Chapter 14: Basic Science of Patient Safety

Question 1

What are the 5 R’s to help reduce or prevent medication errors?

Answer 1

• right drug
• right patient
• right dose
• right route
• right time

Question 2

What is the pneumonic to help remember how to assess the fitness of a health care professional?

Answer 2

I: Illness
M: medications
S: stress
A: alcohol
F: fatigue
E: eating

Question 3

Availability bias.

Answer 3

tendency to assume a diagnosis based on recent patient encounters or memorable cases

Question 4

What is RCA and is it prospective or retrospective?

Answer 4

root cause analysis

retrospective

Question 5

What is the name of an analysis tool which takes a prospective approach to engineering a method which seeks to anticipate and prevent adverse events through safety design?

Answer 5

FMEA (failure mode effects analysis)

Question 6

What are the 6 aims of healthcare? (Principles of Quality Improvement)

Answer 6

STEEEP

1. safe
2. timely
3. effective
4. efficient
5. equitable
6. patient-centered

Question 7

What are balancing measures?

Answer 7

ask whether changes made to improve one part of the system causes an unanticipated decrease in performance in another part of the system

Question 8

What does PDSA stand for?

Answer 8

plan, do, study, act

Question 9

What is the aim of the six sigma system?

Answer 9

uses specific steps to reduce variation and improve performance

It is an improvement system for existing processes falling below specification

Question 10

What does DMAIC in the six sigma system stand for?

Answer 10

Define: define problem in detail

Measure: measure defects ( in terms of “defects per million” or sigma level)

Analyze: do in-depth analysis using process measures, flow charts and defect analysis to determine the conditions under which defects occur

Improve: define and test changes aimed at reducing defects

Control: what steps will you take to maintain performance?

Question 11

Lean system of improvement.

Answer 11

improvement process that seeks to improve value from the patient’s perspective by reducing waste in time and resources that do not enhance patient outcomes

Question 12

What are pareto charts?

Answer 12

charts used to describe a large proportion of quality problems being caused by a number of causes; based off of the idea that a number of safety errors stem from only a few recurring contributing factors

Question 13

Convenience sample

Answer 13

a study group or population used in the test of a quality improvement initiative

Question 14

Goals should be SMART means what?

Answer 14

Specific
Measurable
Achievable
Realistic,
Time Sensitive

Question 15

Adverse event.

Answer 15

any injury caused by a medical event

Question 16

Authority gradient.

Answer 16

command hierarchy of power or balance of power measure in terms of steepness

Question 17

Closed loop communication.

Answer 17

a type of communication whereby, when a request is made of team members, someone specifically affirms out loud that he will complete the task and states out loud when the task has been completed

Question 18

Error

Answer 18

failure of planned action to be completed as intended

Question 19

Forcing function.

Answer 19

aspect of a design which prevents a specific action from being performed or allows its performance only if another specific action is performed first

Question 20

Medication reconciliation?

Answer 20

process of avoiding unintended inconsistencies in medication regimens which can occur with any transition in care

Question 21

Near miss (or close call)

Answer 21

an error or other incident which does not produce patient injury, but only because of intervening factors or pure chance

Question 22

Compare and contrast QA with QI?

Answer 22

QA an older term not likely to be used today, was reactive, retrospective, policing

QI involves both prospective and retrospective reviews; aimed at improvment measruing where you are and figuring out ways to make things better

Question 23

SBAR

Answer 23

a form of communication first developed for use in naval military procedures

S situation (what is going on with the patient?)
B background ( what is the clinical backgroud or context?)
A assessment (what do I think the problem is?)
R recommendation/request (what would I do to correct it?)

Question 24

Sentinel event

Answer 24

adverse event in which death or serious harm to a patient has occured; used to refer primarily to events that were not at all expected or acceptable

Question 25

Wrong site procedure?

Answer 25

operation or procedure done on the wronng part of the body or on the wrong person;

can also mean the wrong surgery or procedure performed