Chapter 11 Part 1 Flashcards
An exposure to the change of injury or financial loss and its associated liability
Risk
Occurrences involving liability for injury or property loss
Potentially compensable events (PCEs)
An unexpected occurrence involving death of a patient or employee or serious injury, or the risk thereof through avoidable causes
Joint Commission established this notification and maintains a list of events
Sentinel event
Include occurrences that do not necessarily affect an outcome, but if they were to recur, carry significant change of being a serious adverse event
Patient safety events by Joint Commission and are reviewable
Near-misses
Examines influences of human worker on the situation
Example: In the case of Mrs. Yu’s death, a human worker influence was the obstetrical nurses’ lack of training in surgical procedures. This lack of training meant that surgical procedures could not be preformed in the delivery room
Manpower
Examines the influences of supplies and equipment on the situation
Example: Surgical supplies and equipment were not available to Dr. Low in the delivery room, so she could not preform the necessary exploratory procedures there
Material
Examines influences of policies and procedures on the situation
Example: In Mrs. Yu’s case, it was the policy of the institution to take all obstetrical cases requiring surgical delivery or other surgical procedures to the OR on the third floor of the hospital. This policy caused a fairly long period of time to elapse during transport and in this situation led to patient’s death from blood loss
Methods
Examines influences of machines or other major pieces of equipment on the situation
Example: The slowness of the elevator in the hospital contributed to the delay of the effective treatment
Machinery
________ is a process in which a sentinel event is evaluated from all aspects (human, procedural, machinery, and material) to identify how each contributed to the occurrence of the event and to develop new systems that will prevent recurrence.
Root-Cause Analysis
What question do you ask in an RCA?
Why?
