PATIENT
SAFETY

A Real Problem Affecting Real People and Families 

Reading and watching stories helps humanize patient safety and the effect medical error has on families. The Patient Safety Technology Challenge funds competitions and events that fold in one or more of the five most common categories of medical harm into an award/prize structure. You’ll find some featured patient stories below. A more comprehensive list is found lower on this page. 

5 Problem Categories 

  1. Medication-related – 44% of patient harm and injury 

  2. Medical Complications with Patient Care – 23% 

  3. Procedure/surgery-related – 22% 

  4. Infections – 11% 

  5. Diagnostic Errors 

The first four categories are drawn from the Institute for Healthcare Improvement (IHI) Global Trigger Tool (GTT). In addition to the IHI GTT categories, we believe diagnostic error also should also be considered, as it is a leading cause of preventable patient harm and death and spans the continuum of care, particularly primary care. Teams should be clear about what category their idea addresses.  

Medication Error

The National Coordinating Council for Medication Error and Prevention defines 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 health care professional, patient, or consumer. Such events may be related to professional practice, health care products, procedures, and systems including: prescribing; order communication; product labeling, packaging and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use”. Common types of harm events related to medication identified by the Office of the Inspector General include delirium or other change in mental status, hypotension, acute kidney injury, excessive bleeding and hypoglycemia.

PODCAST: A Health System That Won’t Learn From Its Mistakes (Health Affairs)

Infections

Hundreds of millions of patients are affected by healthcare-associated infections (HAIs) every year. It is estimated that 7 out of 100 hospitalized patients (7%) in high-income countries will acquire one or more HAIs, and that rate is even higher in low- and middle-income countries. Common types of harm events identified by the Office of the Inspector General include respiratory infections, surgical site infections, thrush, sepsis and C. diff infection.

Procedural/ Surgical Safety

More than one million patients die from complications due to surgery each year. Unsafe surgical procedures can cause complications in as many as 25% of patients. Common types of harm events identified by the Office of the Inspector General include hypotension, excessive bleeding, embolisms, cerebrovascular accidents, and prolonged ileus.

Patient Care

Patient care pertains to the daily care of patients, which is often performed by nurses. The Office of the Inspector General identified several common types of harmful events in their latest report. They include pressure injury, skin tears, abrasions and breakdowns, falls, fluid and electrolyte disorders, and intravenous catheter infiltration, burn or phlebitis.

Diagnostic Errors

According to the World Health Organization, inaccurate or delayed diagnosis is one of the most common causes of patient harm and affects millions of patients each year. Diagnostic errors, the failure to identify the nature of an illness in a timely and accurate manner, occur in about 5% of adults in the outpatient care setting in the United States. Medical record reviews have also revealed that diagnostic errors account for between 6% and 17% of harmful events in the hospital.

The Basics

We’ve pulled together the following resources to help you dive deeper into the topic of patient safety and help you understand the problem as you think about innovating.

Additional Stories

Here are some additional stories to help you understand the problem from the perspective of patients and patient advocates, including doctors who want to help.

Additional Patient Videos

  • Patients for Patient Safety US (PFPS US) has an excellent collection of patient stories here

Vignettes

TedX Talks

All of these videos are less than 15 minutes in length and relate to patient safety and medical error.

DOCUMENTARIES

Resources for AI in Health care

Artificial intelligence is in its nascent stages in healthcare, especially as it relates to its application to improve patient safety and reduce preventable patient harm and death. These resources should be helpful in gaining an understanding about its potential application as well as tools that can be applied during the process of building a product or solution.