusion reactions and the transmission of infections (14). Patient 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. Consider a patient who’s placed prone with … "Super" superbugs. 15. This annual meeting is the must-attend event for those … Health care-associated infections occur in 7 and 10 out of every 100 hospitalized patients in high-income countries and low- and middle-income countries respectively (11). Investments in reducing patient harm can lead to significant financial savings, and more importantly better patient outcomes (2). Slawomirski L, Auraaen A, Klazinga N. The Economics of Patient Safety in Primary and Ambulatory Care: Flying blind. Patient Safety Quiz As a patient, you must take an active role in your own health care, and that includes educating yourself on important patient safety topics. 2009;92:15-21 https://doi.org/10.1016/j.radonc.2009.03.007, 18. Aitken M, Gorokhovich L. Advancing the Responsible Use of Medicines: Applying Levers for Change. 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. Patient safety- Global action on patient safety. Unintended exposure in radiotherapy: identification of prominent causes. The harm can be caused by a range of adverse events, with nearly 50% of them being preventable (3). Clinical transfusion process and patient safety: Aide-mémoire for national health authorities and hospital management. Seventy-Second World Health Assembly, provisional agenda item 11.1. It is also important to recognize the impact of patient safety in reducing costs related to patient harm and improving efficiency in health care systems. Unsafe injections practices in health care settings can transmit infections, including HIV and hepatitis B and C, and pose direct danger to patients and health care workers; they account for a burden of harm estimated at 9.2 million years of life lost to disability and death worldwide (known as Disability Adjusted Life Years (DALYs)) (5). Assuming that individual perfection is possible will not improve safety (7). Every year, millions of patients suffer injuries or die because of unsafe and poor-quality health care. nurses, doctors, midwives, pharmacists), health-care workers in training (e.g. Leape L. Testimony before the President’s Advisory Commission on Consumer Production and Quality in the Health Care Industry, November 19, 1997. Jha AK, Larizgoitia I, Audera-Lopez C, Prasopa-Plaizier N, Waters H, W Bates D. The global burden of unsafe medical care: analytic modelling of observational studies. Doctors are perceived—by patients and clinicians—as being the captain of the health care team, with good reason. 14. 37 0 obj <>/Filter/FlateDecode/ID[<9A23903E7F1A5EDD52C7C61EE92C5610><8B5CFA560F533B488BB7BC1C89A0D6F8>]/Index[27 24]/Info 26 0 R/Length 65/Prev 59873/Root 28 0 R/Size 51/Type/XRef/W[1 2 1]>>stream h�b```f``R����(��Na~�������vPF�5]�5B�Tt�"!�J �e`d �@� ��;%�ϊ�G� |A�` >F+ ��]@,��~�g�0 i�( Geneva: World Health Organization; 2019 (http://apps.who.int/gb/ebwha/pdf_files/WHA72/A72_4-en.pdf, accessed 23 July 2019). Because these infections are often resistant to antibiotics, they can rapidly lead to deteriorating clinical conditions, affecting an estimated 31 million people worldwide and causing over 5 million deaths per year (18). Throughout the scenario, the facilitator will need to provide data for the patient’s vital signs (see “Scenario … Radiation errors involve overexposure to radiation and cases of wrong-patient and wrong-site identification (16). But, physicians may spend only 30 to 45 minutes a day with even a critically ill hospitalized patient, whereas nurses are a constant presence at the bedside and regularly interact with physicians, pharmacists, families, and all other members of the health care team. 2014;23(9):727–31. In this situation, a lack of standard procedures for storage of medications that look alike, poor communication between the different providers, lack of verification before medication administration and lack of involvement of patients in their own care might all be underlying factors that led to the occurrence of errors. Fleischmann C, Scherag A, Adhikari NK, et al. Paris: OECD; 2017 (http://www.oecd.org/els/health-systems/The-economics-of-patient-safety-March-2017.pdf, accessed 26 July 2019). When autocomplete results are available use up and down arrows to review and enter to select. Jha AK. This is a culture where a high level of importance is placed on safety beliefs, values and attitudes and shared by most people within the workplace (9). The challenges thus far have been: WHO has also provided strategic guidance and leadership to countries through the annual Global Ministerial Summits on Patient Safety, which seek to advance the patient safety agenda at the political leadership level with the support of health ministers, high-level delegates, experts and representatives from international organizations. Department of Nursing, University of South Dakota at Vermillion . providing global leadership and fostering collaboration between Member States and relevant stakeholders, providing technical support and building capacity of Member States, engaging patients and families for safer health care, monitoring improvements in patient safety. 10. Roberto didn’t pay attention when the teacher explained where safety … Assessment of Global Incidence and Mortality of Hospital-treated Sepsis. Boadu M, Rehani MM. 7��e����ً>���h8�9��Q�k�M&˃Dk[�DzV�� ��. 19. Slawomirski L, Auraaen A, Klazinga N. The economics of patient safety: strengthening a value-based approach to reducing patient harm at national level. Scenario 4: Disclosure After Event Analysis Alphonse, a 50 year-old CEO of a large aerospace company with a family history of high cholesterol has come to your hospital for cardiac bypass … Simulation scenario; Safety: Patient safety. Geneva: World Health Organization; 2009 (http://apps.who.int/iris/bitstream/handle/10665/44185/9789241598552_eng.pdf?sequence=1, accessed 26 July 2019). The WHO estimates that patient … Despite significant advances in patient care within the United States and around the world, the number of patients harmed while receiving health care is still unacceptably high. In OECD countries, 15% of total hospital activity and expenditure is a direct result of adverse events (2). Report on the burden of endemic health care-associated infection worldwide. Safe Surgery Saves Lives (2008); dedicated to reducing risks associated with surgery. Had there been safe guarding processes in place at the different levels, this error could have been quickly identified and corrected. The simulation scenarios … Crossing the global quality chasm: Improving health care worldwide. Learners will use real-world strategies, tools, and techniques to resolve various patient safety and quality issues based on authentic scenarios that occur in medical and clinical settings. Many medical practices and risks associated with health care are emerging as major challenges for patient safety and contribute significantly to the burden of harm due to unsafe care. These germs can be spread in healthcare settings from patient to patient on unclean hands of healthcare personnel … SLIPPs simulation scenarios Development of the SLIPPs Simulation scenarios (IO 4) was led by Prof. A Bagnasco and Prof. L Sasso University of Genoa, Italy, working with the SLIPPs sim-scenario sub group. There are three framework levels for patient safety. 2008;17(3):216–23. Implemented debriefings after every delivery, learned TeamSTEPPS/CRM through simulation, and improved their safety culture and … Scenario 2 An 80 year-old male was admitted for an elective orthopedic procedure. Almost 7 million surgical patients suffer significant complications annually, 1 million of whom die during or immediately following surgery (12). endstream endobj startxref Presentation at the “Patient Safety – A Grand Challenge for Healthcare Professionals and Policymakers Alike” a Roundtable at the Grand Challenges Meeting of the Bill & Melinda Gates Foundation, 18 October 2018 (https://globalhealth.harvard.edu/qualitypowerpoint, accessed 23 July 2019). 3. de Vries EN, Ramrattan MA, Smorenburg SM, Gouma DJ, Boermeester MA. A surgical nurse who was present for the patient… He slanted the tube away from his work area, but toward students on the opposite side of his lab table. Situational questions expect you to imagine yourself in certain scenarios you may have never faced before (i.e “What would you do if the patient you were caring for couldn’t understand … Safety of patients during the provision of health services that are safe and of high quality is a prerequisite for strengthening health care systems and making progress towards effective universal health coverage (UHC) under Sustainable Development Goal 3 (Ensure healthy lives and promote health and well-being for all at all ages) (7). Medication Without Harm (2017); with the aim of reducing the level of severe, avoidable harm related to medications globally by 50% over five years. Workplace Health and Safety Queensland. Annually, there are an estimated 3.9 million cases in high-income countries and 6 million cases in low- and middle-income countries (19). 16. Washington (DC): The National Academies Press; 2018 (https://www.nap.edu/catalog/25152/crossing-the-global-quality-chasm-improving-health-care-worldwide, accessed 26 July 2019). %%EOF https://doi.org/10.1136/bmjqs-2013-002627 https://www.ncbi.nlm.nih.gov/pubmed/24742777. The IHI Patient Safety Congress, brings together people who are passionate about ensuring safe care equitably for all across the globe. Radiother Oncol. Most people will suffer a diagnostic error in their lifetime (13). 7. Inadequate staffing at healthcare facilities can greatly hamper patient … WHO has been pivotal in the production of technical guidance and resources such as the Multi-Professional Patient Safety Curriculum Guide, Safe Childbirth Checklist, the Surgical Safety Checklist, Patient Safety solutions, and 5 Moments for Medication Safety (available in print and in App form). The 3 scenarios were: (1) a healthcare provider not properly conducting hand hygiene before a patient encounter, (2) a healthcare provider not properly conducting a fall risk assessment on a hospitalized patient, … Paris: OECD; 2018 (http://www.oecd.org/health/health-systems/The-Economics-of-Patient-Safety-in-Primary-and-Ambulatory-Care-April2018.pdf, accessed 23 July 2019). Singh H, Meyer AN, Thomas EJ. A mature health system takes into account the increasing complexity in health care settings that make humans more prone to mistakes. Traditionally, the individual provider who actively made the mistake (active error) would take the blame for such an incident occurring and might also be punished as a result. To promote global solidarity, WHO has also encouraged the creation of networking and collaborative initiatives such as the Global Patient Safety Network and the Global Patient Safety Collaborative. It is when multiple latent errors align that an active error reaches the patient. Each year, 134 million adverse events occur in hospitals in low- and middle-income countries (LMICs), due to unsafe care, resulting in 2.6 million deaths (4). Nurse-patient ratios. Unsafe surgical care procedures cause complications in up to 25% of patients. 8. Raskob E, Angchaisuksiri P, Blanco N, Buller H, Gallus A, Hunt B, et al. The author has used unfolding case studies to illustrate principles of patient-centered careContinue reading July 3, 2019 August 29, 2019 QSEN Institute Teaching Strategies Pediatric End-of-Life Simulation Scenario to patient safety? The specialty scenarios … 2021 Patient Safety Component Manual pdf icon [PDF – 8 MB] 2020 Patient Safety Component Manual pdf icon [PDF – 6 MB] 2020 Long-term Care Facility Manual pdf icon [PDF – 3 MB] … Radiother Oncol. 4.National Academies of Sciences, Engineering, and Medicine. It aims to prevent and reduce risks, errors and harm that occur to patients during provision of health care. Geneva: World Health Organization; 2010 (http://www.who.int/bloodsafety/clinical_use/who_eht_10_05_en.pdf?ua=1, accessed 26 July 2019). Patient 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. %PDF-1.5 %���� Understanding safety culture. To err is human, and expecting flawless performance from human beings working in complex, high-stress environments is unrealistic. 2. A review of 30 years of published data on safety in radiotherapy estimates that the overall incidence of errors is around 15 per 10 000 treatment courses (17). http://doi.org/10.1136/qshc.2007.023622 https://www.ncbi.nlm.nih.gov/pubmed/18519629. 0 Patient Safety Case Study Read how the leaders. May 31, 2017 | Health & Safety Safety stories stem from scary near misses, serious injuries, and worst case scenarios. Report by the Director-General. The scenarios in our … https://doi.org/10.1016/j.radonc.2009.08.044 https://www.ncbi.nlm.nih.gov/pubmed/19783058, 17. 20. nursing students, medical students, residents), health-care managers or administrators, patient safety … A cornerstone of the discipline is continuous improvement based on learning from errors and adverse events. 6. Scenario 6 75 y/o female initial visit who has not seen a physician for over 20 years, presenting for progressively increasing confusion and hallucinations. Geneva: World Health Organization; 2019 (https://apps.who.int/gb/ebwha/pdf_files/WHA72/A72_26-en.pdf, accessed 23 July 2019). hޤVYo�0�+~l�b}�D��(�6��a��.�4�(q��� ���"����擃F�.�^@\Fx����K� ��P� ����rP��7 !6$�s��]f99��"-�x%� Unpublished manuscript. Patient claims to occasionally see small … Common scenarios include a patient with excited delirium and/or an uncooperative patient with police involvement. Patient Safety: What You Can Do to Be a Safe Patient. Patient Safety as a global health priority, The purpose of World Patient Safety Day is to promote patient safety by increasing public awareness and engagement, enhancing global understanding and working towards global solidarity and action. Up to 80% of harm is preventable. Recognizing that Patient Safety is a global health priority, the World Health Assembly (WHA) adopted a resolution on Patient Safety which endorsed the establishment of World Patient Safety Day to be observed annually by Member States on 17 September. Unfortunately, this does not consider the factors in the system previously described that led to the occurrence of error (latent errors). Thrombosis Research. Target 3.8 of the SDGs is focused on achieving UHC “including financial risk protection, access to quality essential health care services, and access to safe, effective, quality, and affordable essential medicines and vaccines for all.” In working towards the target, WHO pursues the concept of effective coverage: seeing UHC as an approach to achieving better health and ensuring that quality services are delivered to patients safely (20). 1. With the lack of interprofessional communication between physicians and nurses, shortage of patient-staff interaction, and deficiency of effective nurse handovers, it is a major risk point leading to poor patient experience and having an effect on both patient safety … Therefore, focusing on the system that allows harm to occur is the beginning of improvement, and this can only occur in an open and transparent environment where a safety culture prevails. 5. At the primary level of prevention of adverse events, simulation is used to develop system components in ways that maximize safety prior to the installation of a system. OB. Below are some of the patient safety situations causing most concern. Sepsis is frequently not diagnosed early enough to save a patient’s life. Data on adverse transfusion reactions from a group of 21 countries show an average incidence of 8.7 serious reactions per 100 000 distributed blood components (15). Indeed, there is a clear consensus that quality health services across the world should be effective, safe and people-centred. The incidence and nature of in-hospital adverse events: a systematic review. Each of the Challenges has identified a patient safety burden that poses a major and significant risk. The Patient Safety and Risk Management unit at WHO has been instrumental in advancing and shaping the patient safety agenda globally by focusing on driving improvements in some key strategic areas through: WHO's work on patient safety began with the launch of the World Alliance for Patient Safety in 2004 and this work has continued to evolve over time. Globally, as many as 4 in 10 patients are harmed in primary and outpatient health care. Keep health workers safe to keep patients safe: WHO, Ionizing radiation, health effects and protective measures, Coronavirus disease outbreak (COVID-2019), Coronavirus disease outbreak (COVID-19) », https://mailchi.mp/who.int/wha-72-achievements-commitment-accountability, https://www.who.int/patientsafety/policies/global-health-priority/en/. 2009; 93(3):609–17. WHO has facilitated improvements in the safety of health care within Member States through establishment of Global Patient Safety Challenges. For example, a patient in hospital might receive a wrong medication because of a mix-up that occurs due to similar packaging. … Scenario #7. @¥�mqÀ�|u&F�U �d��}0 $ Clean Care is Safer Care (2005); with the goal of reducing health care-associated infection, by focusing on improved hand hygiene. Janssen MP, Rautmann G. The collection, testing and use of blood and blood components in Europe. 11. Team Strategies & Tools to Enhance Performance & Patient Safety Specialty Scenarios-1 LTC Specialty Scenarios Long-Term Care Specialty Scenarios These specialty scenarios can be used to customize the TeamSTEPPS scenarios, vignettes, and practical exercises for long-term care staff. The frequency of diagnostic errors in outpatient care: estimations from three large observational studies involving US adult populations. Recognizing the importance of patients’ active involvement in the governance, policy, health system improvement and their own care, the WHO also established the Patients for Patient Safety programme to foster the engagement of patients and families. An example of prevention is engaging patients, if done well, it can reduce the burden of harm by up to 15% (6). patient safety workshop is designed to be suitable for health-care workers (e.g. Abstract Patient safety is an essential and vital component of quality nursing care. Geneva: World Health Organization; 2011 (http://apps.who.int/iris/bitstream/handle/10665/80135/9789241501507_eng.pdf?sequence=1, accessed 26 July 2019). Diagnostic errors occur in about 5% of adults in outpatient care settings, more than half of which have the potential to cause severe harm. 9. Sam was heating a test tube. The occurrence of adverse events due to unsafe care is likely one of the 10 leading causes of death and disability in the world (1). scenario twice in the same training session so that learning and re-enforcement of communication and teamwork skills can be applied to their clinical practice. Time Allotment (each simulation is designed to be … Humans are guarded from making mistakes when placed in an error-proof environment where the systems, tasks and processes they work in are well designed (8). BMJ Qual Saf. Qual Saf Health Care. 1. Who is responsible for patient safety… Two days after surgery, he was diagnosed with pneumonia. By Adam Welsh, BSc, MBA Mark Frost, BS, MS Nicole Weepie, BA, MA. In addition, to realize the benefits of quality health care, health services must be timely, equitable, integrated and efficient. Am J Respir Crit Care Med 2016; 193(3): 259-72. https://doi.org/10.1164/rccm.201504-0781OC https://www.ncbi.nlm.nih.gov/pubmed/26414292. It aims to prevent and … Medication errors are a leading cause of injury and avoidable harm in health care systems: globally, the cost associated with medication errors has been estimated at US$ 42 billion annually (10). Scenario #6. Strasbourg: European Directorate for the Quality of Medicines and HealthCare (EDQM) of the Council of Europe; 2014 (https://www.edqm.eu/sites/default/files/report-blood-and-blood-components-2014.pdf, accessed 26 July 2019).

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