even if patient safety were not an issue, is it his responsibility to report what he has observed?

What are some of the patient safety situations causing most concern?

Below are some of the patient safety situations causing most concern. 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).

What is the main goal of patient safety in the health system?

From a moral perspective, the main goal of patient safety in the health system can be studied from two aspects. It can be studied as a practical value, in the sense that the main focus is its positive outcomes and benefits. It can also be studied as a moral value by focusing on the protection and promotion of humanity and human dignity.

How to encourage voluntary reporting of incidents of patient safety?

Furthermore, the provision of emotional support and legal protection of the staffs by the organization is essential to encourage voluntary reporting of incidents. Moreover, training and emphasizing on the professional code of ethics can be effective on deepening the understanding of and belief in the moral foundations of patient safety.

What are the laws and regulations related to patient safety?

Forensic medicine aspect Laws and regulations related to patient safety, which may vary based on the legislation system of each country, should encourage the disclosure of medical errors while supporting the implementation of the ethical imperatives of patient safety.

What are the concerns of the NHS?

Among the concerns raised about NHS services were: inadequate staffing levels, bullying, errors in drug administration, cases of misdiagnosis, delays in patients being examined and a lack of follow-up appointments.

What is the role of Care Quality Commission?

As the industry regulator, it is key that the Care Quality Commission provides clear guidance to workers about how to express any concerns they may have.

Can whistleblowers be adversely affected?

I won’t pretend whistleblowers are never adversely affected as a result of their actions, but under the Public Interest Disclosure Act 1998, those who suffer dismissal, victimisation or any other detriment can take a compensation claim to an employment tribunal.

Is the CQC a fault?

After the alleged abuse of people with learning disabilities at Winterbourne View private hospital, the CQC admitted there had been fault on its part in failing to follow up the concerns of a whistleblower. After reviewing its systems and processes, it set up a special team at its national customer service centre in Newcastle to ensure all whistleblowing concerns that come to the CQC are logged and the follow-up action is tracked until it reaches a conclusion.

What is a pharmacist's role in a patient's care?

When a practitioner voices a concern, there may be an explanation from competent practitioners that dispels the initial concern too quickly, before it has been given sufficient consideration. A pharmacist reassures a technician that the compounding directions are correct when questioned about an unusual volume of ingredients; a pharmacist assures a nurse that the strength of an infusion is correct when questioned about the final volume; a nurse reassures a patient that the medication is correct when questioned about its appearance; a physician convinces a pharmacist that the prescribed dose is correct when questioned because it differs from what he found during investigation. These are real, all-too-frequent examples of backing away from an initial concern that subsequently led to fatal adverse drug events. Those who questioned the patients’ care were easily convinced that others knew more than they did, particularly if the provider who was questioned had an otherwise stellar reputation.

What is perceived safety of speaking up?

Perceived safety of speaking up, such as a psychologically safe work environment and managerial/coworker support

Why do healthcare practitioners speak up?

Healthcare practitioners are expected to speak up about patient safety concerns to help intercept errors and avoid adverse patient outcomes. By ‘speaking up,’ we mean raising concerns for the benefit of patient safety and quality of care upon recognizing or becoming aware of a risk or a potential risk. 1 Such risks may include concerns about the safety of an order or treatment modality, a possible missed diagnosis, questionable clinical judgment, rule breaking, dangerous shortcuts, incompetence, and disrespect. Healthcare practitioners, especially frontline staff, are well positioned to observe unsafe conditions and bring them to the attention of those who can remediate them.

Is it reasonable to question a patient?

Is this a form of intimidation? Perhaps, but it may be more akin to a logical deference to expertise, meaning it is natural and often reasonable for people to defer final judgment to those they perceive to be more “qualified.” The person questioning the patient’s care has been easily convinced that their concern is unfounded, and the person being questioned has not perceived the voiced concern as a possible, credible patient threat. Neither the questioner nor the person being questioned possess a required element to safeguard patients: an appropriately high index of suspicion for errors. A low index of suspicion is particularly problematic in a healthcare system that is often reluctant to acknowledge human error or value the contributions from every person, regardless of rank, who interacts with the patient.

Do nurses take safety concerns to their managers?

Although nurses in the study were more likely to take their safety concerns to their managers than to speak directly to the practitioner, fewer than half of these managers followed through and spoke up about the reported safety issue; thus, taking safety concerns to a manager may not produce reliable results.

Is patient safety important in ISMP?

ISMP is not discounting the fact that many complex factors influence whether healthcare practitioners speak up about patient safety concerns. We also do not discount the extraordinary courage it may take for many to step up to these conversations. However, tolerance of risk that goes unchallenged is a serious patient safety concern, and to combat that, all who interact with patients must become an observant questioner and raise their index of suspicion of errors. Healthcare practitioners need to ensure that patient safety concerns are not only raised but also properly investigated and addressed. You can be sure that those involved in serious and fatal errors wish that they had taken the opportunity to do just that.

What is patient safety event reporting?

Patient safety event reporting systems are ubiquito us in hospitals and are a mainstay of efforts to detect patient safety events and quality problems. Incident reporting is frequently used as a general term for all voluntary patient safety event reporting systems, which rely on those involved in events to provide detailed information. Initial reports often come from the frontline personnel directly involved in an event or the actions leading up to it (e.g., the nurse, pharmacist, or physician caring for a patient when a medication error occurred), rather than management or patient safety professionals. Voluntary event reporting is therefore a passive form of surveillance for near misses or unsafe conditions, in contrast to more active methods of surveillance such as direct observation of providers or chart review using trigger tools. The Patient Safety Primer Detection of Safety Hazards provides a detailed discussion of other methods of identifying errors and latent safety problems.

What is the Patient Safety and Quality Improvement Act?

The legislation provides confidentiality and privilege protections for patient safety information when health care providers work with new expert entities known as Patient Safety Organizations (PSOs). Health care providers may choose to work with a PSO and specify the scope and volume of patient safety information to share with a PSO. Because health care providers can set limits on the ability of PSOs to use and share their information, this system does not follow the pattern of traditional voluntary reporting systems. However, health care providers and PSOs may aggregate patient safety event information on a voluntary basis, and AHRQ will establish a network of patient safety databases that can receive and aggregate nonidentifiable data that are submitted voluntarily. AHRQ has also developed Common Formats —standardized definitions and reporting formats for patient safety events—in order to facilitate aggregation of patient safety information. Since their initial release in 2009, the Common Formats have been updated and expanded to cover a broad range of safety events.

How is event reporting used in health care?

A 2016 article contrasted event reporting in health care with event reporting in other high-risk industries (such as aviation), pointing out that event reporting systems in health care have placed too much emphasis on collecting reports instead of learning from the events that have been reported. Event reporting systems are best used as a way of identifying issues that require further, more detailed investigation. While event reporting utilization can be a marker of a positive safety culture within an organization, organizations should resist the temptation to encourage event reporting without a concrete plan for following up on reported events. A PSNet perspective described a framework for incorporating voluntary event reports into a cohesive plan for improving safety. The framework emphasizes analysis of the events and documenting process improvements arising from event analysis, rather than encouraging event reporting for its own sake.

Why are event reports limited?

The spectrum of reported events is limited, in part due to the fact that physicians generally do not utilize voluntary event reporting systems.

What are the most frequently reported events in a hospital?

Studies of electronic hospital event reporting systems generally show that medication errors and patient falls are among the most frequently reported events.

What does an event report do?

While event reports may highlight specific concerns that are worthy of attention, they do not provide insights into the epidemiology of safety problems. In a sense, event reports supply the numerator (the number of events of a particular type–and even here, this number only reflects a fraction of all such events) but do not supply the denominator (the number of patients vulnerable to such an event) or the number of "near misses." Event reports therefore provide a snapshot of safety issues, but on their own, cannot place the reported problems into the appropriate institutional context. One way to appreciate this issue is to observe that some institutions celebrate an increase in event reports as a reflection of a "reporting culture," while others celebrate a reduction in event reports, assuming that such a reduction is due to fewer events.

What must be disseminated in a timely fashion?

Summaries of reported events must be disseminated in a timely fashion.

What is the relationship between patient safety and professional ethics?

Professional ethics and patient safety are intertwined fundamental concepts in medicine. Patient safety is grounded in ethical principles which are considered as care quality indicators (15). The realization of patient safety requires the provision and implementation of a professional code of ethics. Based on the Iranian healthcare professional code of conduct, it is expected that all patients be treated with dignity and be protected from any possible harm (16). Accordingly, adherence to ethical principles requires healthcare providers to identify potential safety failures to prevent falling incidents (15).

What is the moral value of patient safety?

It can be studied as a practical value, in the sense that the main focus is its positive outcomes and benefits. It can also be studied as a moral value by focusing on the protection and promotion of humanity and human dignity. It should be emphasized that both aspects are important in the health system. From a professional point of view, moral values in patient safety are not separated from basic medical obligations, but are so central that they may be the source of other moral values emphasized in medicine. This means that patient safety is closely related to the concept of human dignity and all patient safety measures taken must insure the protection of human’s dignity (10). In other words, the responsibility of the health care staff and professional commitment, in general, are closely related to human dignity (11).

What should not be used in a care team announcement?

Moreover, irritating phrases such as “It happens” and “Nothing has happened though” should not be used.

Why can't we hide medical errors?

Although anger under such circumstances is a natural reaction, we cannot hide medical errors because of fear of parents’ reaction. Moreover, parents’ anger would be more severe if they found out that the hospital personnel have concealed the truth.

How to reduce the possibility of such events in clinical settings?

The most important step to reduce the possibility of such events in clinical settings is to establish policies and procedures that work best for each ward. Furthermore, the continuous training of the personnel in patient safety, steady supervision, and controlling the efficacy level of the performed actions are some other steps that can be taken in this regard. For instance, in this case, frequent checking of the incubator door, the use of two locks, and explanation of safety tips regarding the incubator to the staff are also important. Furthermore, evaluation and constant controlling of compliance with patient safety rules, and feedback are also necessary.

How to reduce the incidence of patient injuries?

Searching for the causes and finding the right solution, in other words, the basic analysis of the incident is one of the initial and essential measures taken to decrease the incidence of patient injuries. It should be noted that the mentioned process must be free of any bias and should focus on finding the main cause and resolving it instead of identifying the responsible person. One way of preventing such events is to have a special guideline for reporting the event in a suitable organized ethical atmosphere without accusing anyone. Indeed, fear of blame, penalties, limited organizational support, inadequate feedback, and lack of knowledge about the associated factors are some of the barriers to reporting medical errors in hospitals (12).

What is the most common cause of injury in healthcare?

Since 2004, with the beginning of the patient safety project, so far 140 countries have attempted to improve their patients' safety plans in their own health system (7). The most common cause of injury is medication errors and falling. Although falling includes 21% of total incidents, only 4% of them are serious. Meanwhile the neonatal falling statistics in the USA is 1.6-4.4 in 10,000 live births, an estimated 600-1600 falling incidents in a year. These cases are often the result of shortcomings in systems and processes, organizational complexity and ambiguity, and poor communication (8, 9).

Why is patient safety important?

Patient safety is an essential and vital component of quality nursing care. However, the nation’s health care system is prone to errors, and can be detrimental to safe patient care, as a result of basic systems flaws. A variety of stakeholders (society in general; patients; individual nurses; nursing educators, administrators, and researchers; physicians; governments and legislative bodies; professional associations; and accrediting agencies) are responsible for ensuring that patient care is safely delivered and that no harm occurs to patients. The responsibility of these stakeholders in addressing patient safety in the context of a nursing shortage is discussed, along with specific actions they have taken, and can continue to take, to promote safe care.

How has nursing research made a significant contribution to patient safety?

Nursing research has made a significant contribution to patient safety by identifying the need for adequate staff.

How can nurses improve patient care?

Nurses can also enhance safe care by serving as competent team leaders. The delivery of nursing care to patients is often a team effort in which RNs direct non-registered nurses. RNs must know the competencies, legal parameters, and tasks that can be performed by others, such as licensed practical nurses (LPNs) and unlicensed assistive personnel (UAPs). In 1990, the American Association of Critical Care Nurses (AACN) developed a list of six risk factors (potential for harm; condition/stability of the patient; complexity of the task; level of problem solving or innovation that might be needed; unpredictability of the outcome, and level of interaction required with the patient to successfully complete the task) for an RN to consider when evaluating whether an UAP could perform a certain task on a particular patient ( AACN, 1990 ). RNs must provide the appropriate levels of direction and supervision when nursing care is being delivered by others so that the patient receives safe and competent care.

How can informed patients improve their care?

The ANA’s campaign during the last nursing shortage, entitled " Every Patient Deserves a Nurse ," helped patients understand the need to have Registered Nurses oversee their care. In addition, patients can request that health care facilities provide an "institutional report card" that describes such indices as outcomes of patient care for medical conditions and surgical interventions, medical error rates, nosocomial infection rates, RN to patient staffing ratios, availability of support personnel, morbidity and mortality rates, lengths of stays for patients with certain conditions, opportunities for pre-admission and discharge planning, and incidents of malpractice.

What is the scientific basis of nursing?

Nursing is a knowledge-based profession. The basis for the scientific practice of nursing includes nursing science ; the biomedical, physical, economic, behavioral and social sciences; ethics; and philosophy. A nurse’s ability to be a critical thinker and to use this knowledge in the delivery of nursing care is essential to the well being and safety of those for whom nurses care ( ANA, 2003b; Ballard, 2002 ).

What is patient centered care?

Patient-centered – providing care that is respectful of and responsive to patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions.

Why do RNs need to provide direction?

RNs must provide the appropriate levels of direction and supervision when nursing care is being delivered by others so that the patient receives safe and competent care. It is a nurse’s professional responsibility to remain safe and competent by being a lifelong learner.

How to engage patients in safety?

Efforts to engage patients in safety efforts have focused on three areas: enlisting patients in detecting adverse events, empowering patients to ensure safe care, and emphasizing patient involvement as a means of improving the culture of safety.

Why is patient engagement important?

Although patient engagement is a promising strategy for error reduction, there is reason for caution on several grounds. From a systems engineering viewpoint, the level of patient and family participation will always be difficult to predict, leading some to argue that a robust safety program should not depend on such engagement. Furthermore, patients and caregivers already shoulder a significant emotional burden for ensuring safety while hospitalized. An important study found that a surprising number of patients and family members feel guilty after a medical error, and another study found that most parents of hospitalized children felt personally responsible for ensuring their child's safety in the hospital. Engaging patients in error prevention therefore risks simply shifting the responsibility for safety from providers and institutions to patients themselves.

What is the paternalistic model of medicine?

The traditional paternalistic model of medicine, in which patients have little voice in their care, has slowly but surely been evolving toward a model in which patients and clinicians work in a partnership toward the common goal of improved health. As articulated in the seminal Institute of Medicine report Crossing the Quality Chasm, such patient-centered care should be "respectful of and responsive to individual patient preferences, needs, and values and ensure that patient values guide all clinical decisions."

What is patient engagement?

Patient engagement in safety efforts is a strong priority of influential regulatory and governmental organizations. The Agency for Healthcare Research and Quality and the World Health Organization sponsor a variety of programs centered around patient education and encouraging patient perspectives to improve safety culture.

Can a patient survey be used as an error detection mechanism?

Hospitalized patients are routinely surveyed about their satisfaction with the care they received, and recent research has examined whether patient surveys may be used as an error detection mechanism. Studies in the inpatient setting have found that patients often report errors that were not detected through traditional mechanisms such as chart review; indeed, patient-reported errors formed the basis of landmark studies of adverse events after hospital discharge. Concerns have been raised, however, that patient complaints may center on poor service quality rather than on clinical adverse events.

What are the rights of a patient?

Commonly established rights tend to derive from a core set of ethical principles, including autonomy of the patient, beneficence, nonmaleficence, (distributive) justice, patient-provider fiduciary (trusting) relationship, and the inviolability of human life. The establishment of whether one principle is of greater inherent value than another is a philosophical endeavor that varies from authority to authority. In many situations, beliefs may directly conflict with one another. When a legal standard does not exist, it remains the obligation of the health care provider to prioritize these principles to achieve an acceptable outcome for the patient.

Why should we have patient rights?

Establishing clearly defined patient rights helps standardize care across healthcare fields and enables patients to have uniform expectations during their treatment. According to the American Cancer Society, organizations should develop patient bills of rights “to empower people to take an active role in improving their health, to strengthen the relationships people have with their health care providers, [and] to establish patients’ rights in dealing with insurance companies and other specific situations related to health coverage.” As with other bills of rights, modern bills of patient rights establish that persons can expect certain treatment regardless of their socioeconomic status, religious affiliation, gender, or ethnicity.

What is patient autonomy?

A patient who can defend his or her judgments has the right to make decisions that do not coincide with what the physician believes is beneficial to that patient. This philosophical concept has become a legal right essentially throughout the Western world. As legal precedents have advanced the requirements for patient autonomy to a greater degree than the requirements for health care provider beneficence, patient autonomy has arguably become the dominant principle affecting patient rights. For example, a patient may refuse treatment that the physician deems to be an act of beneficence. In such cases, the unwritten social contract between patient and physician requires that medical professionals still attempt to inform the patient of the potential consequences of proceeding against medical advice. A patient's autonomy is violated when family members or members of a healthcare team pressure a patient or when they act on the patient’s behalf without the patient’s permission (in a non-emergency situation).

What is the conflict between a physician and a patient?

Of the other principles, a physician's intent for beneficence conflicts most often with patient autonomy. This conflict has led to the development of documentation in which the patient must demonstrate their understanding of the predictable consequences of his decision to act against medical advice. When disagreements arise between a healthcare provider and a patient, the health care provider must explain the reasons for their recommendations, allowing the patient to make a more informed decision.

What is NCBI bookshelf?

NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.

Do countries have a patient bill of rights?

However, none of these countries has a specific law outlining a general patient bill of rights, in contrast to multiple European countries. The North American countries' "bills of rights" protecting human rights do not relate to healthcare per se. The closest that a North American government has come to pass an actual patient bill of rights was in 2001. That year saw the failed American Bipartisan Patient Protection Act, the failed Canadian Standing Senate Committee on Social Affairs, Science and Technology bill, and the failed Canadian C-261 bill. Many individual states and provinces have created their own specific patient rights policies. In the states that have no plans, the decision regarding whether or not to use such a system is up to the individual hospital. Thus, there continues to be considerable variation in standards from region to region and from hospital to hospital.

Is patient rights a human right?

Patient rights are a subset of human rights. Whereas the concept of human rights refers to minimum standards for the ways persons can expect to be treated by others, the concept of ethics refers to customary standards for the ways persons should treat others. As such, rights and ethics are usually flip sides of the same coin, and behind every ‘patient right’ is one or more ethical principle from which that right is derived. This activity discusses how the interprofessional team can ensure that ethical principles are followed and the patient's rights are assured.

What is the first and most important issue when a patient receives less than ideal care?

Rationale: The first and most important issue when a patient receives less than ideal care is to make sure you stabilize and care for the patient. Only after the patient's safety and comfort are addressed should you consider an apology. You're a new resident (house officer).

What does "you experienced harm due to a medical intervention" mean?

"You experienced harm due to a medical intervention. We think your nurse gave you the wrong dose of medication. I wrote the prescription for it incorrectly. We're looking into it now."

What does it mean when you are about to administer the wrong medication?

A. You are about to administer the wrong medication, but the patient corrects you and is not harmed.

What is the first action upon discovering an adverse event?

Rationale: The first action upon discovering an adverse event always is to take care of the patient's physical needs.

Who needs to be notified of an adverse event?

Various people, departments, entities, or agencies may need to be notified that there has been an adverse event, so once the immediate patient needs are addressed, you'll want to make sure the proper parties are informed.

Who is best suited to communicate with patients following adverse events?

C. Due to its complexity, communication with patients following adverse events is best done by lawyers.

What does it feel like to be a caregiver after an adverse event?

Raionale: After an adverse event, the caregivers involved may be feeling a multitude of emotions. They can feel upset, guilty, self-critical, depressed, and scared after an event. In addition, their job satisfaction, ability to sleep, relationships with colleagues, and self-worth can be negatively affected.

Why is it important to have two way communication in health care?

For example, according to The Joint Commission, an estimated 80 percent of serious medical errors can be linked to miscommunication between caregivers when patients are transferred or "handed-over." One of the hallmarks of effective health care teams is frequent, two-way communication — a characteristic that would likely have an immediate and positive effect on care transitions and safety. While better teamwork can lead to fewer delays, elimination of waste, and even less costly care, these results would likely be secondary to an increase in safety.

What are the characteristics of a strong health care team?

Rationale: One of the main characteristics of strong health care teams is effective and frequent communication. The absence of unprofessional behavior does not necessarily mean the team is effective. And the failure to share information during shift changes is risky for patients.

Has a complaint about unprofessional behavior been filed by clinic members over the past year?

A. Not a single complaint about unprofessional behavior has been filed by clinic members over the past year.

Background

• While there are numerous studies2 and anecdotes that demonstrate the positive relationship between speaking up and patient safety, hesitancy to speak up is an important contributing factor in errors and adverse events.1 Most practitioners, regardless of their position and specialty, have some experience with hesitating to voice a concern related to...

See more on ismp.org

Characteristics of Incident Reporting Systems

Limitations of Event Reporting

Using Event Reports to Improve Safety

See more on psnet.ahrq.gov

Current Context