ADVERSE EVENTS IN HEALTHCARE Flashcards
what are the 6 key factors for ensuring healthcare quality?
safe effective timely efficient equitable patient centred
what is an adverse event?
an unintended event resulting from clinical care and causing patient harm
what is a near miss?
a situation in which events arising during clinical care fail to develop further, whether or not as a result of compensating action, thus preventing injury to a patient
what is a no harm adverse event?
when an event occurs during clinical care but doesnt actually cause harm
what are some examples of adverse events in healthcare?
pressure ulcers, patient falls, medical errors, hospital acquired infections
what are never events?
serious incidents that are entirely preventable because guidance or safety recomendations are available at a national Level and should have been implemented by all healthcare providers
what are some examples of never events?
giving medication that is a known allergen, retained foreign object post procedure, transfusion incompatibility problems, wrong site surgery
why might hospital standardised mortality ratios not be an accurate representation of safety
hospitals are only a part of a patient’s journey, only about 5% of hospital deaths are avoidable, data vagaries
what are active failures?
errors or violations committed by people in direct contact with the patient
what are errors?
mistakes that are unintentional e.g. may occur due to deficiency in knowledge
what are violations?
intentional mistakes but not usually made with the intention of causing harm e.g. routine, reasoned, malicious, situational
what are latent errors?
mistakes that develop over time and lay dormant until they combine with other factors/active failures
what is normalisation of deviance?
failings because staff become blind to what is going on around them, assuming that the practices being tolerated are normal
what are some situations associated with an increased risk of error?
unfamiliarity with a task inexperience shortage of time inadequate checking poor procedures
what is the duty of candour?
a professional responsibility to be honest with patients* when things go wrong.
