Patient safety -- Learning from Commonwealth fellowship

Dr Nikhil Datar ( At WHO )

1991, Harvard medical practice study

1999, IOM :” To err is human”

Studies from Australia and other countries

Patient safety

Dr Lucian Leap

“Many people in the healthcare profession and

in the general public still believe that mistakes in

medical care are episodes of individual failure

and that most errors occur as a result of

someone not doing his or her job.” ---Don Burwick (Achieving safe and reliable health care)

Inferences:

•Out of the 3.7% cases, the acts which could be

called as “negligence” were only 1%.

•50% of these are preventable.

•The majority of them were not individual failures

but the system failures. It was a defective system

which was just waiting to fail.

With Sir James Reason

57 per 100000 deaths happen due to unintended injuries..It is the 9th cause of mortality in the world.

“Swiss cheese” model of errors

Sir James Reason

Medicine is complex

• Harvard Venuguard query:– 250 primary problems+ 900 secondary

problems+300 medicines+ 100 diagnostic tests+40 procedures

– In ICU settings , 179 procedures per day .. Which can prove dangerous.

Philosophy of errors

• Ignorance• Ineptitude

– Samuel Gorovitz ( journal of medicine and philosophy, 1970)

• Situational Awareness

Test your awareness

How reliable is health care?

1000010010 1000 1million 10million100000

hazardous Ultra-safe

Bungee jumping

Mountainclimbing

Chemical manufacturing

Scheduled airlines

European rail

Nuclear power

health

Learning from Aviation industry

• Team work and communication

• Incidence reporting system

• Protocols and check lists