Patient Safety Programme initiated at Armed Forces Healthcare Facilities by holding Patient Safety seminar at PNS Shifa


Most Medical Errors, “Near Misses” occur due to system failure,
a few due to individual negligence

Patient Safety Programme initiated at Armed
Forces Healthcare Facilities by holding
Patient Safety seminar at PNS Shifa

Navy Chief Admiral Asif Sandila reminds doctors of
morality & upholding
of professional medical ethics

Essential components of patient safety programme are
based on certain principles for safe procedures
and practices - Surg Rear Admiral Adil Khan

KARACHI: Patient Safety Programme has been initiated in the Armed Forces Healthcare facilities all over the country by holding a one day seminar at PNS Shifa Karachi on February 7th 2013. The entire top leadership of Pakistan Navy including the Chief of Naval Staff Admiral Muhammad Asif Sandila Deputy Chief of Naval Staff Vice Admiral Sayyid Khawar Ali, Director Medial Services Navy Surg Rear Admiral Adil Khan graced the occasion with their presence chairing different sessions. The programme started with an excellent and most comprehensive presentation by DMS Navy Surg. Rear Admiral Adil Khan on organization of patient safety programme in Pakistan Navy Hospitals which was followed by different scenarios consisting of Role Playing Patient Simulation highlighting “Near Misses” in Hospitals in which students of Baharia Medical and Dental College, nursing staff, technicians and paramedics of PNS Shifa participated. These role plays apart from highlighting the issues like failure to listen to the patients, relying too much on one’s memory and the way over worked doctors and nursing staff can commit mistakes, also provided lot of amusement to the participants and got well deserved applause.

PNS Shifa organized a Patient Safety Seminar on February 7th 2013. Group photograph taken
during the seminar shows Chief of Naval Staff, Admiral Muhammad Asif Sandila , Deputy
Chief of Naval Staff Vice Admiral Sayyid Khawar, Surg. Rear Admiral Adil Khan DMS Navy
who were chief guests during different sessions along with officers, consultant staff of PNS Shifa.

Addressing the participants Chief of Pakistan Navy Admiral Asif Sandila said that he was pained to read that two children died who were living just close to the PNS Shifa because they were brought late to the hospital. The public needs to be educated to go to the nearby healthcare facility in any serious situation in time so that precious lives could be saved. I have been thinking for quite sometime to come to PNS Shifa and talk to the healthcare professionals but today since we have many guests from civilians, he would not speak the way he had thought of but would try to modify his speech. Very few people in Pakistan, he said, have access to medical care and you people in uniform have access to the best healthcare and if some facility is not available at PNS Shifa it is made available to you. Hence all those of you who are in uniform are a privileged class. Doctors are very busy and as stated earlier public needs to be educated to avail the healthcare facilities. However, if they do not feel comfortable to come to you, it means we have failed somewhere. We need to look at our attitude towards patients. People in need of medical care should be able to reach you. When a child living half a kilometer away from PNS Shifa dies, it needs to be investigated. By and large there are no serious issues, being busy practitioners, many a times doctors have to attend to the patients at the cost of their personal comfort. If 99% of the time you are performing your duties with devotion, nobody bothers about it but in 1% of cases, when there is some failure, it is highlighted by the media and criticized by everyone. You should be careful while accepting patients and listen to them carefully, he remarked.

Vice Admiral Sayyid Khawar Ali Deputy Chief of Naval Staff presenting
a memento to Dr. Erum Khan during the Patient Safety Seminar held
at PNS Shifa on February 7th 2013

Speaking in between the lines the Admiral Asif did say a lot to convey his feelings to the healthcare professionals present in the meeting. He then reminded them of morality and urged them to uphold professional medical ethics. To the patients, doctors are like angels. A few incidents have been there. Doctors do make mistakes leading to serious complications. Those among you who wear uniform have to be more careful. He hoped that patient safety programme being launched today will benefit the patients and we will learn from our mistakes and experiences. We must share our mistakes and also share good thing, he added.
Addressing the young doctors present in the meeting, he said that the professions they have chosen demand them to work twenty four hours. Usually it is said that the doctors after studying for over five years get very little return as compared to other professions but remember the prayers you get from the patients when they get better is much more than monetary gains. Those healthcare professionals who serve with devotion and dedication the ailing humanity will get the real rewards from God Almighty in Akhrat, he remarked.

Prof. Syed Tipu Sultan Principal Bahria University Medical and Dental College photographed
along with the participants in the different patient scenarios during Role Playing Patient
Simulations at the Patient
Safety Seminar organized by PNS Shifa on February 7, 2013.

Earlier in his presentation in the inaugural session Surg. Rear Admiral Adil Khan speaking on patient safety programme said that medical errors are quite common. We as doctors must abstain from harming or doing any wrong to any patient. We have no local data but studies conducted in United States have shown that as many as ninety eight thousand deaths are attributed to medical error and adverse events annually. Another study from Harvard Medical School showed that almost 49% of injuries were due to errors. An Australian study from twenty eight hospitals showed that adverse events accounted for 16.6% of deaths, 13.7% accounted for patient disabilities and 51% due to adverse drug events which were all preventable.
Common medical errors noted in Pakistan include delayed treatment, wrong identification of patient, wrong operation site etc., because of inadequate training, system failure, long working hours, look alike medicines and name alike medications and lack of proper checks. Healthcare professionals are now trying to make it safe. Doctors usually try to hide the errors. Individual failings or blaming, he said, will not solve the problem but make the situation worse. We have to redesign the system which is the primary cause of medical errors. In order to measure the harm, we have to understand the cause, identify the solution, study evaluation impact, and encourage staff to report medical errors as well as “Near Misses”. We should get information from patient complaints and take it seriously. Medical audit will identify weak areas. To understand the causes, deliberate on patient complaints, determine the cause of error. There could be multiple contributory factors. While identifying solution, there could be issues related to training of staff, equipment, staffing issues, fatigue, policy issues. Under fatigue an individual is liable to make mistakes, hence one might have to reduce their working hours, have clearly defined Standard Operating Procedures (SOPs) and charter of duties. Impact can be evaluated through Key Performance Indicators through patient remarks. Essential components of patient safety programme are based on certain principles for safe procedures and practices.
Continuing Surg Rear Admiral Adil Khan said that safety should be everybody’s business. Managements must accept responsibility. Leaders should have vision and anticipate errors. Safety issues should be considered regularly at the highest level. Past events should be measured and changes implemented. If something has happened, deliberate on it, find out the cause and remove it. Information should go to the top management so that remedial measures are taken. Messengers should be rewarded and not shot at. Efforts should be made to create an event reporting culture by the top managers. Meetings on safety should be attended by staff from all departments and try to find out where things went wrong. Building safe healthcare system should include training in recognition of errors, feedback on current errors, written protocols and SOPs must make clear what do you expect from staff at every level.
Rapid, useful feedback is important. If mistake occurs, acknowledge responsibility and apologize, convince the patient and victims that lessons learnt will reduce chances of recurrence. There is a Command and Control at the top monitoring patient safety. Each and every one serving in the healthcare institution should be motivated. Safety of patient, Rear Admiral Adil Khan opined should be engraved in every one’s mind. Self regulation should be ensured while compliance and monitoring of the whole system is also important. Everyone should be directed to report mishaps and mistakes as well as “Near Misses”. There should be complete coordination as practice of medicine is a team work. In a laid down system with sense of responsibility medical errors can be reduced. One should have a visionary proactive approach to avoid errors taking place. We can change conditions in which individuals work only then we can succeed. Human errors, Surg. Rear Admiral Adil Khan stated are there but we can minimize them by improving the system. Improved emergency care, accuracy of patient identification will prevent mistakes; prevent mistakes in surgery, selection of wrong site and wrong procedure. One must ensure active involvement and communication with every team member. To ensure safe use of medications, pharmacists should be in charge of dispensing. Telephone orders regarding medications should be read back, verbal orders should not be taken. Abnormal laboratory reports should be reported promptly. Prevent hospital infections by ensuring proper hand washing, the staff should not wear artificial nails, they should be educated when to use correct hand hygiene. Ensure identification of patient safety risks by taking care of how to identify materials, samples, have regular fire, disaster drills, ensure proper disposal of hospital waste and monitoring of equipment so that they are functioning properly. Whole staff should work to improve patient safety programme. One should have a dedicated team, patient safety managers for different goals. Patient Safety Managers, he stated, are important pillars of patient safety programme. There should be regular meetings to study weak areas, find out solutions and then ensure its implementation. Careful selection of staff, ensuring that events will be reported and properly investigated which should then be followed by corrective action. Reporting of incidents, he said, was extremely important to run a successful Patient Safety Programme. Keep record of all laboratory, radiology reports, ensure compliance with doctors orders, training of nurses, paramedics is essential and patient safety should be included in undergraduate as well as postgraduate curriculum. He hoped that PNS Shifa will serve as a role model for patient safety for all other armed forces healthcare facilities in Pakistan.
Surg. Cdre Muhammad Ayub Sabir Commandant of PNS Shifa in his welcome address thanked the speakers from Aga Khan University as well as from PNS Shifa. He also referred to the Hippocratic Oath and said that it is important that we prevent harm to the patient during procedures and healthcare. Do No Harm should be our Mission. Saving patients from all harm and ensuring patient safety is a continuous effort, he added.

“Near Misses” in a Hospital

The next session which was devoted to different case scenarios depicting “Near Misses” in a Hospital was chaired by Prof. Syed Tipu Sultan Principal Baharia Medical and Dental College along with Surg. Rear Admiral Adil Khan while Surg. Cdre Aamir Ijaz was the moderator. Near Misses, it was stated is something which is intercepted which could have lead to harm. The plays depicted the scenarios where in busy overworked doctors, can result in medical errors. Too much reliance on memory can be dangerous. In these plays it was also highlighted that one should never bypass the SOPs and Check List. One must listen to the patients carefully and how a psychiatric patient admitted to general medical wad can create problems for other patients. The plays were named as Aik Anar, Sau Beemar, Dr.Genius, Baji’s Order which showed the working of nursing staff in the wards. Wrong identification of patient, careless attitude could encourage people with criminal mind to indulge in child theft etc.
Prof. Rasheed Jooma former DG Health in Federal Health Ministry and a noted neurosurgeon along with Brig. Mrs.Shaheen Moeen and Brig. M. Waseem chaired the next session. Ms. Gulzar Lakhani was the first speaker who talked about patient safety through quality improvement. Speaking about healthcare risk management she stated that one should reduce, assess risk of patient, and reduce accidents injuries. She discussed in detail risk identification, risk analysis, risk planning and risk tracking besides incident reporting. Previously at Aga Khan University Hospital we had reporting on paper but now it is all computerized. Adverse incidents are defined as those incidents which result in unexpected harm. Even incidents of fire, theft, pick pocketing in the hospital should all be taken seriously. She also talked about misdiagnosis, equipment failure, accidents, Near Misses, medication errors. It is the physicians who prescribe the drugs; they are dispensed by the pharmacy while nurses administer the drugs. Incident reporting, she said, will minimize errors and improve patient safety. It is important that incidents are reported within twenty four hours. Giving figures from Aga Khan University Hospital she said that during 2011, they had 2167 incidents reported while during the Year 2012 this number was 2161. It consisted of delay in treatment, wrong drug dispensing, delayed medication, ineffective communication besides needle stick injuries etc.
Dr. Ayesha Habib Khan also from AKUH made a presentation Delta Check: an effective patient safety measure in pathology laboratory. She covered wrong labeling of specimens, identical names of the patient etc. This system can only be practiced in a hospital having in-patients.
Mr. Abdul Lateef Sheikh an eminent pharmacist and Director of Pharmacy Services at Aga Khan University Hospital talked about safe use of medications. He pointed out that it is not an individual but is the result of system failure. A system failure is responsible for almost 85% of medical errors while individual negligence accounts for just 15%. In Pakistan, pharmacist is a misunderstood profession. Medication use has now become very complex. Medication errors are a major cause of preventable patient harm. Healthcare professionals play an important role in safe use of medications. Medical Error is defined as any preventable event that may cause or lead to inappropriate use or patient harm while the medication is in the hands of healthcare professionals. He discussed at length drug prescribing, administration monitoring, prescription dispensing and said that one must do route call analysis as to why it has happened. Prescription accounts for 39% of medical errors while administration, transcribing and dispensing account for 38%, 12% and 11% respectively. He then showed some of the doctors prescriptions which leads to incorrect transcribing and thus overdose leading to serious complications. At times doctor’s prescription is misinterpreted, there are unclear orders, and there is insufficient drug information. Speaking about fragmentation of care systems, he opined that we need a multidisciplinary committee based on the disease pattern and active involvement of pharmacists. Selection of the drugs should be based on availability, safety, efficacy, cost effectiveness besides ensuring that manufacturers follow CGMP producing quality products. All this should be evidence based. Emergency purchase should only be from approved vendors. He then also showed the look alike and name alike drugs which are likely to result in unsafe medications. He also showed slides depicting the same colour of ampoules of different drugs, similar colour, similar packing which does create problems while these drugs are stored and administered. Hence it is advisable to ensure appropriate labeling by designing an internal labeling system to avoid medical errors. High risk drugs should be properly labeled, they should be closely monitored.
Surg. Capt. Shehla Baqai Consultant Obstetrician and Gynaecologist at PNS Shifa in her presentation on improved emergency care talked about administration of First Aid, Triage and quick disposal of patients. She also talked about limb saving, management of trauma and handling of the dead. Availability of guidelines and protocols must be ensured in the Emergency Room. She emphasized the importance of training of medical assistant besides maintaining a proper inventory of drugs. One should give preference to life over limb and function over cosmetics. Triage, Dr. Shehla Baqai remarked is a dynamic process. She then discussed primary and secondary survey, labeling the patient with red, yellow and green cards. After ensuring ABCDE which stands for Airway, Breathing, Circulation, Disability and Exposure, do head to toe examination of the patient. Careful look at the back, extremities and make sure that the injured are properly, safely transferred to the healthcare facilities so that their injuries do not get worse. Great care should be taken in case of patients with spinal injuries. Those with red card must be handled immediately, they should be seen by the specialists within ten to fifteen minutes and if need be operated within one to two hours. Those with Yellow card can be operated within eight to ten hours and then one can look after the remaining patients with green card. After the patient has been stabilized, use pain killers to provide relief from pain. She also talked about shifting of causalities to operation theatre, wards, technique of supporting the patient during transfer so that their conditions are not made worse. Proper training of ER staff and paramedics, she opined, was extremely important. Dead bodies should be disposed off after proper documentation.
Proper training of staff, Surg. Capt. Shehla Baqai opined was very important for successful running of Emergency Department. The staff should be trained in Life Support Courses, ACLS, and Basic Life Support. We also train the staff in primary trauma care. She concluded her presentation by stating that everyone has to contribute to patient safety.
Dr. Erum Khan from AKUH talked about Biosafe Hospitals and highlighted the importance of communication between different sections and departments of a hospital to ensure safety. She also discussed the challenges in developing Biosafe Management System due to lack of Vision. One should plan, Do, Check and then Act to ensure Biosafe healthcare facilities, she remarked.
Surg. Cdre Tahir Khadim talked about learning and applying patient safety in undergraduate curriculum. Patient safety, he said, was a new discipline. It is multidisciplinary in which Pharma industry and device manufacturers also play an important role to make it safe. It is important that we save our patient from any harm. Medical errors take place because of system failures and rarely due to individual negligence. Harm to patient, he opined, was not inevitable and we can avoid it. We must learn from our past mistakes and avoid future mistakes. WHO has designed a patient safety curriculum for medical schools? Medical educationists have now recognized patient safety. It used to be taught earlier as well in subjects like communication skills, medical ethics but we were not taught about patient safety as such. We can minimize infections through infection control programme. He was of the view that we should have flexible curriculum which is easily understandable and curriculum should be reviewed regularly.
Surg. Cdre Zahid Akhtar Rao from PNS Shifa discussed implementation of universal protocol in operation theatre. He opined that we must understand the cause, identify solution and then evaluate its impact. WHO has given a theme that safe surgery saves life. Inadequate anesthetic safety practices can result in mishaps. In United States, four thousand surgical mistakes are recorded annually which are considered as ‘Never Events” which should not have happened. Practicing WHO Surgical Check List improves safety outcome. Studies have shown that safe surgical check list resulted in 47% reductions in post operative mortality while it also decreased morbidity by one third. A single person should be responsible for checking the boxes in the operation theatre. Check list coordinator should be selected very carefully so that he does not antagonize other members of the team, he added.
In his concluding remarks Surgeon Rear Admiral Adil Khan DMS Navy remarked that it is difficult to inculcate patient safety as a culture. In patient safety everyone from doctors to nursing staff and paramedics are its important components. Patient Safety Programme at PNS Shifa, he said, was a leader driven programme. It is an excellent beginning which will go a long way in improving patient safety, he remarked. Surg. Capt Hassan Ibrahim thanked the leadership of Pakistan Navy and the distinguished speakers for making the programme a great success.

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