Let's shift now to talking about some of the key themes in patient safety, as we start with part one of the first nine chapters, the epidemiology of error and safety. What is an error? One way to look at an error is that it's when you did the wrong thing but were intending to do the right thing. And that should be differentiated from a violation where the actor intentionally engaged in the wrong action. It's important to remember also that not all errors lead to adverse events. There are many different kinds of ways in which errors can occur, and many different descriptors. There are errors that come as a matter of commission or omission. Another dichotomy is the blunt and latent end, and we'll talk about that in a little bit. The sharp end or the active end, that is to say the person who's at the sharp end is the person who actually touches the patient. But the sharp end of the error may be as much involved or even less the origin of the error when you compare it to the latent or the blunt ends of the error. We also think about slips and mistakes. We always have known that errors occur in medicine and healthcare, but frequently we used to think, and we still do, think about blaming the one person. The attitude of the patient safety movement is to think in terms of systems and to think where the system may have allowed human fallibility to lead to that error that may have occurred and that may have affected the patient. We think that perhaps almost 100,000 errors lead to deaths in the United States per year. Other statistics have come along since then, but that is a stark reminder that errors can lead to problems and also a wake-up that we should be paying more attention to it. The Institute of Medicine's reports certainly have highlighted these findings, and even as of three years ago, studies can show that errors continue to be pervasive in hospitals around the United States. The most common types of adverse events in the United States are drug-related, medication-related, followed by surgical-site infections. Prevention of drug-related morbidity and mortality is certainly an important task, and it's certainly something that we can pay attention to within psychiatry. There certainly are high-risk medications in psychiatry that we should pay attention to. Overall, then, the causes of errors are listed on this slide. They mainly include, when we're talking about causes, communication problems, inadequate information flow, human factors, patient-related issues, organizational transfer of knowledge, staffing patterns or workflow, technical failures, and inadequate policies or procedures. Those, the last point, would certainly be on the latent or the blunt end of errors when they occur. As you can see, there are ways in which latent or blunt errors can lead to harm to patients. This model, the Swiss cheese model of accident causation, implies that an error passes through many successive different layers, layers that have been built as defenses against adverse events. But in some cases, the error slips all the way through all the holes of the Swiss cheese, leading to the patient. This slide is another perspective on the same concept, which is to say that potential adverse events can be stopped by policy writing, standardization or simplification, automation, improvements to devices or architecture. These are all components of defenses which may protect the patient. Now in mental health, certainly there is suicide and violence as potential causes of harm. But procedures which happen on inpatient units, ECT, medications, seclusion and restraint, falls or elopements, all these are potential adverse events that can be looked at now through the patient safety lens. Actually, medication errors are far from rare in psychiatry. One study of 31 inpatient charts and 22,000 dispensing events yielded more than 2,000 medication errors, many of which had a high likelihood of harm. And so, we have talked about an introduction to patient safety and the range of safety events. In the next chapter, we'll talk more about what we mean by the culture of patient safety. Thank you. Thank you. Thank you.

patient safety

errors

adverse events

systems thinking

Swiss cheese model