Block 7

Question 1

Minor Near Miss

Answer 1

An error that would have resulted in no/very minimal temporary harm but did not because it was caught/good luck

Question 2

Minor Event

Answer 2

An event involving no harm or very minimal temporary harm to patient

Question 3

Moderate Event

Answer 3

An event causing discomfort sufficient enough to interfere with usual activity ad requires additional specific intervention but poses no significant/permanent harm

Question 4

Major Near Miss

Answer 4

An event that would have resulted in death or serious physical/psychological injury but did not because it was caught or good luck

Question 5

Major Event

Answer 5

An event involving death or serious permanent physical/psychologica injury

Question 6

T or F: Events causing Major Events should not be considered “stuff” that “just happens” nor should they be considered inevitable

Answer 6

True

Question 7

What is the difference between Near Misses and Events?

Answer 7

Near misses can be caught far from or very close to the patient
Events actually happen and cause varying degrees of harm from none to severe

Question 8

What is the definition of ‘Patient Safety’?

Answer 8

Patient safety refers to the prevention of errors and adverse effects to patients associated with health care.

Question 9

What are the key aims of the Institute of Medicine (IOM) regarding quality in healthcare?

Answer 9

The IOM aims for quality improvement in healthcare.

Question 10

What are the two contrasting cultures in healthcare regarding safety?

Answer 10

• Culture of Safety
• Culture of Blame

Question 11

Define ‘Medical Error’.

Answer 11

Any act of commission or omission that has the potential to cause patient injury. May not reach pt.

commission = doing
omission = not doing

Question 12

What is an ‘Adverse Event’?

Answer 12

An adverse event occurs when a medical error reaches the patient.

Question 13

What are ‘Never Events’?

Answer 13

Specific events that can never happen while under care, associated with the Federal Govt’s Hospital-Acquired Condition (HAC) Reduction Program.

If they happen are no longer paid for by CMS

Question 14

List some examples of Never Events.

Answer 14

• Death/Serious Injury associated with restraints/bedrails and Use of devices for unintended functions

All:
* Falls, Fractures, Dislocations
* Stage III and IV pressure ulcers
* Electric shock

Question 15

What factors increase patient risk in healthcare?

Answer 15

• Dealing with sick, vulnerable people
• High stress environments
• Historical ‘Authority Gradient’
• Technology interfaces
• Resource limitations
• Staffing pressures
• Poor physical environments

Question 16

What are Latent Conditions?

Answer 16

Conditions that precede errors and contribute to system failures.

Question 17

What is ‘Active Failure’?

Answer 17

The direct actions of individuals that lead to errors.

Question 18

What is the Donabedian Model?

Answer 18

There will always be antecedent conditions that will affect the outcomes of the care process/structure and if you are unable to change them you can implement patient safety management into the structure and change the processes to reduce or eliminate the risks of events that create poor outcomes

Question 19

True or False: A culture of blame focuses on identifying who is at fault for errors.

Answer 19

True

Question 20

What does the Swiss Cheese Theory illustrate in patient safety?

Answer 20

It illustrates how defensive layers or safeguards can prevent errors from reaching the patient.

Question 21

What is the purpose of Root Cause Analysis?

Answer 21

To identify the underlying causes of errors and near misses in healthcare.

Question 22

Fill in the blank: ‘Human Factors Design’ is the study of all the factors that make it easier for workers to _______.

Answer 22

[do work the right way]

Reduces risk of errors reaching pt. and providers letting errors reach pt.

With a good design, accomodates the whole range of employees

Question 23

How might Human Factors be implemented?

Answer 23

Avoiding reliance on memory
Standardize and simplify common processes and procedures
Use Checklists

Question 24

What are some strategies to consider for falls prevention?

Answer 24

• Implementing system-level safeguards
• Human factors design in practice
• Standardizing processes and procedures

Question 25

What is a key characteristic of High Reliability Organizations (HROs)?

Answer 25

They adopt a culture of safety and open reporting.

Question 26

What is an example of a situation that increases the risk of error in healthcare?

Answer 26

Unfamiliarity with tasks, especially when combined with poor supervision.

Question 27

What is the significance of the Agency for Healthcare Research and Quality (AHRQ)?

Answer 27

It provides guidelines and research for improving healthcare quality and safety.

Question 28

What does ‘optimum stress’ refer to in the context of patient safety?

Answer 28

The level of stress that allows for optimal performance without increasing the likelihood of errors.

Question 29

How does the healthcare error rate compare to other industries?

Answer 29

Healthcare error rate is much higher than in other industries.

Question 30

What is a common misconception about medical errors?

Answer 30

That they are primarily due to individual carelessness or misconduct.

Question 31

What is the role of checklists in patient safety?

Answer 31

To help reduce errors by standardizing processes and ensuring critical steps are not missed.