The patient safety day was first initiated by the World Health
Organization (WHO) in 2004. From then it has conducted several awareness
campaigns to promote the effects of unsafe healthcare practices and the
importance of ensuring proper safety to the patient in hospitals.
‘To err is human, World Patient Safety Day emphasizes the effects of healthcare errors that pose a risk to the patient safety and increase mortality rates of preventable deaths.’
Patient safety can be defined as the process of eliminating any
preventable harm to the patient during the process of healthcare. Patient
safety has emerged as a global threat and WHO considers this to be the main
cause of increased mortality rates in the world.
According to the WHO estimates, 1 in 10 people dies due to preventable
deaths globally. Therefore, this day focuses on creating awareness regarding the factors
that contribute to preventable deaths
to ensure proper patient safety.
Threats to Patient Safety
The main factors that contribute to preventable deaths and impose
threat to the safety of patients are the following:
Healthcare-associated Infections (HCAIs):
HCAI is considered to be the
most harmful cause of deaths around the world. Both the developing and the
developed countries have fallen prey to this. It is estimated that in every 100 hospitalized patients, about 7 in developed and
10 in developing countries will acquire health care-associated infections (HCAIs)
. WHO has launched "Clean Care is Safe Care"
and " Save Lives: Clean Your Hands" in 2005 to emphasize the importance of giving clean treatment and
washing hands regularly before and after contact with a patient.
errors contribute to a higher mortality and morbidity rates in the world. The
main drawback in ensuring proper drug administration is due to the confusion
between "look-alike and sound-alike" medications
and nurses tend to make errors while prescribing medications which can cause
harm to the patient's life.
Surgery is the most
common and preferred technique for eliminating disabilities and critical
injuries. It is estimated that surgeries are done mainly for cardiovascular
diseases, cancer and orthopedic injuries. Unsafe surgical practices can lead to
fatal errors and significant complications. WHO reports that the crude mortality rate after major surgery is 0.5-5%; it has started the "Safe Surgery Saves Lives" campaign in 2009 to improve the safety of surgical care around the world.
important factor contributing to the interpretation of a disease is diagnosis.
Millions of medical devices are available and the chances of committing errors
are high. Errors can occur due to faulty devices, misinterpretation, exchange
of samples, improper doses, etc.
Unsafe Injection Practices:
Reusing syringes and needles contribute to millions of deaths
annually. They act as a powerful medium of transmission for diseases like Hepatitis B
and Hepatitis C infection
. These indirectly increase the mortality
Unsafe Maternal and Childbirth Care:
WHO reports that about 2.6 million in stillbirth
, and another 2.7 million in a newborn
annually. The majority of these deaths are preventable. Lack of timely care,
continuous monitoring and simple errors committed during diagnosis and delivery
period contribute to the increased maternal and infant mortality rates.
Unsafe Blood Transfusions:
Majority of healthcare providers use central venous catheters (CVC) for giving medicines and fluids to the patients, but the complications
associated with it remain unaware. They cause several bloodstream infections
resulting in prolonged
hospital stay and increased costs of care. About 25 % of patients who acquire
CVC die globally.
Lack of Proper Hospital Infrastructure & Manpower:
Hospital infrastructure also plays an
important role in patient safety. It is must to ensure that hospitals are well
equipped with adequate beds, medicines, diagnostic devices, intensive care
units, neonatal and maternal care, well-trained healthcare personnel. Lack of
any of these factors can increase the rate of preventable deaths. Improper Communication and Co-Ordination:
Ineffective communication and coordination
between doctors, nurses and hospital staffs can cause risk to the patient
safety. Work stress
, longer working hours,
lack of holidays can also add stress to their communication resulting in
miscommunications, misdiagnosis, prescribing wrong medicines and tests, etc.
Patient Safety Solutions
In 2005, the World Health Organization (WHO) summoned a Center for
Patient Safety Solutions. Experts
conducted several surveys and established key criteria for reducing healthcare
errors to ensure proper patient safety.These include:
Look-Alike, Sound-Alike Medication Names:
Confusion regarding drugs with similar generic and brand names can be
eliminated by proper labeling. It is must to label drug storage boxes with correct
label for easy handling and prescription.
Ensure correct patient identity by providing identity cards to
eliminate testing, medication and discharge errors. Correct Procedure at Correct Body Site:
Surgical procedures must be performed at the correct injured site to
eliminate unwanted post-operative complications. Increased foot traffic
, ineffective communication
inside the operation theaters must be avoided.
Avoiding Catheter and Tubing Mis-Connections:
Eliminate use of catheters for blood transfusions to reduce the risk of
bloodstream infections. Misplacing catheter and tubing and delivering
medications through the wrong route can cause harm to the patient.
Single Use of Injection Devices:
Ensure syringes are used for a single shot and immediately thrown off.
It is estimated that the reuse rate of injection devices has reduced to 5.5% and the number of
injections per person by
2.88% in 2010.
Improved Hand Hygiene to Prevent Health
prevention and control (IPC) has been set up to
prevent the harm caused by infection to patients and health workers. Simple and low-cost infection
prevention and control measures, such as appropriate hand hygiene
can reduce the frequency of
health care-associated infections (HAIs) by more than 50%.
WHO reports that
prolonged hospitalization, litigation costs, hospital acquired infections,
disability and medical expenses cost some countries as much as US$ 19 billion
annually. Therefore, the economic benefits of improving patient safety are
WHO's Current Plans for Ensuring Patient Safety:
identified the following as the key technical areas of work for the 2015-2017
What Must a Patient Do?
- Proper hand hygiene
- Prevention of surgical site
- Control of antimicrobial
- Safe injection procedures
- Burden of health care-associated infections
- IPC country capacity-building
- Prevention of catheter-associated
bloodstream infections and urinary tract infections
- Make sure you know
about the standards of care and treatment of the hospitals in your
locality. Every hospital will be given a
safety score based on the quality of care provided.
- Give proper personal
data to the hospital staffs. Ensure you get a personal identity card.
- Inform doctors about
your medical history, previous surgeries undergone, allergies, prescribed
medications and tests and also about the current medications.
- Ensure the
medications and tests provided to you are appropriate. Ask
questions if you have any doubt or if you are not sure of any detail about
a second opinion on a medical condition without fear.
- Ask the
doctor about the pros and cons of any medical procedure and be clear about its side effects.
- Inform hospital staffs if you are
pregnant or breastfeeding.
- Ask reasons in case of prolonged hospital stay and
also about dietary patterns.
- Inform doctors if you have difficulty
breathing, pain, fever, dizziness, vomiting or unexpected reactions
- Ask when you should come back for