1 Intersemestral

Question 1

What is patient safety?
according to the Institute of medicine

Answer 1

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

Question 2

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

Answer 2

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

Question 3

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

Answer 3

40%

Question 4

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

Answer 4

80%

Question 5

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

Answer 5

400,000 deaths

Question 6

“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”

Answer 6

Murphy’s Law

Question 7

“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”

Answer 7

Hippocratic oath

Question 8

Hippocrates phrase

Answer 8

First, do no harm

Question 9

What did Ernest Codman stated?

Answer 9

“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

Question 10

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

Answer 10

Institute of Medicine 1999

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

Question 11

What does the swiss cheese model states?

Answer 11

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.

Question 12

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

Answer 12

1. Communication
2. Orientation/ training
3. Patient assessment

Question 13

What did Avedis Donabedian stated?

Answer 13

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.

Question 14

List the hierarchy of intervention effectiveness

Answer 14

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

Question 15

Explain forcing functions

Answer 15

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.

Question 16

Explain constraints

Answer 16

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

Question 17

Why do we need a Global Patient Safety Action Plan?

Answer 17

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

Question 18

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

Answer 18

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

Question 19

What is patient safety? according to World Health Organization

Answer 19

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

Question 20

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”

Answer 20

Goal

Question 21

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”

Answer 21

Vision

Question 22

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”

Answer 22

Mision

Question 23

Mention the partners of the Global patient safety action plan

Answer 23

• Governments
• Healthcare facilities and services
• Stakeholders
• World Health Organization

Question 24

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

Answer 24

Governments

Question 25

Which partner does this institutions belong to? * Tertiary, secondary and primary care facilities and providers * Mental health * Palliative care * Specialized clinics

Answer 25

Healthcare facilities and services

Question 26

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

Answer 26

Stakeholders

Question 27

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

Answer 27

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

Question 28

Explain the 1st guiding principle

Answer 28

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

Question 29

Explain the 2nd guiding principle

Answer 29

Collaborative working Everybody contributes, shares and learns

Question 30

Explain the 3rd guiding principle

Answer 30

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

Question 31

Explain the 4th guiding principle

Answer 31

Translate evidence into actionable and measurable improvement Knowing-doing gap

Question 32

Explain the 5th guiding principle

Answer 32

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.

Question 33

Explain the 6th guiding principle

Answer 33

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.

Question 34

Explain the 7th guiding principle

Answer 34

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

Question 35

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

Answer 35

2002

Question 36

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

Answer 36

National Crusade for Quality in Health Care

Question 37

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

Answer 37

* 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.

Question 38

How many steps were implemented in wave one organizational change?

Answer 38

8

Question 39

How many disciplines was the wave one design based on?

Answer 39

5

Question 40

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

Answer 40

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

Question 41

Name the Kotter's eight steps of organizational change

Answer 41

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

Question 42

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

Answer 42

From 6 to 8 months after the intervention

Question 43

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

Answer 43

* 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 .

Question 44

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: _______

Answer 44

Ibero-American Adverse Events Study

Question 45

Mexico adopted the first two WHO patient safety campaigns:

Answer 45

1. "Clean Care is Safer Care" 2005 2. "Safe Surgery Saves Lives" 2007

Question 46

Formal patient safety structures that were established in wave two:

Answer 46

* 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

Question 47

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

Answer 47

* 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

Question 48

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

Answer 48

* 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

Question 49

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

Answer 49

International Patient Safety Goals

Question 50

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

Answer 50

* 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.

Question 51

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?

Answer 51

TRUE

Question 52

Third leading cause of death after heart disease and cancer

Answer 52

medical errors

Question 53

What is the main disease the second victim has?

Answer 53

post- traumatic stress disorder

Question 54

Four groups of the domino effect

Answer 54

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

Question 55

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

Answer 55

surgical or infusion errors

Question 56

first victim

Answer 56

patients and families

Question 57

second victim

Answer 57

healthcare professionals

Question 58

First victims repercusions

Answer 58

* financial * social * psychological * physical