TWELVE COMMANDAMENTS FOR PATIENT SAFETY

1. TWELVE COMMANDAMENTS FOR PATIENT SAFETY Patient safety is the prevention of adverse events that patients may suffer as a result of their contact with the health system 1KNOW THAT IS PATIENT SAFETY The purpose of patient safety is to reduce the risk associated healthcare 2KNOW THAT IS RESPONSIBLE FOR PATIENT SAFETY Working in patient safety is to be aware of the risks involved, inform, analyze and establish improvement measures to avoid, as much as possible, that patients are reexposed to them 3 CONSIDER WHY ADVERSE EVENTS OCCUR The Reason’s Swiss cheese model shows us how advers events occur: they are caused by system falilures and human errors combination 4 UNDERSTAND THAT TO ERR IS INHERENT TO THE HUMAN CONDITION 5 CHANGE THE WAY WE WORK Although we can not change the human condition, we can change the conditions under wich humans work 6 LEARN FROM MISTAKES Every mistake is an opportunity to improve

2. TWELVE COMMANDAMENTS FOR PATIENT SAFETY Patient safety is the prevention of adverse events that patients may suffer as a result of their contact with the health system 7 DRIVE FORWARD THE NOTIFICATION Report faults is essential. The reporting of adverse events is a long chain of work including analyze, learn from them, establish corrective actions and, finally, disseminate recommendations for all professionals 5 Disseminate recommendations 4 Propose improvements 3 Learn 8 INTEGRATE RISK MANAGEMENT INTO OUR DAILY WORK When we detect a fault, we should try to find out how it happened and why. Normally the person who detected the error is who has the better information to propose improvement measures to prevent its recurrence. 2 Analize 1 Notify 9 SPREAD THE RECOMMENDATIONS SHARING SAFETY LESSONS In the health sector is not possible to achieve the zero risk, so the dissemination of lessons learned is key to improving health care quality 10 IMPROVE COMMUNICATION BETWEEN THE VARIOUS PEOPLE WHO ARE INVOLVED The risk of adverse events decreasses when patients are sufficiently informed about their condition and the treatment required and when the communication between different health proffesionalsinvolved in their care is proper. 11 LEAD AND SUPPORT OUR PROFFESIONALS To develop a Safety Plan is essential to have a Patient Safety Leader locally and with the commitment of the Organization’s clinical manager, supporting proffesionals for incidents management and facilitating the implementation of the improvement measures 12 CONSIDERER PATIENT SAFETY AS A CHALLENGE TO ACHIEVE IN THE HEALTH SYSTEM The same failures can be repeated with different consequences increasingly rosamaria.anelrodriguez@osakidetza.net