2 quality and safety Flashcards
two dimensions of quality
excellence and consistency
a major goal of quality
decrease unnecessary variation both in processes and outcomes
QC
reviews and corrects errors in radiology report
QA
report templates
QI
implement report templates, monitor, make adjustments
basic level of quality activities
qc
maintain rather than improve performance
QA
QI
changes in processes, systems, organizational structure
responsible for quality
everyone in the organization, organizational leaders too
practice based learning and improvement
show an ability to investigate and evaluate patient care practices, appraise and assimilate scientific evidence, improve practice of medicine
systems based
awareness and responsibility to the larger context and systems of health care
professionalism
commitment to carrying out professional responsibilities and adhering to ethical principles and being sensitive to diverse patient populations
to err is human
44 to 98, 000 in hospital deaths per year were attributable to medical errors
to err is human report, societal costs of medical errors
17 to 29 billion
factors contributing to errors
non system decentralized nature, failure to focus on errors, impediment of the liability system to identify errors, failure to provide financial incentive to improve safety
most errors are single or multifactorial
multi
multifactoral reasons of errors
unsafe systems and processes, human error
strategy to decrease medical errrors
design safety into systems and processes of care
not a viable solution to decrease error
rooting out bad apples
who are key team players in the collaborative efforts required to prevent diagnostic error
PATIENTS
2015 follow up report
report is focused on patients
post mortem exams associated with diagnostic errors
10%
what do fee for services lack
lack incentives to coordinate care among team members
significant contributor to diagnostic errors
failures in communications
human factors engineering
aviation and nuclear power, checklists
major parts of communication
conveyance and convergence
HRO
constant state of vigilance that results in fewest number of errors
anticipation three elements
preoccupation with failure, reluctance to simplify, sensitivity to operations
containment
resilience and deference to expertise
tying ones shoes or driving on open freeway
skill based
intermediate level of attention
rules based, which clothes to wear, when to proceed at a 4 way stop
knowledge based
new, sport for first time, driving in unfamiliar city or poor visibility
second victim
traumatized by an error or adverse patient event in which they were involved
console
human error
coach
at risk behavior
punish/sanction
reckless
reckless
conscious disregard
at risk
taking short cuts
flaunting firmly established safety rules
reckless behavior
reconciling need for reduced focus on blame and maintaining accountability
JUST CULTURE
