Patient Safety Written Report

August 8, 2019

Submitted by:

PBL III Group 9

Cabahug, Kurt
Chan, Lance
Israel, Goldameir
Kho, Rachelle
Layese, Lex
Sales, Gene
Talili, Pauline
Urgel, Mary
Valmoria, Tiara
Ymbong, Au Bain

Submitted to:

Dr. Emmalyn L. Reveldez

 Patient Safety Video #2

1. What were the IPSG issues you have identified in the video?

According to the IPSGs, the issues in the video included the following:

In opposition to IPSG 1 (Identify patients correctly), the medical team displayed a failure to
confirm patient, condition & procedure, and site of operation.

In opposition to IPSG 2 (Improve effective communication), there was a lack among the medical
team to introduce/confirm themselves and specify their roles in the operation.

In opposition to IPSG 3 (Improve the safety of high alert medications), the team failed to identify
any allergies the patient might have to the anesthetic to be given.

In opposition to IPSG 4 (Ensure safe surgery), a number of issues were completed including
failure to count instrumentation, position the surgical lamp correctly, properly maneuver the patient while
on her bed, and to adequately secure the patient to her bed.

In opposition to IPSG 5 (Reduce the risk of health care-associated infections) the team failed to
observe proper hand washing and gowning & gloving procedures, which are essential to the surgical
process.

In opposition to IPSG 6 (Reduce risk of patient harm resulting from falls), there was a failure to
properly secure the patient.

2. What are the possible reasons why incorrect practices occur?

In general, medical care team mistakes result out of a failure to communicate and observe proper
teamwork synergy/fundamentals.

In a surgical setting, we would like to point the dangers of falling into routine. As a surgical team
goes through numerous operations, there may rise a tendency to become complacent. It is this
complacency which leads into the myriad of mistakes which can be committed by the team. These
mistakes include but are not limited to hurriedly doing procedures out of a desire to be done with work, or
not doing things with caution out of a sense of leniency.
 3. What is the impact of the failure of ISPG practices on the patient, doctor, and the
hospital or institution?

With regards to the patient, he/she may feel neglected on a physical, emotional, and mental level.
Physically, negative outcomes may include morbidity, repeat surgeries, sepsis, and other complications.
On an emotional & mental level, his/her confidence in the health care system may be severely diminished.

With regards to the doctor responsible, he/she may be subject to lawsuits, revocation of needed
licenses (PRC, etc.), and a loss of integrity and liability.

With regards to the hospital, its license may be revoked and its reputation may be severely tarnished.

4. How can we promote and practice patient safety?

In terms of safety, we can avoid injuries to patients from the care that is intended to help them.

In order to be effective, we can provide services based on scientific knowledge to all who could
benefit and refraining from providing services to those not likely to benefit.

Patient-centered mentalities can be cultivated by providing care that is respectful of and

responsive to patient preferences, needs, and values, and ensuring that patient values guide all clinical
decisions.

Medical teams can be mindful of time by reducing waits and sometimes harmful delays for both
those who receive and those who give care.

Efficiency can be practiced by avoiding waste, including waste of equipment, supplies, ideas, and
energy.

Equity can be achieved by providing care that does not vary in quality because of personal
characteristics such as gender, geographic location, and socioeconomic status.