7 October, 2022

HIPPOCRATIC OATH – I will prescribe regimens for the good of my patients according to my ability and my judgment and “never do harm” to anyone.

The origin of the concept of patient safety is not recent; it is an age old ethical practice in medical field. Hospitals were founded to give care to those who need it and to keep patients safe is their moral duty. The occurrence of adverse events due to unsafe care is one of the 10 leading causes of death and disability in the world. In high-income countries, it is estimated that one in every 10 patients is harmed by unintentional medical errors while receiving hospital care. The harm can be caused by a range of adverse events, with nearly 50% of them being preventable. Each year, 134 million adverse events occur in hospitals in low- and middle-income countries, due to unsafe care, resulting in 2.6 million deaths. Globally, as many as 4 in 10 patients are harmed in primary and outpatient health care. Up to 80% of harm is preventable. The most detrimental errors are related to diagnosis, prescription and the use of medicines.

Patient safety is the prevention of harm to the patient with emphasis on system of care, prevention of errors, learning from the errors that occur and building a culture of safety.

World Health Organization (WHO) through various studies and analysis has compiled the following as patient safety situations of utmost concern:

  • Medication errors are a leading cause of injury and avoidable harm in health care systems.

  • Health care-associated infections occur in 7 and 10 out of every 100 hospitalized patients in high-income countries and low- and middle-income countries respectively.

  • Unsafe surgical care procedures cause complications in up to 25% of patients. Almost 7 million surgical patients suffer significant complications annually, 1 million of whom die during or immediately following surgery.

  • Unsafe injection practices in health care settings can transmit infections, including HIV and hepatitis B and C, and pose direct danger to patients and health care workers.

  • Diagnostic errors occur in about 5% of adults in outpatient care settings, more than half of which have the potential to cause severe harm. Most people will suffer a diagnostic error in their lifetime.

  • Unsafe transfusion practices expose patients to the risk of adverse transfusion reactions and the transmission of infections. Data on adverse transfusion reactions from a group of 21 countries show an average incidence of 8.7 serious reactions per 100 000 distributed blood components.

  • Radiation errors involve overexposure to radiation and cases of wrong-patient and wrong-site identification. A review of 30 years of published data on safety in radiotherapy estimates that the overall incidence of errors is around 15 per 10 000 treatment courses.

  • Sepsis is frequently not diagnosed early enough to save a patient’s life. Because these infections are often resistant to antibiotics, they can rapidly lead to deteriorating clinical conditions, affecting an estimated 31 million people worldwide and causing over 5 million deaths per year.

  • Venous thromboembolism (blood clots) is one of the most common and preventable causes of patient harm, contributing to one third of the complications attributed to hospitalization. Annually, there are an estimated 3.9 million cases in high-income countries and 6 million cases in low- and middle-income countries.


To err is human, and expecting flawless performance from human beings working in complex, high-stress environments is unrealistic. Then what can be done? The answer is continuous improvement based on learning from errors and adverse events along with clear policies, leadership capacity, data to drive safety improvements, skilled health care professionals and effective involvement of patients in their care. There should be continuous monitoring and review of processes in the form of regular introspection and audits, competency mapping for work assignment, effective and safe communication, clinical care pathways, evidence based medicine, monitoring of KPIs/quality indicators and reporting of incidents irrespective of near miss, adverse or sentinel events.

One of the best solutions to improve patient safety in hospitals is compliance to International patient Safety goals defined by Joint Commission international (JCI).


IPSG. 1 Identify Patients Correctly
·      With 2 identifiers – CRN & full name before providing any treatment or procedure
IPSG. 2 Improve Effective Communication

·      Read back & spell back while taking verbal orders, record and get countersigned.
·      Define critical values, report and document
·      Handover communication by nurses and doctors during shift handovers and transfers

IPSG. 3 Improve the Safety of High-Alert Medications

·      Identification, labelling, storage & administration of high alert medications, Look alike sound alike drugs & concentrated electrolytes

IPSG. 4 Ensure safe surgery

·      Site marking to be done by the person performing the procedure
·      Time out by full surgical team
·      Adherence to WHO surgical Safety checklist

IPSG. 5 Reduce the Risk of Health Care-Associated Infections

·      Compliance to hand hygiene guidelines
·      Evidence based practices to prevent HAIs
·      Follow care bundles for VAE, Central line & Catheter care
·      Compliance to Antibiotic policy

IPSG. 6 Reduce the Risk of Patient Harm Resulting from Falls

·      Fall risk assessment for all inpatients & outpatients)
·      Re-assessment of patients identified at risk of fall
·      Implementation & monitoring of fall risk reduction measures

The bottom line is, in order to ensure safe practices the laid down SOPs & policies should be followed at all patient care settings. The error happens only when there is a breach or non-adherence to the standard protocol. Therefore, all health care professionals should play their part to ensure patient safety as “SAFETY IS EVERYONE’S RESPONSIBILITY”.

Another initiative to promote safety is Patients for Patients Safety (PFPS), a programme of WHO Flagship Initiative “A Decade of Patient Safety 2021-2030” that engages and empowers patients and families and facilitates their partnership with health professionals and policy-makers to make health care services safer worldwide. The goal is to engage and empower patients, families and communities to play an active role in their own care, bring the voices of patients and people to the forefront of health care, and create an enabling environment for partnerships between patients, families, communities and health professionals.

Do it safe way, do it right way and do it every day.

Do things right, with right people, at right time, first time and every time with empathy.

Guest Editor
Ms. Renu Katnauriya
Head – Quality Department, RGCIRC, Delhi

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