Basic Science Of Patient Safety

Question 1

Mention two important models of Quality improvement

Answer 1

• PDSA (plan, do, study, act) “actplandos”

- Six Sigma (DMAIC - define, measure, analyze, improve, control)

Question 2

What is root cause analysis (RCA)?

Answer 2

• Fishbone or Ishikawa diagram (Cause and Effect diagram).
• Restrospective
• Analizes a complex system and Id possible causes
• Diagram allows display and explore all possible causes

Question 3

What are the outcomes measure of quality?

Answer 3

Final product or end result in patient care, Ex: HAI

Question 4

How can the errors be categorized?

Answer 4

• Slips: observable, not intended, actions not carried as intended
• Lapses: Not observable, not intended, missed actions or omissions (forget)
• Mistakes: Intended actions is wrong, incorrect intentions (but Not bad intentions - don´t apply correctly guides to extubate)

Question 5

Which are the type of errors?

Answer 5

1. Treatment
2. Preventive
3. Diagnostic
   + No-fault errors
   + Systema-related
   + Cognitive errors
   
   • Anchoring bias
   • Confirmation bias
   • Availability bias

Question 6

Named and shortly define the others models of quality improvements

Answer 6

• Lean: reduce resources that don’t improve patients outcomes
• Flowcharts: steps involved in the delivery of patient
• Pareto charts: largue proportions of problems caused by small number of causes
• Run charts (time plots): Id true trend vs a random pattern over time
• All the tests of a quality improvement uses convenience sample - study group or population