Healthcare providers always make great attentiveness to meet patient needs and provide the best possible care. Unfortunately, too often, these efforts falter when the patient is handed off, or transferred, to another healthcare provider. As, ineffective hand-off communications are one of the top primary contributing factors of sentinel events, it must be addressed appropriately to standardize the process of communication between the sender of the information and the receiver.
Pressure injury/ulcer is one of the most significant issues facing healthcare system nowadays. All patients are potentially at risk, it’s more likely to occur in long‐term care facilities and inpatient hospitals. Patients who are critically ill, have a neurological impairment or deformity, impaired mobility, impaired nutrition are at a higher risk of hospital-acquired pressure ulcers. Implementation of best practice recommendations can reduce its occurrence and achieve better patient outcomes, it includes methods for identification, risk assessment and the preventive measures.
Medication error is a defect in the treatment process that leads to, or has the potential to lead to, morbidity and mortality. The National Coordinating Council for Medication Error Reporting and Prevention defines a medication error as: “any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer “. It is a widespread issue challenging the healthcare system, despite all the efforts to prevent it. The best method to avoid medication error and enhance patient safety is to develop and implement a multi-faceted strategy, based on the available best practices.
Fall prevention in adults
Fall is a common and devastating harm that represent a continuous challenge to the healthcare system globally, particularly in elderly patients. The risk of serious illness from fall-related injuries such as hip fracture, head trauma, and major lacerations increases with age. Which can lead to decline in health status and in physical performance, increased rate of ICU admission, rate of mortality and health care cost. However, by identifying people at high risk and adhering to fall prevention measures these incidents can be reduced.
Healthcare providers always Saudi Patient Safety Center (SPSC) recognizes the necessity to address the national need to standardize the just culture principles as a core component to improve patient safety and emphasizes that organizations need to balance systemic factors (system failures) alongside accountability for individual actions to achieve a consistent and fair approach to patient safety improvement and performance outcomes.
SPSC encourages all healthcare institutions to have policies and procedures that address Patient Safety Culture, including the Just culture principle.
Healthcare providers always SPSC recognizes the necessity to address the national need to standardize the disclosure of patient safety events process and emphasize that disclosure is a process of several steps, not a single event. When a patient safety incident occurs, patients need to have timely and full disclosure of the event that includes an apology, acknowledgment of responsibility, what happened, expressions of sympathy, and a discussion of what is being done to prevent recurrence of the event. Barriers that may hinder the disclosure process include lack of training, a culture of blame, and fear of lawsuits. To reduce these concerns, it is recommended that health care facilities establish a just culture that encourages staff to report events. SPSC encourages all Healthcare institutions to have policies and procedures that address patient safety events, including the disclosure process.
Falls and Fall Prevention in Adults.pdf