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Patient Safety

Fury Maulina

Prescribing antibiotics without regard for the


patients underlying condition and whether
antibiotics will help the patient, or administering
multiple drugs potential for adverse drug reactions

Many studies confirm medical error is prevalent in our


health system and that the costs are substantial
Australia
US

18 000 unnecessary deaths/year


> 50 000 disabled patients/ year
44 000 (perhaps 98 000) unnecessary deaths/ year
1 million excess injuries

Studies show additional hospitalization, litigation costs,


infections acquired in hospitals, lost income, disability and
medical expenses have cost some countries between
US$ 6 billion and US$ 29 billion/year

Many studies highlight that alongside the


enormous benets of medical care
signicant risks for patients
Managing these risks is a great challenge that
requires a culture of safety to be established
throughout medicine, from redesigning health
systems to training doctors competent in both
the clinical sciences and safety sciences.

Why do medical students need to know


about patient safety?
They need underpinning knowledge about
patient safety as well as know how to apply the
principles and concepts at the bedside
They must be aware of the multiple factors
that inuence healthcare outcomes and act to
reduce the opportunities for errors
They need to know how the system of
healthcare operates and impacts on the
quality and safety of healthcare

Patient safety a complex topic which


includes new areas of knowledge such as
human factors, systems, root cause
analysis and risk reduction

The Australian Patient Safety Education


Framework (APSEF), published in 2005
knowledge, skills and behaviours
WHO Patient Safety Curriculum Guide for
Medical Schools was developed by a team
from the University of Sydney and Monash
University and assisted by an Expert Consensus
Working Group with representatives
from the six WHO regions + APSEF

Patient safety is the freedom for a patient from


unnecessary harm or potential harm
associated with healthcare refocuses
learning on the patient and the multiple
interactions that can either heal or harm them
Flexner, early 20th century recognised
attributes such as ethical practice,
professionalism, population health,
compassion and integrity equally important

New framework
Ethical codes
(perspective of
the doctor)
Patient safety
(perspective of
the patient)

complex
environment and
the needs of
patients

The significant number of studies


most adverse events are preventable

In a landmark
study by Leape
et al. (1993):
> 2/3 adverse
events
preventable

28%: negligence
of a health
professional

42%: other factors


not related to such
negligence

Poor medical
Management
Substandard
care

Swiss Cheese Model

Source: Coombes ID et al. Why do interns make prescribing errors? A qualitative study, Medical
Journal of Australia, 2008, 188(2): 8994. Adapted from Reasons model of accident causation

What need to do?


Apply patient safety thinking in all clinical
activities
Relationships with patients
Understand the multiple factors involved in failures
The five whys
Avoid blaming when an error occurs
Practise evidence-based care
Maintain continuity of care for patients
Student awareness of the importance of self-care
Act ethically everyday

Multumesc!

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