1)

Patient

Setup

Introduction

A)

Safety

in

Indian

Outpatient

Patient Safety holistic view

Patient safety is one of the most pressing health care challenges.

Unintended medical errors are the leading cause of deaths all over the
world.
The frequency and magnitude of avoidable adverse patient events was
not well known until the 1990s, when multiple countries reported
staggering numbers of patients harmed and killed by medical errors.
Recognizing that healthcare errors impact 1 in every 10 patients
around the world, the World Health Organization calls patient safety an
endemic concern.
The 10 facts about patient safety as per World Health Organization
(WHO):
1.
Patient safety is a serious global public health issue. In recent
years, countries have increasingly recognized the importance of
improving patient safety. In 2002, WHO Member States agreed on a
World Health Assembly resolution on patient safety.
2.
Estimates show that in developed countries as many as one in 10
patients is harmed while receiving hospital care. The harm can be
caused by a range of errors or adverse events.
3.
In developing countries, the probability of patients being harmed
in hospitals is higher than in industrialized nations. The risk of health

Table of Contents

1) Introduction......................................................................................3
A)
B)

Patient Safety holistic view.........................................................3

Patient safety in Outpatient setup..............................................5

2) Issues in Patient safety.....................................................................7

Medicine error

Treatment

Surgical error

1) Physical Patient
Safety in Transfusion
Indian(Blood
Outpatient
environment accidents
& Fluid)
Setup

Introduction
Diagnostic

A)

Patient Safety holistic view

HAI

errorhealth care challenges.

Patient safety is one of Healthcare
the most pressing
Unintended
medical errors are the leading cause of deaths
all over the
Communication
Equipment
world.
The frequency and magnitude of avoidable adverse patient events was
not well known until the 1990s, when multiple countries reported
staggering numbers of patients harmed and killed by medical errors.
Recognizing that healthcare errors impact 1 in every 10 patients

ERR
When actions are plann

around the world, the World Health Organization calls patient safety an
Classification
endemic concern.
andpatient
Lapses safety as per World Health Organization
The Mistakes,
10 facts Slips
about
R E ARONSON 2006

Mistakes
(WHO):
Errors
in Planning
Actions
1.
Patient safety is a serious global public health
issue.
In recent

years, countries have increasingly recognized the importance of

improving patient safety. In 2002, WHO Member States agreed on a

Knowledge based errors

Rule based Errors Act

World Health Assembly resolution on patient safety.

2.
Estimates show that in developed countries as many as one in 10
Good rule misapplied

patients is harmed while receiving hospital care. The harm can be

caused by a range of errors or adverse events.
3.
In developing countries, the probability of patients being harmed
in hospitals is higher than in industrialized nations. The risk of health
B)
Medical errors.............................................................................9
I) Patient Identification...................................................................9
II)
Diagnosis................................................................................12
III) Medication..............................................................................14
II)
Healthcare associated infections (HCAI)................................16
B)

Patient errors............................................................................19

Bad Rul

Medicine error

Treatment

Surgical error

1) Physical Patient
Safety in Transfusion
Indian(Blood
Outpatient
environment accidents
& Fluid)
Setup

Introduction
Diagnostic

A)

Patient Safety holistic view

HAI

errorhealth care challenges.

Patient safety is one of Healthcare
the most pressing
Unintended
medical errors are the leading cause of deaths
all over the
Communication
Equipment
world.
The frequency and magnitude of avoidable adverse patient events was
not well known until the 1990s, when multiple countries reported
staggering numbers of patients harmed and killed by medical errors.
Recognizing that healthcare errors impact 1 in every 10 patients

ERR
When actions are plann

around the world, the World Health Organization calls patient safety an
Classification
endemic concern.
andpatient
Lapses safety as per World Health Organization
The Mistakes,
10 facts Slips
about
R E ARONSON 2006

Mistakes
(WHO):
Errors
in Planning
Actions
1.
Patient safety is a serious global public health
issue.
In recent

years, countries have increasingly recognized the importance of

improving patient safety. In 2002, WHO Member States agreed on a

Knowledge based errors

Rule based Errors Act

World Health Assembly resolution on patient safety.

2.
Estimates show that in developed countries as many as one in 10
Good rule misapplied

patients is harmed while receiving hospital care. The harm can be

caused by a range of errors or adverse events.
3.
In developing countries, the probability of patients being harmed
in hospitals is higher than in industrialized nations. The risk of health
III) Ignorance...............................................................................20
IV) Awareness..............................................................................20
2) Solution recommendation and standards.......................................22
A)

Avoiding medical errors / minimizing medical errors................22

I. Patient misidentification:..........................................................22
II.
Diagnosis................................................................................23

Bad Rul

Medicine error

Treatment

Surgical error

1) Physical Patient
Safety in Transfusion
Indian(Blood
Outpatient
environment accidents
& Fluid)
Setup
A)

Introduction
Diagnostic

Patient Safety holistic view

HAI

errorhealth care challenges.

Patient safety is one of Healthcare
the most pressing
Unintended
medical errors are the leading cause of deaths
all over the
Communication
Equipment
world.
The frequency and magnitude of avoidable adverse patient events was
not well known until the 1990s, when multiple countries reported
staggering numbers of patients harmed and killed by medical errors.
Recognizing that healthcare errors impact 1 in every 10 patients

ERR
When actions are plann

around the world, the World Health Organization calls patient safety an
Classification
endemic concern.
andpatient
Lapses safety as per World Health Organization
The Mistakes,
10 facts Slips
about
R E ARONSON 2006

Mistakes
(WHO):
Errors
in Planning
Actions
1.
Patient safety is a serious global public health
issue.
In recent

years, countries have increasingly recognized the importance of

improving patient safety. In 2002, WHO Member States agreed on a

Knowledge based errors

Rule based Errors Act

World Health Assembly resolution on patient safety.

2.
Estimates show that in developed countries as many as one in 10
Good rule misapplied

patients is harmed while receiving hospital care. The harm can be

caused by a range of errors or adverse events.
3.
In developing countries, the probability of patients being harmed
in hospitals is higher than in industrialized nations. The risk of health
III. Medication..............................................................................24
IV. Healthcare associated infections (HCAI)................................26
A)
B)
C)

Patient awareness.....................................................................27
Patient for patient safety..........................................................28
Patient Safety Standards and Implementation..........................28

2) Conclusion......................................................................................32
3) References.....................................................................................33
1) Appendix........................................................................................34

Bad Rul

Medicine error

Treatment

Surgical error

1) Physical Patient
Safety in Transfusion
Indian(Blood
Outpatient
environment accidents
& Fluid)
Setup
A)

Introduction
Diagnostic

Patient Safety holistic view

HAI

errorhealth care challenges.

Patient safety is one of Healthcare
the most pressing
Unintended
medical errors are the leading cause of deaths
all over the
Communication
Equipment
world.
The frequency and magnitude of avoidable adverse patient events was
not well known until the 1990s, when multiple countries reported
staggering numbers of patients harmed and killed by medical errors.
Recognizing that healthcare errors impact 1 in every 10 patients

ERR
When actions are plann

around the world, the World Health Organization calls patient safety an
Classification
endemic concern.
andpatient
Lapses safety as per World Health Organization
The Mistakes,
10 facts Slips
about
R E ARONSON 2006

Mistakes
(WHO):
Errors
in Planning
Actions
1.
Patient safety is a serious global public health
issue.
In recent

years, countries have increasingly recognized the importance of

improving patient safety. In 2002, WHO Member States agreed on a

Knowledge based errors

Rule based Errors Act

World Health Assembly resolution on patient safety.

2.
Estimates show that in developed countries as many as one in 10
Good rule misapplied

patients is harmed while receiving hospital care. The harm can be

caused by a range of errors or adverse events.
3.
In developing countries, the probability of patients being harmed
in hospitals is higher than in industrialized nations. The risk of health
Abbreviations....................................................................................34

Bad Rul