Is a hospital stay safe?
Our mission: Ensuring safe care in your facility
“…Because life is the highest price patients pay for a serious adverse event, and that should never happen again.”
Non-safety of care, does it cost money?
The cost of prescription errors has been estimated at US$42 billion per year. This represents almost 1% of total global health spending.
What is a Care-Related Adverse Event (CRAE)?
It is an unexpected circumstance or event associated with the care that could have or has resulted in harm to the patient and which it is hoped will not happen again.
What is the likelihood of having a CRAE?
It is estimated that there is a 1 in 3 million risk of a person dying during air travel.
In comparison, the risk of a patient dying from an adverse event during care is estimated to be 1 in 300.
Industries known to have a much higher risk than health, such as aviation and nuclear energy, have a much better safety record than health care.
What kind of mistakes are we talking about?
Each of these contributing factors, alone or in combination, can cause serious harm, disability or even death to the patient concerned.
There are four main infection sites described in the literature. In order of frequency: pneumonia, urinary tract infections, surgical site infections and bacteremia.
Infections account for about 40% of adverse surgical events. The rate of infected surgical sites has been reported to range between 2 and 20% depending on risk factors.
Infections are the cause of additional costs, particularly due to the subsequent extension of the hospital stay.
No health system in the world is spared from infections, anaesthesia-related complications, or surgical site or surgical site errors.
In ambulatory care services in the United States, 5% of adults face misdiagnosis. In Malaysia, a study has established the frequency of misdiagnosis at 3.6%.
Risk of falls
The latent error factors, the "Swiss cheese model"...
Upstream of the individual, there is the workstation, where several elements, mainly organizational, are conditions that favour error. And even further upstream, latent factors located in particular at the strategic and budgetary level determine the circumstances favouring error, as well as the flaws in the “safety barriers” downstream of the act of care, which are supposed to protect the patient from an undesirable event.
To illustrate the consequences of these faults when they “line up” in time and place, Reason proposes the “Swiss cheese model”, where latent factors, error-prone conditions and gaps in safety barriers are holes in cheeses that, when aligned, allow the harmful process of error to proceed without ever being blocked, ultimately leading to an adverse event in the patient.
Bibliographic reference :
1. James Reason: patient safety, human error, and Swiss cheese. Interview by Karolina Peltomaa and Duncan Neuhauser. – PubMed – NCBI [Internet]. [cité 24 févr 2020]. Available: https://www.ncbi.nlm.nih.gov/pubmed?term=(reason%20J%5BAuthor%5D)%20AND%20swiss%20cheese
"Swiss cheese model"
Référence bibliographique :
1. James Reason: patient safety, human error, and Swiss cheese. Interview by Karolina Peltomaa and Duncan Neuhauser. – PubMed – NCBI [Internet]. [cité 24 févr 2020]. Disponible sur: https://www.ncbi.nlm.nih.gov/pubmed?term=(reason%20J%5BAuthor%5D)%20AND%20swiss%20cheese
Prevention of legal consequences
However, it is essential for the institution to have a global vision of the risks associated with care, a safety plan and a follow-up of preventive and corrective actions related to the patient care process.
In medicine, the legal consequences can be referred to Article 28 of the Swiss Civil Code, which states that
Anyone who suffers an unlawful attack on his personality may take legal action for his protection against any person involved.
An attack is unlawful unless it is justified by the consent of the victim, by an overriding private or public interest, or by law.
Types of legal consequences
- Civil liability, which is intended to provide financial compensation for harm caused to others without just cause.
- Criminal liability, which aims to impose a personal sanction for the violation of a criminal provision. The penalty is deprivation of liberty and/or a fine.
- Administrative liability, implemented by the employer, aimed at sanctioning the employee in his/her function within the institution. This responsibility obliges the institution to set up a body to examine the event by persons competent to judge the facts, their chronology and the responsibilities of the different actors involved, and requires the establishment of a system guaranteeing fair treatment.
Legal framework in Switzerland
It is essential to know the starting point before programming your security strategy.
Sensitize all your staff to the prevention of clinical risks
The vulnerable patient
The second victim
The barriers for second victims seeking help are :
- Inadequate organizational safety culture
- Stigma associated with seeking help
- Fear of losing respect as a professional
- Fear of loss of income
- Difficulty taking time off work
- Doubts about the confidentiality of the services offered
- For contract or casual employees, lack of organizational support
the quality of care
To assess quality, it is necessary to use indicators, measurable quantities that provide information on one or more parameters of the quality of care. An example of a process indicator would be the time it takes to manage a patient with a heart attack, which is determined by “good practice”. Outcome indicators may include the rate of pressure ulcers, the rate of falls, the rate of nosocomial infection, the rate of unplanned reoperations, patient satisfaction,etc.
Quality & Safety of care advice
We provide you with all our expertise in clinical risk management as well as complete audit and monitoring tools for your establishment.
We offer complete and specific training courses for all trades. Our goal? To improve the safety and quality of the services and care provided within your institution.
Let’s draw up together the prevention plan for your establishment and your teams
Case postale 104, Cologny 1223, Suisse
Genève : +41 783 13 30 01
Visit us at our next events
- 27 February 2020 in Morges, Switzerland :
Swiss Association for Quality and Proqualitas Health
- 11 May in Winterthur, Switzerland :
e-Healthcare Applications Summit
- 15-17 June in Zurich, Suisse :
Patient Safety Conferences
- 30-2 September in Florence, Italy :
International Society for Quality _ISQUA
- 2-5 November in Barcelona, Spain :
Congrès Mondial des Hôpitaux
- 9-11 November in London :
Leadership dans les Institutions de Santé
Construisons ensemble votre projet !
Établissons ensemble le plan de gestion de risques cliniques de votre établissement et de vos équipes