Patient Journey - Safeguarding

• what are the levels of harm:

  • no harm
  • low harm
  • moderate harm
  • severe harm
  • death
• which events class as low harm?

  • minimal harm occurred – patient(s) required extra observation or minor treatment
  • did not or is unlikely to need further healthcare beyond a single GP, community healthcare professional, emergency department or clinic visit
  • did not or is unlikely to need further treatment beyond dressing changes or short courses of oral medication
  • did not or is unlikely to affect that patient’s independence
  • did not or is unlikely to affect the success of treatment for existing health conditions.
• which events class as moderate harm?

  • healthcare beyond a single GP, community healthcare professional, emergency department or clinic visit, and beyond dressing changes or short courses of medication, but less than 2 weeks additional inpatient care and/or less than 6 months of further treatment, and did not need immediate life-saving intervention
  • has limited or is likely to limit the patient’s independence, but for less than 6 months
  • may affect success of treatment, but without meeting the criteria for reduced life expectancy or accelerated disability described under severe harm.
• which events class as severe harm?

  • permanent harm/permanent alteration of the physiology
  • needed immediate life-saving clinical intervention
  • is likely to have reduced the patient’s life expectancy
  • needed or is likely to need additional inpatient care of more than 2 weeks and/or more than 6 months of further treatment
  • has, or is likely to have, exacerbated or hastened permanent or long term (greater than 6 months) disability, of their existing health conditions
  • has limited or is likely to limit the patient’s independence for 6 months or more.
• A Never Event is wholly preventable (e.g., surgery on wrong side)
• Examples of Serious Incidents (SI):

  • Unexpected/avoidable deaths or injury
  • Incident prevents ability to continue to deliver healthcare services, like security breeches and property damage
  • Never Events
• Significant Events - is any unintended or unexpected event, which could or did lead to harm of one or more patients.
• Near miss -  Any patient safety incident that had the potential to cause harm but was prevented, resulting in no harm
• Examples of where harm or mistakes can come from:

  • mistakes (acts of commission (doing something wrong) and omission (not doing the right thing))
  • intercurrent illness
  • patient action
  • side effects
• Swiss Cheese model of accident causation:

  In a complex system, hazards are prevented from causing human losses by a series of barriers. Each barrier has unintended weaknesses, or holes