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Calidad y seguridad en el px > 1 Intersemestral > Flashcards

1 Intersemestral Flashcards

1
Q

What is patient safety?
according to the Institute of medicine

A

The freedom from accidental injury due to medical care or from medical error

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2
Q

What is patient safety?
according to the National patient safety foundation

A

The prevention of healthcare errors, and the elimination of mitigation of patient injury caused by healthcare errors

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3
Q

% of patients that experience harm in ambulatory care settings (WHO)

A

40%

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4
Q

% of harm that could be prevented of the patients that experience harm in ambulatory settings

A

80%

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5
Q

Deaths that happen in the US because of errors of preventable harm

A

400,000 deaths

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6
Q

“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”

A

Murphy’s Law

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7
Q

“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”

A

Hippocratic oath

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8
Q

Hippocrates phrase

A

First, do no harm

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9
Q

What did Ernest Codman stated?

A

“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

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10
Q

What did the book “To err is human” stated?

A

Institute of Medicine 1999

It shed light on the grave consequences of medical errors and led to substantial increase on awareness about this topic

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11
Q

What does the swiss cheese model states?

A

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.

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12
Q

Why do errors happen in healthcare? Mention 3 main root causes of sentinel events

A
  1. Communication
  2. Orientation/ training
  3. Patient assessment
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13
Q

What did Avedis Donabedian stated?

A

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.

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14
Q

List the hierarchy of intervention effectiveness

A

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

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15
Q

Explain forcing functions

A

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.

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16
Q

Explain constraints

A

Not avoiding completely, but it still helps in minimizing errors.
Example: color coding

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17
Q

Why do we need a Global Patient Safety Action Plan?

A

Patient harm due to unsafe care is a large and growing global public health challenge

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18
Q

Mention the 5 reasons why we need the global patient safety action plan

A
  1. Leading causes of death and disability worldwide
  2. Most of this patient harm is avoidable
  3. Reduced public confidence and trust in local health systems
  4. Human costs
    • Patient and family
    • Health care workers suffer psychological harm
  5. Economic and financial costs
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19
Q

What is patient safety? according to World Health Organization

A

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

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20
Q

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”

A

Goal

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21
Q

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”

A

Vision

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22
Q

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”

A

Mision

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23
Q

Mention the partners of the Global patient safety action plan

A
  • Governments
  • Healthcare facilities and services
  • Stakeholders
  • World Health Organization
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24
Q

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
A

Governments

25
Q

Which partner does this institutions belong to?

  • Tertiary, secondary and primary care facilities and providers
  • Mental health
  • Palliative care
  • Specialized clinics
A

Healthcare facilities and services

26
Q

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
A

Stakeholders

27
Q

Mention the 7 guiding principles of the Global Patient Safety Action plan

A
  1. Engage patient and families
  2. Collaborative working
  3. Analyse and share data
  4. Translate evidence into actionable and measurable improvement
  5. Base policies and action on the nature of the care setting
  6. Use both scientific expertise and patient experience to improve safety
  7. Instill a safety culture
28
Q

Explain the 1st guiding principle

A

Engage patient and families.

Patients be informed, involved and treated as full partners in their own care.

29
Q

Explain the 2nd guiding principle

A

Collaborative working

Everybody contributes, shares and learns

30
Q

Explain the 3rd guiding principle

A

Analyse and share data

Gain greater understanding of why safety incidents occur and to devise solutions to prevent them.

31
Q

Explain the 4th guiding principle

A

Translate evidence into actionable and measurable improvement

Knowing-doing gap

32
Q

Explain the 5th guiding principle

A

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.

33
Q

Explain the 6th guiding principle

A

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.

34
Q

Explain the 7th guiding principle

A

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

35
Q

In which year did the Patient safety journey started in Mexico?

A

2002

36
Q

Which institution launched the patient safety journey in Mexico? (the first Quality policy in latin america)

A

National Crusade for Quality in Health Care

37
Q

Wave one
* length
* name
* what was it about?

A
  • 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.
38
Q

How many steps were implemented in wave one organizational change?

A

8

39
Q

How many disciplines was the wave one design based on?

A

5

40
Q

Mention and describe the 5 disciplines of a learning organization - Senge

A
  1. system thinking: seeing the organization not as individual components but systems of interactive parts
  2. mental models: we each carry within us a number of models that allows us to make sense of the world in all its complexity
  3. 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.
  4. personal mastery: need for us to be constantly learning and striving.
  5. team learning: dialogue and discussion, multiple perspectives to come up with the best solution
41
Q

Name the Kotter’s eight steps of organizational change

A

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

42
Q

In how many time was it shown to have statistically significant improvements in safety culture qualification measurement and showing a favorable patient safety culture?

A

From 6 to 8 months after the intervention

43
Q

Wave two
* length
* name
* what was it about?

A
  • 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
    .
44
Q

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: _______

A

Ibero-American Adverse Events Study

45
Q

Mexico adopted the first two WHO patient safety campaigns:

A
  1. “Clean Care is Safer Care” 2005
  2. “Safe Surgery Saves Lives” 2007
46
Q

Formal patient safety structures that were established in wave two:

A
  • 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
47
Q

The advisory group of the ministry of health that focuses on:

A
  • 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
48
Q

Wave three
* length
* name
* what was it about?

A
  • 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
49
Q

The Mexican Essential Actions of
Patient Safety builds upon the: ________

A

International Patient Safety Goals

50
Q

Wave four
* length
* name
* what was it about?

A
  • 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.
51
Q

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?

A

TRUE

52
Q

Third leading cause of death after heart disease and cancer

A

medical errors

53
Q

What is the main disease the second victim has?

A

post- traumatic stress disorder

54
Q

Four groups of the domino effect

A
  1. the patient and the family
  2. the health care professional
  3. the hospital reputation
  4. patients who are harmed subsequently
55
Q

In hospitals, most of the malpractice assertion are related to:

A

surgical or infusion errors

56
Q

first victim

A

patients and families

57
Q

second victim

A

healthcare professionals

58
Q

First victims repercusions

A
  • financial
  • social
  • psychological
  • physical

Calidad y seguridad en el px (1 decks)

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