History and background

Question 1

What is patient safety (Institute of medicine)

Answer 1

The freedom from accidental injury due to medical care or from medical error

Question 2

What is patient safety (National patient safety foundation)

Answer 2

The prevention of health care errors, and the elimination of mitigation of patient injury caused by health care errors

Question 3

How many patients experience harm in ambulatory care settings

Answer 3

40 %

Question 4

______ of this harm could be prevented

Answer 4

80 %

Question 5

Hippocratic oath

Answer 5

5th century B.C

Question 6

Florence Nightingale

Answer 6

1854
- Collected data on the causes of mortality of the soldiers
- Earliest evidence of the concept of “preventable harm in healthcare” and of evidence-based quality improvement

Question 7

Dr Ernest Codman

Answer 7

1910
- Founder of evidence-based medicine

Question 8

Avedis Donabedian

Answer 8

1966
- Errors can be prevented by designing systems that make it hard for people to make mistakes

Components of quality in healthcare services:
- Structure –all of the factors that affect the context in which care is delivered
- Process –the sum of all actions that make up healthcare
- Ouctome –all the effects of healthcare on patients or populations

Question 9

The Err is human

Answer 9

1999
- 4 strategies for improving

Question 10

James Reason

Answer 10

Swiss cheese theory. Faults in different layers of the system

Question 11

Steps to minimize medical error

Answer 11

1. education and training
2. rules and policies
3. reminders, checklists, and double checks
4. simplifications and standardization
5. automation and computerization
6. forcing function