key concepts of patient safety. what OSAP and other organizations are doing. Enrique Acosta Gío, CD, PhD. acostag@servidor.unam.mx National University of Mexico School of Dentistry. Patient safety is a serious public health issue globally All health care systems have the potential to hurt, unintentionally, those they are trying to help. Adverse events are an important cause of morbidity and mortality in developed countries as many as one in 10 patients is harmed while receiving hospital care. 1
Because of the complex nature of health care, there is no single reason why things go wrong. Human beings make mistakes because the systems, tasks and processes they work in are poorly designed. Dr Lucian Leape, testifying to the US President s Commission on Consumer Protection and Quality in Health Human systems ergonomics 2
urged WHO and Member States to pay the closest possible attention to the problem of patient safety. http://apps.who.int/gb/archive/pdf_files/wha55/ewha5518.pdf Lessons to learn Industries with a perceived higher risk such as aviation and nuclear plants have a much better safety record than health care. PATIENT CENTRED CARE REQUIRES: New knowledge & skills required Partnerships with patients & carers Teamwork Risk management/communication Data collection Adverse events Professional responsibility Professional accountability Competent care providers Deliver patient centred care Active member of multidisciplinary teams Report and learn from errors Apply evidenced-based health care Ethical and safer practices Use quality improvement and patient safety approaches Use information technology 3
Curricular guide In recent years, a science of patient safety has developed. Harm to patients is not inevitable Learn from past to prevent errors Adapt work to make safe care an achievable goal. www.who.int/patientsafety/activities/technical/medical_curriculum_downloa d/en/index.html WHAT IS THE CURRICULUM GUIDE? Part A: Teachers Guide to assist teachers implement curriculum guide and building capacity in patient safety education Comprehensive programme for educating in patient safety Part B: Comprehensive, ready to teach, topic based patient safety programme that can be implemented as a whole or per each topic ( or module) PATIENT SAFETY AND EDUCATION 'Patient safety is a core attitude and thus needs to be introduced early and then reinforced throughout postgraduate education and continuing professional development.' t' Stefan Lindgren, President of the World Federation for Medical Education 4
WHO PATIENT SAFETY CURRICULUM GUIDE: CULTURE CHANGE AREA or ATTRIBUTE EXAMPLES OLD WAY NEW WAY medical hierarchies hand hygiene: doctor does not clean hands between patients student says nothing and conforms to inadequate practices. imitates senior doctor. (1) Seek clarification on the 'when and how' for hand hygiene with the doctor or other senior person. (2) Say nothing but use safe hand hygiene practices (3) Say something in respectful manner to the doctor concerned and continue to use safe hand hygiene practices Medical Hierarchies Site of surgery Surgeon does not participate in checking the correct site for surgery or verifying the correct patient The surgeon is resentful of the pre-operative checking protocol, believing it to be a waste of time, and pressures the rest of the team to hurry-up. Adopt the approach of the surgeon and don t participate in checking decide that checking is too menial a task for a doctor anyway. (1) Actively help the rest of the team to complete the checking protocol Heterogeneous Solo No assistants New tech and materials More invasive adverse events in dentistry 5
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Introduce all curriculum topics/modules OR one topic at a time. Each topic contains technical information and instructions on how to teach it. Universities and faculties Suggestions about introducing case studies are provided The topics have been designed so that students can be responsible for much of their own learning (e.g reading on line materials) Educators encouraged to add professional literature and data on topics to teach. Download the Curriculum and teaching slides for free: http://www.who.int/patientsafety/education/cu rriculum 7
National Patient Safety Education Framework Walton M, Shaw T, Barnett S, Ross J Developing a National Patient Safety Education Framework for Australian Quality and Safety in Health Care 2006 15:437 42 What exactly is patient safety? Emanuel L, Berwick D, Conway J, Combes J, Hatlie M, Leape L, Reason J, Schyve P, Vincent C, Walton M. In: Henriksen K, Battles J B, Keyes M A, Grady ML, eds. Advances in Patient Safety: New Directions and Alternative Approaches. Rockville: Agency for Healthcare Research and Quality August 2008 WHO Patient Safety Curriculum Guide for Medical students Walton M, Woodward H, Van Staalduinen S,Lemer C, Greaves F, Noble D, Ellis B, Donaldson L, Barraclough BThe World Health Organization (WHO) Patient Safety Curriculum Guide for Medical Schools ( for submission) Dr. Enrique Acosta Gío acostag@servidor.unam.mx 8