3°COHORTE MÓDULO 5 SEMANA 3: Clase grabada Lic. Virginia Vilchez

Summary

Lic. Virginia Vilchez introduces patient safety as a core responsibility of healthcare services and reviews its history, the causes and terminology of patient harm, and Argentina’s Ministry of Health patient-safety manual.

Definition and guiding principle

Following the World Health Organization (WHO), patient safety means minimizing avoidable harm associated with healthcare. It relies on evidence-based structures, processes, tools, and methods to reduce the risk of adverse events or limit their consequences. Because care carries ongoing risks, institutions should assess those risks and establish safety barriers. The basic principle is “first, do no harm.”

The lecture also emphasizes the changing role of patients: they should be active participants in their own care and safety.

Historical development

The presentation traces patient safety through several periods:

• Ancient Mesopotamia: The Code of Hammurabi included 282 laws, 11 of which concerned medical practice. One law imposed severe punishment on a physician whose treatment caused a patient’s death or serious injury, reflecting the era’s punitive approach to harm.
• Hellenistic and Roman traditions: Medicine increasingly sought rational explanations for illness rather than relying on magic or religion. Hippocrates and the Hippocratic tradition are associated with the principle primum non nocere—first, do no harm—and an ethical orientation toward safe care.
• Humanism, the Renaissance, and the Industrial Revolution: Renewed anatomical study and the development of medicine as a science helped advance clinical practice. The lecture highlights Ambroise Paré and Andrea Vesalius, as well as:
  • Ignaz Semmelweis, who proposed antiseptic handwashing in 1847 after studying deaths from puerperal fever.
  • Florence Nightingale, who promoted safer nursing and infection-control practices while caring for wounded soldiers during the Crimean War.
• Statistical quality and safety research: Audits and data collection made it possible to document harm and identify opportunities to improve diagnosis and treatment. One study discussed in the lecture reported that about 20% of patients in an audited hospital experienced iatrogenic injury.
• Modern patient-safety initiatives: The 2000 Institute of Medicine report To Err Is Human and later WHO initiatives helped bring patient safety to the forefront. The WHO global challenges mentioned are Clean Care is Safer Care, safe surgery, and medication safety.

Studies and causes of adverse events

The lecture names studies focused on different care settings, including IBEAS (hospitals in Latin America), ENEAS (hospital care), APEAS (primary care), CREC (intensive care), and EVADUR (emergency care). Their results helped estimate how often adverse events occur and how many may be preventable. Examples include estimates that 60% of adverse events in IBEAS and 70.2% of those identified by APEAS were preventable.

A fishbone diagram and the Swiss-cheese model illustrate that harm usually results from several contributing factors and failed safeguards—not simply from one person’s mistake. Examples include:

• Medication-related factors: Incorrect or omitted doses, administration errors, and problems with adherence.
• Communication problems: Inadequate handoffs between clinicians, poor coordination between doctors and nurses, and insufficient communication with patients.
• Organizational and system factors: Weak supervision, poor processes, or unavailable information when electronic systems fail.
• Human factors: Fatigue, stress, and excessive workload.
• Patient-related factors: Limited understanding of a procedure or lack of adequate explanation and informed consent.
• External and technological factors: Circumstances outside the immediate care team’s control, including technology failures.

The lecture compares healthcare risk with aviation risk to underline the importance of strong systems and safeguards. It also identifies common harms, such as diagnostic or treatment errors, sepsis, surgical mistakes, pressure injuries, embolisms, healthcare-associated infections, unnecessary transfusions or injections, falls, and medication errors.

Hospital falls are described as frequent and potentially consequential. They can cause trauma that complicates the condition for which the patient was admitted.

Key terminology

• Error: A departure from accepted practice, whether or not it causes harm. It may be an error of commission (doing something incorrectly or unnecessarily) or omission (failing to do something required).
• Incident: An unexpected event or situation that could cause harm.
• Near miss: An incident that does not reach the patient.
• No-harm incident: An incident that reaches the patient but causes no harm.
• Adverse event: An incident that causes unintended harm related to healthcare rather than to the patient’s underlying illness.
• Failure: A weakness or breakdown in a system, rather than simply a fault attributed to an individual.
• Harm: A harmful structural or functional change in the body, or another damaging effect.

How safety barriers can prevent harm

The Swiss-cheese model shows how several safeguards can prevent an initial risk from reaching a patient. In the example of wrong-patient surgery, possible weaknesses include poor communication, lack of supervision, inadequate knowledge of procedures, and insufficient monitoring.

A surgical checklist is presented as one practical barrier. It covers the preoperative, intraoperative, and postoperative stages and helps confirm the patient, procedure, and surgical site. Marking the correct site—for example, the left rather than the right leg—is another safeguard.

Argentina’s patient-safety manual

The lecture describes the Ministry of Health of Argentina’s patient-safety manual, associated with Resolution 248/2023. It is intended to help institutions understand care-related risks, share good practices, and improve safety over time.

The manual recommends that institutions begin with an institutional self-assessment to identify their current position and prioritize action. Its nine lines of action do not necessarily need to be implemented all at once; institutions should select them according to their needs and findings:

1. Safety culture: Develop institutional values, attitudes, skills, and behaviors that support patient-safety programs.
2. Safe medication use: Strengthen medication systems and reduce preventable medication-related harm. The lecture connects this to the WHO’s “medication without harm” challenge and its goal of reducing serious avoidable harm.
3. Healthcare-associated infections: Establish infection-prevention and control programs, including committees, defined responsibilities, data, and indicators.
4. Safe surgery: Use surgical checklists and reduce surgical-site infection risk through appropriate measures, including antibiotic prophylaxis and preoperative bathing where indicated.
5. Safe practices in patient care: Detect clinical deterioration and prevent falls and pressure injuries, with attention to each patient’s condition and mobility.
6. Correct patient identification: Verify identity throughout care, from admission to discharge, before procedures, medication administration, or other interventions.
7. Effective communication: Improve handoffs and communication during transfers and between professionals and services; use structured tools such as SBAR for critical information.
8. Adverse-event management: Use organizational, procedural, methodological, and practical strategies to reduce risk and mitigate the consequences of events.
9. Patient participation: Involve patients actively in their care as part of a safer, higher-quality model.

The lecture closes by assigning a CDC video about an adverse event and the role of committees, to be discussed in a subsequent class.

Speakers and sources featured

Speaker

• Lic. Virginia Vilchez — lecturer in nursing, with specialization in epidemiology and infection control.

Organizations, publications, studies, and educational sources mentioned

• World Health Organization (WHO)
• Pan American Health Organization (PAHO)
• Argentina’s Ministry of Health and its patient-safety manual
• Institute of Medicine of the U.S. National Academy of Sciences, including To Err Is Human
• Centers for Disease Control and Prevention (CDC), whose video is assigned for follow-up
• El Mundo, cited for an article comparing hospital risk with air-travel risk
• The IBEAS, ENEAS, APEAS, CREC, and EVADUR studies

Historical figures and texts discussed

• Code of Hammurabi
• Hippocrates and the Hippocratic tradition
• Ambroise Paré
• Andrea Vesalius
• Ignaz Semmelweis
• Florence Nightingale