Background

Question 1

What is patient safety according to WHO, 2021?

Answer 1

“A framework of organized activities that
creates cultures, processes, procedures,
behaviors, technologies and environments in
health care 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 2

% of px who experience medical errors in ambulatory care settings:

Answer 2

40%.
80% of this harm could be prevented.

Question 3

What is the Hippocratic Oath code?

Answer 3

A code that establishes principles such as non-maleficence and medical confidentiality.

Question 4

Who was Florence Nightingle and what did she do (1854)?

Answer 4

• She found that very poor care was given for wounded soldiers-medication shortages, poor hygiene in the hospitals, and widespread infections among the soldiers.
• Collected data on the causes of mortality of the soldiers.
• Implemented hand washing, flushing out sewer systems and improving ventilation.
• Reduced the death rate from 42% to 2% among Crimean War soldiers.
• Earliest evidence of the concept of “preventable harm in healthcare”

Question 5

What did Dr Ernest Codman do (1910)?

Answer 5

• Founder of evience-based medicine.
• “The end result idea”.
• Doctors and hospital staff should follow up with all patients to asses the results of the treatment and the outcomes be made in public.
• Limiting staff memberships well-educated competent and licensed physicians and surgeons.
• Rules and regulations to ensure regular staff review.
• Medical records that included history, laboratory, physical examination.

Question 6

What did Avedis Donabedian did (1977)?

Answer 6

-Evaluating the quality of medical care”.
- Components of quality in heathcare services:
- Structure: all of the factors tha affect the conext in which care is delivered.

- Process: the sum of all actions that make up healthcare

- Outcome: all the effect of healthcare on patients or populations.

Not bad people but bad systems

Question 7

What did the Institute of Medicine did (1999)?

Answer 7

• To Err is human: building a safer healthcare systems.
• Shed light on the grave consequences of medical errors and increase awareness about it.
• Outlined four strategies for improvement.

Question 8

What does James Reason did?

Answer 8

• He explained how faults in different layers of a system lead to incidents.
• One fault in one layer of a healthcare system is usually not enough to cause an accident.
• Advers events usually occur when several faults occur in several leyers.

Question 9

What does the Swiss Cheese Model says?

Answer 9

“Any safeguard has inherent holes. Problems occur when multiple holes line up”.

Question 10

Which are the main errors in healthcare?

Answer 10

1. Communication.
2. Training.
3. Patient assessment.

Question 11

Steps to minimize medical errors:

Answer 11

1. Education and training.
2. Rules and policies.
3. Reminders, checklist and double checks.
4. Simplification and standarization.
5. Automation and computerization.
6. Forcing functions.

Question 12

Which intervention is more effective, human oriented or system oriented?

Answer 12

System oriented.

Question 13

What does forcing functions and constraint do?

Answer 13

• Constraint makes it hard to make a mistake.
• Forcing functions: makes it impossible.

Question 14

Which are the benefits of simplifying key processes?

Answer 14

• Can minimize problem solving and errors.

Examples:
- Reducing the number of times per day a drug is administered.

• keeping a single medication administration record.
• Easy-to-use and maintain equipment.

Question 15

Which are the benefits of standardization?

Answer 15

• Allows newcomers who are unfamiliar with a given process or device to use it safely.

Examples:
- Use of standard order forms, administration times, prescribing conventions.

Question 16

Which is the topic of the Global patient safety action plan 2021-2030?

Answer 16

Eliminating avoidable harm in health care.

Question 17

Which is the vision of the safety action plan 2021-2030?

Answer 17

A world in which no one is harmed in health care, and every patient receives safe and respectful care, every time, everywhere.

Question 18

Mission of the safety action plan 2021-2030:

Answer 18

Eliminate all sources of avoidable risk and harm to patients and health workers.

Question 19

Goal of the safety action plan 2021-2030?

Answer 19

Achieve the maximum possible reduction in avoidable harm due to unsafe health care globally.

Question 20

These are some stakeholders involved in the action plan:

Answer 20

• The WHO secretariat at all levels
• Research institutiones
• Media
• United nations

Question 21

Which are de 7 guiding principles of the safety action plan?

Answer 21

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 22

Explain the engage patient and families principle:

Answer 22

As users of the health care system, the people who are most familiar with the entire patient journey should be involved to.

Question 23

Explain the collaborative working principle:

Answer 23

Everybody contributes, shares and
learns.

Question 24

Explain the analysis and share data principle:

Answer 24

Sources of data, including
malpractice claims, patient-reported experience, etc.

• Greater understanding of why safety incidents occur and give solutions to prevent them.
• Less time is spent on analysing and sharing data.

Question 25

Explain the translate evidence into actionable and measurable improvement principle:

Answer 25

Knowing-doing gap

Question 26

Explain the base policies and action on the nature of the care setting principle:

Answer 26

More attention and research in patient safety based on
experience of high-resourced health care systems and large
hospitals.

• Adaptation to local context is important.

Question 27

Explain the use both scientific expertise and patient experience to improve safety principle:

Answer 27

Winning combination of formulating and delivering a plan.

Question 28

Explain instill a safety culture principle:

Answer 28

Culture of safety has to percolate into the attitudes, beliefs, values, skills and practices of health workers, managers and leaders of health care organizations.

Question 29

What involves the “Seven by Five Matrix”?

Answer 29

• Seven strategic objectives.
• 35 strategies, 5 under each of the strategic objectives.

Question 30

When did the safety journey start in Mexico? and what with?

Answer 30

In 2002 with the launch of the National Crusades for Quality in Health Care. Was the pilot workshop.

The first Quality Policy in Latin America.

Question 31

What does the wave one was about and when?

Answer 31

Raising awareness and initiating a safety culture (2002 - 2006).

Question 32

Characteristics of the first wave (raising awareness and initiating a safety culture):

Answer 32

• Aimed to sensitize health-care workers to build patient
  safety knowledge and culture.
• IOM → Globally 10% injury due to medical errors → high-income countries, greater in low- and middle-income countries.
• Initiating awareness on patient safety and building a safety culture.