The Patient Safety Movement Foundation – PSMF is a global non-profit foundation whose mission is to eliminate preventable medical errors. According to PSMF, Adverse Events (AE) are responsible for approximately 4.8 million deaths per year worldwide, which is equivalent to 125 thousand deaths per year in Brazil. In 1999, through the report To err is Human: Building a Safer Health […]
In 400 BC, the Greek doctor Hippocrates said, “The first thing is to do no harm”; the quote shows the importance of managing patient-related actions to avoid events that cause harm. In other words, there is always a “quid pro quo” (something for something). As models in risk management, we can cite high-reliability industries (HRO), such as […]
Adverse Events (AE) caused by medications present the greatest single risk of harm to patients in hospitals. The medication chain involves several sectors of the hospital: Standardization; Reception Distribution; Unitarization; Prescription; Clinical pharmacology; Medication administration; Medication return. In all these steps, quality and safety are essential. According to the IHI – Institute for Healthcare Improvement, public health researchers […]
YES, there are organizations that work with zero error. Or at least, do not consider an option, to have a single error (although sometimes it happens). These are called High Reliability Organizations (HRO). When we see that some industries have a thousand times less errors than the health industry, we can learn something from their […]
1 Introduction Process management defines the step-by-step of the company’s key activities. It evaluates the effectiveness of routines and procedures and is able to visualize the best points of improvement and vulnerability in processes. Organizations need processes that are structured, organized and guided by management. All company activities should be treated as a chain of […]
The economy is important, YES, but it cannot solve all the problems of this crisis, which had its apex with the Pandemic, but which had already given several signs that it was brewing long before COVID. Smartphones for immediate use in the hands of 6 billion people, brought a level of transparency that exposed the […]
We don’t want to write a blog only with data from advanced countries. We have traveled to many countries; we have visited hospitals and we have seen a lot of disparity of levels. In some, they don’t really know what we are talking about when we talk about Patient Safety or ISMP. The study into […]
As per our education and culture we have incorporated assurances such as the following: We are the result of our dedication and effort. We are the product of our desire to be and do things. Good people get the best results and do not make mistakes. We cannot fail. We have free will and we […]
Defining processes and standardizing procedures is an objective to be achieved within the activities of the hospital and the hospital pharmacy. We know that a high percentage of Adverse Events comes from a communication failure. Problems of similarity in medicines must be attacked, there´s a large number called LASA (look alike and sound alike), producing […]
Implementing a change is a great effort, whether it is a personal matter, or within a group or institution. As in a personal way, the force of habit dominates us, so does it happen to human groups. The improvements that must be made inside a hospital, with no doubt, are changes. Sometimes they are small […]
