Ensuring patient safety

Question 1

What is patient safety

Answer 1

The avoidance, prevention and amelioration of adverse outcomes or injuries

Question 2

Define adverse event

Answer 2

Any event or circumstance arising during care that could have or did lead to unintended or unexpected harm, loss or damage

Question 3

Define a near miss

Answer 3

Any incident that could have led to harm but did not, either by chance or by timely intervention

Question 4

Define a significant event

Answer 4

Any signifcant event, positive or negative during the care of a patient

Question 5

What is an error

Answer 5

The failure of a planned action to achieve its intended outcome

Question 6

What are mistakes a result of

Answer 6

Rule and knowledge based errors

Question 7

What are lapses based on

Answer 7

skill based errors, memory failures

Question 8

What are slips based on

Answer 8

Skill based errors- attetional failure

Question 9

What are active errors

Answer 9

Noticed first
on frontline operator
effects felt immediately
difficult to predict

Question 10

What are latent errors

Answer 10

Less apparent failures
result from organizational design
gernerally results from lack of standardistation of equipment and processes

Question 11

What is human error attributable to

Answer 11

human cogntition and limitation of memory
cant remember everything
cut corners?

Question 12

What human factors might contribute to the risk of error

Answer 12

Unfamiliarity
inexperience
time
failure to check and confirm
poor procedures to complete task
poor equipment design/ease of use

Question 13

What reduces attention and memory

Answer 13

Fatigue
stress
hunger
illness
language or cultural barries
hazardous activites

Question 14

What are the individual factors that predispoe to error

Answer 14

Distraction
attention and memory deficits
multitasking or deviation from routine
knowledge based thought from past experience

Question 15

Explain the swiss cheese model

Answer 15

Many holes in the cheese, some are active errors, some are latent errors. Hazards can either be deflected or sometimes mutiple errors or holes lead to an adverse event- sucessive failur of mutiple defences, barriers and safeguards

Question 16

What should be done if an error is made

Answer 16

First manage the patient
analyse the situation
accept the responsibilty
never blame, point fingers, or gossip

Question 17

What are the 5R’S

Answer 17

Right drug
route
time
dose
patient

Question 18

Which patients are at higher risk of medication error

Answer 18

Patients with
multiple conditions + doctors + medications
problems with communication
do not take an active role in disease management
children and babies

Question 19

When should you HALT

Answer 19

if your hungry angry late or tired

Question 20

How do you know your safe

Answer 20

Illness
Medication
Stress
Alcohol
Fatigue
Emotion

Question 21

What is the optimum goal for establishing a safety culture

Answer 21

acknowledgement of risks
group responsibilty
safety above financial and opperational goals
system encorages and rewards identification of issues
incidents are learning oppertunities
appropriate resources structures and accountability

Question 22

What barries exist to safety

Answer 22

Fear
Whos responsibilty is it 
takes too long
extra admin
no patient impact

Question 23

What are clinical audits

Answer 23

quality improvement process that seeks to improve patient care adn outcomes through systematic review of care against explicit criteria