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PATIENT SAFETY
Faculty of Medicine, Masaryk University
Public Health - VLVZ9X1c
Spring semester 2014
Name and Surname: Mavis Araba Koufie
UCO: 274904
Email: 274904@mail.muni.cz
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Introduction and theoretical background
Patient safety has improved significantly since the last 10 years. It has progressed from being
a relatively insignificant topic to having a high position on the annals for providers of health
care, policy makers in health care, and managers in health care as well as the public in general
(4). It is, at present, essential in health care (1, 2, 3).
“Patient safety is the absence of preventable harm to a patient during the process of health
care.” (4).The regulation of patient safety, according to healthcare system, is to prevent harm
from happening to patients (4). The ambition of healthcare system is to provide maintenance,
protection and promotion of secure care to the general public (1, 5, 6, 7). If treatment and
health care are not delivered safely, then the aim of health care is not attained and much needs
to be done (1, 4, 8).
According to WHO, in developed countries, about 1 out of 10 patients is estimated to be
harmed during health care delivery (9). Many of health care associated harms can be
prevented. Minor errors may be made by some physicians when providing health care
services to patients. Not necessarily, all these errors would have harmful results. During the
delivery of health care services, some forms of harm that may be encountered cannot be
associated with errors. Such harms are complications from surgical procedures, nosocomial
infections (hospital acquired infections) or adverse reactions of medications administered. To
some possible extent, many patients may be ready to adapt to errors that may happen to them
during health care delivery. Patients are most worried about harm. They wish for no harm to
fall upon them while receiving health care (10, 11).
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Some developing countries lack the good medical equipment and facilities in their healthcare
sectors and hospitals compared to developed or industrialized countries. As such, there is
higher probability of patients from developing countries being harmed in hospitals than
patients in developed countries with good hospital facilities (9).
This seminar paper focuses on common errors and mistakes in primary health care and
hospitalisation of patients.
a. Primary health care
Primary health care in the healthcare system provides medical care to people in a community.
General practitioners provide these primary health cares. In primary health care delivery,
General practitioners attend to many patients and need to document all problems and
complains given by the patients. Common errors such as patient’s imprecise description of
their health problem would lead to wrong diagnosis of illness, incorrect prescription of
medications and, in some cases, failure to monitor drug dosage of patients through blood tests
occur in primary health care (10).
In primary health care, medication prescription is the most common and vital form of health
care delivery (12, 19). A Study carried out found error in about 1 out of 20 prescriptions given
by General practitioners in England. Larger numbers of these prescriptions written by General
Practitioners are without errors and adequately being monitored (10, 12). Information on drug
dose is very important and should be monitored through blood testing. Missing information
on the drug dose or incorrect prescribing of drug dose errors are more common in elderly
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patients and patients taking multiple drugs. High complications of medical care, treatment of
the elderly and health compromised patients have increased the challenges of drug
prescription. The probability of benefit has to balance the risk of harm for each decision taken
in prescription. Taking into consideration the patient’s view, the general practitioner must
apply the bodies of evidences, rules and guidance by using his clinical knowledge when
taking prescription decision. (20). Pharmacological harm may happen to such patients.
Pharmacist should always inform Physicians when they come across such errors in drug
prescription receipts. Physicians are recommended to train well in prescribing drugs and use
up-to-date computer systems; to research drugs that are still in use and drugs that are
withdraw from the market due to their severe adverse effects (10, 12).
b. Hospitalisation (hospital admissions)
Errors during administration of medications are quite common in hospital admissions (10, 13,
14, 15). Errors may be associated with improper prescription or improper method of
administrating drugs to patients. Some medications maybe omitted, dose may incorrect
(increased or decreased) or may not be prepared correctly. Route of administration may be
wrong, the labelling or arrangement of the drugs may be wrong and therefore, the drugs may
be given to the wrong patient. If health care providers are distracted or interrupted while
administering medications to patients, such errors may occur. These may lead to or may not
lead to probably unexpected harm to these patients (10, 13, 14, 15).
Nosocomial infection (hospital acquired infection) is one of the most common complications
that patients who are hospitalised encounter. Most common infections found consist of
pneumonia (possibly from ventilators), bloodstream infections (possibly from catheters and
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cannulas), urinary tract infections (possibly from the use of toilet facilities or catheters) and
surgical wound sites (10, 16). According to National Patient Safety Agency 2007, about 5-
10% of the total number of patients hospitalised get affected in the United Kingdom (UK)
(10, 17).
These complications may not be as a result of errors but malpractices by the healthcare
professionals such as improper hand washing while handling patients, not disinfecting hands
in between physical examination of individual patients or unsuccessfully identifying and
treating of infections due to contamination of specimen. Complications may not occur
immediately after a medical procedure or medical care but days to weeks later. All these
complications extend the stay of patients at the hospital and cause potential harm to them
(10). In comparison to some developing countries, the hazard in hospital associated infections
is much higher than industrialized countries (9).
Thoughtful concerns for patients, families and hospital administrators in the hospital care
include falls and fall injuries. Among hospitalised patients, falls quite frequent and in some
situations, repeatedly (21). According to research, factors that contribute to falls are complex,
multifactor and interrelated. Falls are major problem to elder people. In the United state,
research shows that older people over the age of 65years account for about 70% of bed days
in the hospitals (21, 22). Among the most common undesirable adverse events in the older
hospital patient admissions are fall injuries. In comparison to the community hospitals and
long-term health care facilities, evidence of effective prevention is still narrow (23). Of those
who fall, statistics show that 28% have bruises and minor injuries, 11.4% suffer severe soft
tissue wounds and about 5% have fractures. Around 2% suffer head traumas which could lead
to subdural hematoma or death (21, 24, 26). Impairment of function, pain (mild, severe or
extreme) and distress can develop in patients as a result of the injuries (21, 27).
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Discussion
Patient safety can be greatly improved if we learn from all the incidents that happen (10). In
primary health care, it is important for General Practitioners (Physicians) and patients to
establish a bond of trust, understanding and good communication. Communication is critical
factor for achieving enhanced patient safety. If there is improper communication between
physicians and patients, wrong information may be carried across and diagnosis may arise.
General Practitioners (Physicians) should pay much attention when listening to patients. They
must be observant. They should be able to communicate both verbally and nonverbally.
A General Practitioner’s office should provide a comfortable and relaxing ambiance for
patients. Patients should also be encouraged to open up to their physicians as they know much
about their own health conditions. They should be encouraged to follow the medication doses
prescribed to them. General Practitioner (Physicians) should educate patients on the adverse
effects of their medication and to report whenever they have any reactions to their
medications.
Fundamental skill in general practices is prescription of medication to patients. General
Practitioners must always re-check the prescription before handing it over to patients. If they
are unsure about the required dose of drug, they should contact the pharmacist for assistance.
They should conduct frequent blood tests to monitor drug intake of patients to prevent
overdose or under dose. Some pharmacological harm may be irreversible.
Avoidance of distraction and interruption by health care professionals should be a priority
when administering drugs and medications to patients during hospital admission.
Conversations between health care personals can be minimized while attending to patients.
Personal conversations should be discussed after attending to patients. Labels of medicines
and prescriptions must be read carefully. Patients taking multiple drugs could be asked to
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confirm their medications if healthcare professionals are not sure. Most patients know the
medications prescribed to them.
Practising good health care hygiene and taking preventive measures is very essential in the
hospital wards. Physicians should not forget to wash their hands when examining patients.
Before attending to each patient, hands must be washed and/or disinfected properly. In this
way, the chain of transmission of infection can be broken to prevent harm to patients.
At wards in hospitals, cleaners tend to ignore commonly used equipments such as telephones,
keyboards, mouse and computers. If these equipments are not cleaned efficiently microbes
accumulate on their surfaces. Many a time, health care professionals are very busy or stressed
and therefore forget to comply with basic but very crucial routines. Health care professionals
and physicians, who forget to wash their hands or disinfect their hands, can easily transmit
microbes unto patients after using these equipments. Thorough checking of the surfaces of all
equipments used in the hospital is very important.
Many health care professionals also make is point to educate their patients on preventions; the
importance of prevention and their benefits to the patients themselves.
Falls are important issue for hospitals and another threat to patient safety (21, 23). A key
component of fall prevention is to identify the patients who are at most risks; in this case, the
elderly (23, 24). Wheelchairs should be provided for elder patients; whether the patients are
totally mobile or partially mobile. Transportations from one department to the other should be
done on wheelchairs if possible. Elevators and other transportation facilities should be
provided to prevent falls at the hospitals and older patient hospitals. Bed rails should be
attached to hospital bed to prevent falling. Patients who fall and suffer from injuries such as
head trauma, fractures or long-term disabilities may also suffer psychologically. These
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patients may have to go to rehabilitation units or nursing homes, stay longer in the hospital
that required and would have to pay additional bills (21, 28, 29, 30). If low income patients do
not health insurance providers, such situation will be very difficult for them.
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Conclusion
In association with health care services, prevention of harms is very crucial. Patient safety
practices are most essential toward improving overall performance and quality of healthcare
services (10). A lot can be done to improve weak areas and enhance strong areas in the
healthcare system. Open communications, teamwork, good hygiene practices and mutual
dependence are essential key components in quality health care (10).
Patient should be involved in promoting safety health care. They should be educated about
the complexity in health care delivery. To create realistic care expectations, patients and the
public in general need to be informed better about the risks involved in health care delivery
(10). There should be improvement in controlling infection in the hospital, good management
of risks and safe use of clinical equipments and improve safe clinical practices by healthcare
professionals (18).
Facts are undeniable that up to 50% of patients who are hospitalised are at risk for falls.
Within this 50%, almost half of patients who fall suffer from injuries. All these falls and their
resultant in injuries have huge on patients. The length of stay of patients at the hospitals as
well as the costs of their stay is directly affected (23).
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References
1. Kangasniemi M, Vaismoradi M, Jasper M, Turunen H: Ethical issues in patient safety:
Implications for nursing management. Nursing Ethics. 2013, Vol. 20 Issue 8, p904-916.
13p.
http://eds.b.ebscohost.com/eds/pdfviewer/pdfviewer?vid=3&sid=a3d09302-e7f4-41e3-bc6dd83390bc462d%40sessionmgr112&hid=110
(Accessed on June 10, 2014)
2. Runciman W, Hibbert P, Thomson R, et al: Towards an international classification for
patient safety: key concepts and terms. Int J Qual Health Care 2009; 21(1): 18–26.
3. Sherman H, Castro G, Fletcher M.: Towards an international classification for patient
safety: the conceptual framework. Int J Qual Health Care 2009; 21(1): 2–8.
4. http://www.who.int/patientsafety/about/en/ (accessed on June 11, 2014)
5. Aroskar MA, Moldow DG, Good CM: Nurses’ voices: policy, practice and ethics. Nurs
Ethics 2004; 11(3): 266–276.6. International Council of Nurses (ICN). Supporting safe and
competent nursing practice: a conversation with Jean Barry. Int Nurs Rev 2010; 57(4):
409–411.
7. Stievano A, Jurado MG, Rocco G, et al. A new information exchange system for nursing
professionals to enhance patient safety across Europe. J Nurs Scholarsh 2009; 41(4): 391–
398.
8. Woodward S. Review: patient safety: a core value of nursing – so why is achieving it so
difficult?. J Res Nurs 2011; 16(3): 224–225
9. http://www.who.int/features/factfiles/patient_safety/en/ (accessed on June 11, 2014)
10. McCaughan D, Kaufman G: Patient safety: threats and solutions. Nursing Standard.
2013. Vol. 27. Issue 44. p48-55. 8p
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http://eds.b.ebscohost.com/eds/pdfviewer/pdfviewer?vid=7&sid=21e54336-9269-4cc9-8586-
0c32b51d2d0a%40sessionmgr114&hid=105 (Accessed on June 11, 2014)
11. Vincent C: Patient Safety. Second edition. Wiley Blackwell, Oxford. 2010
12. Avery AJ, Barber N, Ghaleb M et al: Investigating the Prevalence and Causes of
Prescribing Errors in General Practice: The Practice Study. 2012
tinyurl.com/prescribing-practice (Last accessed: June 4 2013.) (Accessed on June 11,
2014)
13.Dean B, Schachter M, Vincent C, Barber N: Prescribing errors in hospital inpatients:
their incidence and clinical significance. Quality and Safety in Health Care; 2002, 11, 4,
340-344.
14.McDowell SE, Mt-Isa S, Ashby D, Ferner RE: Where errors occur in the
preparation and administration of intravenous medicines: a systematic review and
Bayesian analysis. Quality and Safety in Health Care. 2010. 19, 4, 341-345
15. Ferner RE: An agenda for UK clinical pharmacology: medication errors. British
Journal of Clinical Pharmacology. 2012. 73, 6, 912-916.
16. Chambers C, Straub M: Standard principles for preventing and controlling
infection. Nursing Standard. 2006 20, 23, 57-65.
17. National Patient Safety Agency: Safer Care for the Acutely Ill Patient: Learning
from Serious Incidents. The Fifth Report from the Patient Safety Observatory. NPSA,
London. 2007
18. http://www.who.int/topics/patient_safety/en/ (accessed on June 11, 2014)
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19. Avery AJ, Barber N, Ghaleb M et al: The prevalence and nature of prescribing and
monitoring errors in English general practice: a retrospective case note review. Br J Gen
Pract, 2013; 63(613): e543 – e553
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3722831/ (Accessed on June 12, 2014)
20. Maxwell S, Walley T, Ferner RE: Using drugs safely. BMJ. 2002;324(7343):930–931.
21. Spoelstra, S., Given, B., & Given, C. (2012). Fall prevention in hospitals: An
integrative review. Clinical Nursing Research, 21(1), p. 92-112.
22. Davison, J., Marrinan, S.: Falls. Reviews in Clinical Gerontology, 2007, 17(2), 93-107
23. von Renteln-Kruse, W., Krause, T.: Incidence of in-hospital falls in geriatric patients
before and after the introduction of an interdisciplinary team-based fall-prevention
intervention. Journal of the American Geriatrics Society, 2007, 55(12), 2068-2074.
24. Mahoney JE. Immobility and falls. Clin Geriatr Med 1998;14:699–72
25. Coussement, J., De Paepe, L., Schwendimann, R., Denhaerynck, K., Dejaeger, E.,
Milisen, K.: Interventions for preventing falls in acute- and chronic-care
hospitals: A systematic review and meta-analysis. Journal of the American Geriatric Society,
2008, 56, 29-36
26. Healey, F., Oliver, D., Milne, A., & Connelly, J. B.: The effect of bedrails on
falls and injury: A systematic review of clinical studies. Age and Ageing, 2008, 37(4),
368-378.
27. Clough-Gorr, K., Erpen, T., Gillmann, G., von Renteln-Kruse, W., Iliffe, S., Beck, J.,
& Stuck, A.: Preclinical disability as a risk factor for falls in community dwelling older
adults. Journal of Gerontology, 2008, 63(3), 314-320
28. Chen, J., Simpson, J., March, L., Cameron, I., Cumming, R., Lord, S., & Sambrook, P.:
Risk factors for fracture following a fall among older people in residential
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care facilities in Australia. Journal of the American Geriatric Society, 2008, 56(11), 1-7.
29. Tinetti, M. E., Allore, H., Araujo, K. L., Seeman, T.: Modifiable impairments predict
progressive disability among older persons. Journal of Aging &
Health, 2005, 17(2), 239-256.
30. van Helden, S., van Geel, A., Geusens, P., Kessels, A., Kruseman, A., Brink, P.: Bone
and fall-related fracture risks in women and men with a recent clinical fracture. Journal
of Bone & Joint Surgery, 2008, 90(2), 241-248.