1 Intersemestral Flashcards
What is patient safety?
according to the Institute of medicine
The freedom from accidental injury due to medical care or from medical error
What is patient safety?
according to the National patient safety foundation
The prevention of healthcare errors, and the elimination of mitigation of patient injury caused by healthcare errors
% of patients that experience harm in ambulatory care settings (WHO)
40%
% of harm that could be prevented of the patients that experience harm in ambulatory settings
80%
Deaths that happen in the US because of errors of preventable harm
400,000 deaths
“Nothing is as easy as it looks, everything takes longer than you expect. IF ANYTHING CAN GO WRONG, IT WILL GO WRONG and at the worst possible moment”
Murphy’s Law
“I will follow that system of regimen which, according to my ability and judgement, I consider for the benefit of my patients, and abstain from whatever is deleterious and mischievous”
Hippocratic oath
Hippocrates phrase
First, do no harm
What did Ernest Codman stated?
“The end result idea”
Doctors and hospital staff should follow up with all patients to assess the results of the treatment and that the outcomes be made public
What did the book “To err is human” stated?
Institute of Medicine 1999
It shed light on the grave consequences of medical errors and led to substantial increase on awareness about this topic
What does the swiss cheese model states?
It explains how faults in different layers of a system lead to incidents.
One fault in one layer of a health care system of care is usually not enough to cause an accident.
That adverse events usually occur when several faults occur in several layers.
Why do errors happen in healthcare? Mention 3 main root causes of sentinel events
- Communication
- Orientation/ training
- Patient assessment
What did Avedis Donabedian stated?
Structure leading to process and process leading to outcome
“Not bad people but bad systems”
Errors can be prevented by designing systems that make it hard for people to make mistakes, and easy for people to do the right.
List the hierarchy of intervention effectiveness
PRIMARILY SYSTEM
1. Forcing functions
2. Constraints
3. Simplification/ standardization
4. Checklists
PRIMARILY HUMAN
5. Communication, team work and reporting
6. Policies/ rules
7. Education
Explain forcing functions
Avoiding completely. Example: using an injection, there is no space for another substance to get in but the one that was introduced. The tubes of feeding and oxigen.
Explain constraints
Not avoiding completely, but it still helps in minimizing errors.
Example: color coding
Why do we need a Global Patient Safety Action Plan?
Patient harm due to unsafe care is a large and growing global public health challenge
Mention the 5 reasons why we need the global patient safety action plan
- Leading causes of death and disability worldwide
- Most of this patient harm is avoidable
- Reduced public confidence and trust in local health systems
- Human costs
- Patient and family
- Health care workers suffer psychological harm
- Economic and financial costs
What is patient safety? according to World Health Organization
A frame of organized activities that creates cultures, processes, procedures, behaviors, technologies and environments in healthcare that consistently and sustainably lower risks, reduce the occurrence of avoidable harm, make errors less likely and reduce the impact of harm when it does occur
Choose if the following text is the vision, mission or goal of the WHO
“Achieve the maximum possible in avoidable harm due to unsafe health care globally”
Goal
Choose if the following text is the vision, mission or goal of the WHO
“A world in which no one is harmed in health care and every patient receives safe and respectful care, every time, everywhere”
Vision
Choose if the following text is the vision, mission or goal of the WHO
“Drive forward policies, strategies and actions on science, patient experience, system design and partnerships, to eliminate all sources of avoidable risk and harm to patients and health workers”
Mision
Mention the partners of the Global patient safety action plan
- Governments
- Healthcare facilities and services
- Stakeholders
- World Health Organization
Which partner does this institutions belong to?
- National and subnational governments
- Ministries of health
- Public health institutions
- Patient safety organism
- Ministres of education, finance, justice
- Regulatory bodies
Governments
Which partner does this institutions belong to?
- Tertiary, secondary and primary care facilities and providers
- Mental health
- Palliative care
- Specialized clinics
Healthcare facilities and services
Which partner does this institutions belong to?
- Organizations OECD
- International nongovernmental organizations
- Universities, academic institutions
- Research institutions
- Media
- United nations
- Pharmaceutical and medical devices
- Industries
- Health insurance organizations
Stakeholders
Mention the 7 guiding principles of the Global Patient Safety Action plan
- Engage patient and families
- Collaborative working
- Analyse and share data
- Translate evidence into actionable and measurable improvement
- Base policies and action on the nature of the care setting
- Use both scientific expertise and patient experience to improve safety
- Instill a safety culture
Explain the 1st guiding principle
Engage patient and families.
Patients be informed, involved and treated as full partners in their own care.
Explain the 2nd guiding principle
Collaborative working
Everybody contributes, shares and learns
Explain the 3rd guiding principle
Analyse and share data
Gain greater understanding of why safety incidents occur and to devise solutions to prevent them.
Explain the 4th guiding principle
Translate evidence into actionable and measurable improvement
Knowing-doing gap
Explain the 5th guiding principle
Base policies and action on the nature of the care setting
More attention and research in patient safety based on experience of high-resourced health care systems and large hospital.
Explain the 6th guiding principle
Use both scientific expertise and patient experience to improve safety
Formulating and delivering a plan requires scientific and
technical expertise, but also insight of those who remember that too many past patients and
families have suffered loss and serious harm as a result of flawed health care.
Explain the 7th guiding principle
Instill a safety culture
Culture of safety has to percolate into the attitudes, beliefs, values,
skills and practices of health workers, managers and leaders of
health care organizations.
Components:
- Leadership
* Commitment
* Transparency
* Open and respectful communication
* Learning from errors and best
practices
* Balance between a no blame policy
and responsibility
In which year did the Patient safety journey started in Mexico?
2002
Which institution launched the patient safety journey in Mexico? (the first Quality policy in latin america)
National Crusade for Quality in Health Care
Wave one
* length
* name
* what was it about?
- 2002 - 2006
- Raising awareness and initiating a safety culture
- The first wave aimed to sensitize healthcare workers to build patient safety
In high income countries, 10% people were injured due to medical errors, these percentage was higher in low and middle income countries.
How many steps were implemented in wave one organizational change?
8
How many disciplines was the wave one design based on?
5
Mention and describe the 5 disciplines of a learning organization - Senge
- system thinking: seeing the organization not as individual components but systems of interactive parts
- mental models: we each carry within us a number of models that allows us to make sense of the world in all its complexity
- shared vision: it inspires bringing people together. They commit to the organization because they value the vision and they believe what they are going to achieve.
- personal mastery: need for us to be constantly learning and striving.
- team learning: dialogue and discussion, multiple perspectives to come up with the best solution
Name the Kotter’s eight steps of organizational change
CREATING THE CLIMATE FOR CHANGE
1. Create urgency
2. form a powerful coalition
3. create a vision for change
ENGAGING & ENABLING THE ORGANISM
4. communicate the vision
5. empower action
6. create quick wins
IMPLEMENTING & SUSTAINING FOR CHANGE
7. build on the change
8. make it stick
In how many time was it shown to have statistically significant improvements in safety culture qualification measurement and showing a favorable patient safety culture?
From 6 to 8 months after the intervention
Wave two
* length
* name
* what was it about?
- 2007 - 2012
- Defining the problem and measurement
- Focusing on measuring the magnitude of the patient safety problem and on giving a structure for focal points
- national level
- each state
- each hospital medical unit
.
Mexico joined the WHO initiative and worked with four other countries in the Latin America region and Spain’s Ministery of Helath to develop the: _______
Ibero-American Adverse Events Study
Mexico adopted the first two WHO patient safety campaigns:
- “Clean Care is Safer Care” 2005
- “Safe Surgery Saves Lives” 2007
Formal patient safety structures that were established in wave two:
- National Directorate for Patient Safety - to implement the initiatives
- National Quality Committee was created - was mirrored in every state with the establishment of a local quality committee at every hospital medical unit
The advisory group of the ministry of health that focuses on:
- Unifying the criteria for the application of policies regarding quality and safety in patient care
- Share evidence-based medicine
- Formulate recommendations and monitor indications of technical quality and perceived quality in the institutions of the National Health System
Wave three
* length
* name
* what was it about?
- 2013 - 2019
- developing the governance for safety
- Strengthening of governance, with the development of the first patient safety regulatory framework with eight essential actions on patient safety
These actions are MANDATORY, aiming to standardize the interventions that have proved to be successful at preventing adverse events
The Mexican Essential Actions of
Patient Safety builds upon the: ________
International Patient Safety Goals
Wave four
* length
* name
* what was it about?
- 2020 - onwards
- responding to COVID-19
- Exposed the deficiencies of the system and the lack of preparedness for emergencies.
We need to be diligent in performing quality evaluations to ensure the system functionality and safety during an emergency.
There are many aspects that are not standardized and regulated that may place the patients, the health workers, and the health-care institutions at risk. TRUE OR FALSE?
TRUE
Third leading cause of death after heart disease and cancer
medical errors
What is the main disease the second victim has?
post- traumatic stress disorder
Four groups of the domino effect
- the patient and the family
- the health care professional
- the hospital reputation
- patients who are harmed subsequently
In hospitals, most of the malpractice assertion are related to:
surgical or infusion errors
first victim
patients and families
second victim
healthcare professionals
First victims repercusions
- financial
- social
- psychological
- physical
