History and Background Flashcards
What’s the definition of Patient Safety according to the Institute of Medicine?
The freedom from accidental injury due to medical care or from medical error.
What’s the definition of Patient Safety according to the National Patient Safety Foundation?
The prevention of healthcare errors, and the elimination of mitigation of patient injury caused by healthcare errors.
____% of patients experience harm in ambulatory care settings.
____% of this harm could be prevented.
40%
80%
What was Florence Nightingale’s contribution in 1854? (4)
- She found the poor care was given to the wounded soldiers.
- Collected the causes of mortality (polar area diagram).
- Begun to implement hand washing.
- She requested other interventions like flushing the sewe system and ventilation.
In which months did Florence Nightingale observe a higher prevalence of infections?
January and February
Who is the founder of evidence-based medicine?
Dr. Ernest Codman (1910).
What was Ernest Codman’s contribution?
- He started the follow-up for the patients.
- Limited staff to well educated and competetens physicians and surgeons
What are the three components of quality in healthcare proposed by Avedis Donabedian?
- Structure (factors that affect the context)
- Process (all actions that make up healthcare).
- Outcome (the effects of healthcare on patients)
According to “To Err is Human,” how many people die each year due to preventable harm?
Between 44k and 98k people
True or False:
Avedis Donabedian (1966) said that errors cannot be prevented.
False.
He said that errors can be prevented by designing systems that make it harder to make mistakes.
What was the importance of the book “To err is Human” in 1999?
- Shed light on the bad consequences of medical errors.
- Led to an increase in awareness of this topic.
- Outlined four strategies for improvement.
What are the 4 strategies proposed in “To Err Is Human”?
- Create leadership, tools and protocols to enhance the knowledge.
- Develop nationwide reporting systems.
- Raise performance standards and expectations to improve PS.
- Implement safety systems, to ensure safe practices.
Who created the Swiss cheese model?
James Reason
What does the Swiss Cheese model mean?
How faults in different layers of a system lead to incidents.
True or False:
One fault in one layer of HC system is enough to cause an accident.
False, it requires a fault in two or more layers.
What are the 3 main root causes of a sentinel event?
- Communication
- Orientation/training
- Patient assesment
Which are the steps (7) to minimize medical error?
- Education
- Polices and rules
- Communication
- Checklist
- Standardization
- Constraints
- Forcing functions
What’s the objective of a Forcing function and a Constraint?
Prevent errors and make it impossible to make a mistake.
