Chapter 3: Pt Safety

Question 1

What is “hard wiring” for reduced risk?

Answer 1

Designing systems that make it difficult for people to make mistakes, and easy for them to do the right thing.

Question 2

Who, in the 19th century, proposed handwashing to decrease puerperal fever?

Answer 2

Semmelweis

Question 3

What were the causes of errors according to Codman (3)?

Answer 3

1. Deficiencies in technical knowledge
2. Surgical judgment-diagnostic skills
3. Equipment

Question 4

Who brought a new perspective on errors in 1994, and how did he do that?

Answer 4

Leape, by focusing on the psychology of error and human performance.

Question 5

In what year was” to err is human” published, and who was it published by?

Answer 5

1999 by the Institute of medicine, IOM

Question 6

What do the terms “sharp end” and “blunt end” refer to, in terms of health systems?

Answer 6

The “sharp end” is the label for the direct action elements of work, and “blunt end” is the support functions of the work. Hence the metaphor of a sword or spear.

Question 7

How are unsafe acts described, and do they occur at the sharp end or the blunt end?

Answer 7

Unsafe acts are referred to as “active failures,” and they occur at the sharp end.

Question 8

What effect does focusing on active failures have?

Answer 8

In this model, blame is commonly assigned to one or more individuals at the sharpened. This is described as the “person approach” because it emphasizes assigning blame to individuals.

Question 9

What is the opposite of a person approach?

Answer 9

A systems approach. This focuses on the “latent conditions,” such as poor supervision and training, in adequate tools, unworkable processes, which we can the barriers to protect patients from harm. The holes in the Swiss cheese.

Question 10

If “latent conditions” are the existing holes in the layers of Swiss cheese, what are “active failures”?

Answer 10

Active failures, or unsafe acts, are new holes that are created in the layers.

Question 11

Active failures have three common types. What are they?

Answer 11

1. Skill-based
2. Rule-based
3. Knowledge-based

Question 12

Define a skill-based task, and an active failure of that task.

Answer 12

Familiar task that is automatic and effortless (restocking shelves). The skill-based failure is a “failure of execution,” unconscious deviation from the task. Slips, lapses, omissions, duplications, often due to waver of attention.

Question 13

Define a rule-based activity, what are failures of the rule-based activity called, and give an example

Answer 13

Rule based activities or basically “if-then” rules.

“Mistakes” are errors that involve the wrong intention or plan. For example, using routine abx therapy for community acquired pnia in a pt with significant immune compromise would represent a rule-based mistake.

Question 14

What is a knowledge-based activity, and a failure thereof?

Answer 14

Occurs with a noble task, requiring conscious thought, mental effort and awareness.

Failure to establish the correct diagnosis and therapy in a challenging case is an example of a failure of a knowledge-based activity.

Question 15

What is confirmation bias?

Answer 15

The tendency to favor solutions that have already been identified, and then to selectively filter data to reinforce the chosen course. For example, if you arrive at a tentative diagnosis for a finding, the tendency is to emphasize information that supports that diagnosis and to minimize conflicting data. This limits consideration of alternative diagnoses.

Question 16

Which cased raised national awareness of fatigue?

Answer 16

Death of Libby Zion

Admitted to a nuclear cuspidal with fever and died within 24 hours. Both supervision and work errors were raised as concerns, but work hours received more publicity. New York mandated changes in resident work hours in 1989, which was adopted by the ACGME in 2003

Question 17

Performance of an individual without sleep for 24 hours is similar to one with an alcohol level of what?

Answer 17

0.1%

According to Dawson

Question 18

What is an adverse drug event, compared with an adverse drug reaction?

Answer 18

An “adverse drug event (ADE)” is an unexpected or dangerous reaction to medication. If it is the result of medication error it is a “preventable adverse drug event.”

An “adverse drug reaction” is synonymous with non-preventable adverse drug event, such as a previously unknown allergic reaction.

Question 19

What is a prescribing error, compared to a transcription error?

Answer 19

A prescribing ever may represent anything from the initial decision to give the drug, don’t give the drug, dose, or be simply due to an illegible prescription.

The transcription error is when the written order or verbal order is incorrectly transcribed. A prescribing error may contribute to this, due to an illegible prescription.

Question 20

What is a dispensing error compared to administration error?

Answer 20

A dispensing error may be due to poor mixing, formulation, labeling, or when the medication dispensed differs from the written prescription, such as because of a drug with a similar name.

An administration error may be due to giving the drug by an improper route, duplicate dose, incorrect time etc

Question 21

In terms of drug administration, what is a monitoring error?

Answer 21

Failure to assess intended therapeutic effect, or lack thereof. Failure of feedback mechanism to the healthcare provider.

Question 22

Name the five types of medication errors

Answer 22

1. Prescribing errors
2. Transcription errors
3. Dispensing errors
4. Administration errors
5. Monitoring errors

Trigger tools can be helpful here.

Question 23

What are the two most common medication errors?

Answer 23

Prescribing and medication administration, with administration errors the most common (3-6/100 admissions)

These two account for three quarters of the total errors

Question 24

Name three systems interventions that reduce medication errors.

Answer 24

1. Routine inclusion of the indication for the drug
2. “Tall man” lettering, which emphasizes the differences between similar sounding drugs
3. Standardized drug formulary lists reducing the number of medications used
4. CPOE to eliminate transcription errors

Question 25

Give examples of two high reliability organizations (HROs)

Answer 25

Aviation industry, nuclear power industry

Question 26

What is a “forcing function”?

Answer 26

A hard stop, such as a pump that will not go above the upper safe limit of infusion rate.

Or, the computer alert that will not let you proceed without override, or make the action impossible.

Question 27

Name three ways to prevent postoperative surgical wound infections

Answer 27

1. Use hair clippers rather than shavers
2. chlorhexidine based cleansing agent
3. Appropriate timing and selection of prophylactic antibiotics.

Question 28

For catheter associated infections, what interventions are effective?

Answer 28

Pick the subclavian first, chlorhexidine based skin cleansers and insertion site dressing.

Question 29

What is the difference between a preventable adverse event and a sentinel event?

Answer 29

Preventable adverse event is an act of omission or commission resulting in harm to the patient.

Sentinel events involving death, serious physical or psychological injury, or risk thereof. Therefore, they are a subset of adverse events containing the most serious occurrences.

Question 30

What is “situation monitoring” of error events?

Answer 30

Also known as “direct observation”, it is actively scanning and assessing routine health standards, such as handwashing.

Question 31

What are the 5 categories of critical event analysis a.k.a. root cause analysis?

Answer 31

1. Data collection
2. Event understanding
3. Possible cause analysis
4. Cause and effect
5. Pattern recognition

Question 32

FMEA, failure mode and effect analysis, evaluates each failure mode according to three categories. What are they?

Answer 32

1. Severity, the consequence
2. Occurrence, the probability or frequency
3. Detection, the probability of the feeder being detected before harm occurs.

Question 33

For failure mode and effects analysis, you multiply the three major features to get a final number, known as?

Answer 33

The composite risk profile number (RPN), which is obtained by multiplying severity, occurrence and detection scores.

Question 34

What are the most common cause(s) of Sentinel events analyzed by the joint commission?

Answer 34

Missed communication and miscommunication

Question 35

What are the six components of crew resource management?

Answer 35

1. Situational awareness
2. Problem identification
3. Decision-making
4. Workload distribution
5. Time management
6. Conflict resolution

Question 36

What is a successful approach used to improve communication in teams? What do the letters stand for?

Answer 36

SBAR
Situation: description of clinical situation
Background: clinical history and context
Assessment: a description of the possible problems
Recommendation: a description of possible solutions.

Question 37

What are some characteristics of high reliability organizations?

Answer 37

1. Preoccupation with failure, regardless of whether actual harm occurred.
2. Reluctance to simplify/oversimplify
3. Sensitivity to operations, the latent conditions the create the Swiss cheese hole. Have an organizational culture the promoting understanding and commit to correcting these.
4. Deference to expertise: push decisions down to the level of the individual most knowledgeable about the process involved
5. Resilience, effectively respond to unanticipated threats and recover

Question 38

What is constrained innovation, also known as adaptive rule-breaking?

Answer 38

The ability to respond to challenges that require new solutions. This is a component of the resilience of high reliability organizations.